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Family Matters: Research on Family Ties and Health, 2010-2020

Debra umberson.

Population Research Center, University of Texas at Austin, 305 E 23 rd Street, Austin TX

Mieke Beth Thomeer

Department of Sociology, University of Alabama at Birmingham

Family ties have wide-ranging consequences for health, for better and for worse. This decade review uses a life course perspective to frame significant advances in research on the effects of family structure and transitions (e.g., marital status), and family dynamics and quality (e.g., emotional support from family members), on health across the life course. Significant advances include the linking of childhood family experiences to health at older ages, identification of biosocial processes that explain how family ties influence health throughout life, research on social contagion showing how family members influence one another’s health, and attention to diversity in family and health dynamics, including gender, sexuality, socioeconomic, and racial diversity. Significant innovations in methods include dyadic and family-level analysis and causal inference strategies. The review concludes by identifying directions for future research on families and health, advocating for a “family biography” framework to guide future research, and calling for more research specifically designed to assess policies that affect families and their health from childhood into later life.

Parents, children, intimate partners, and other family members have the power to improve—or undermine—health. Recent advances in research on family ties and health, built on increasingly sophisticated data and innovative methods, examine variation in these linkages across demographic and social contexts. These studies identify the specific and intersecting biosocial pathways through which family ties influence health in ways that sometimes vary by social position. Through these pathways, family ties exert both short- and long-term effects on health from childhood through later life. In this review, we highlight key themes and advances in the past decade of research on families and health.

We use a life course framework ( Elder, Johnson & Crosnoe, 2003 ) to organize this review. Research on family ties and health tends to fall into two camps: one focusing on health in childhood and the other focusing on health in adulthood. A life course perspective helps synthesize these literatures by emphasizing the inextricable links between these life stages. The life course concepts of cumulative advantage and disadvantage and stress proliferation help scholars show how social contexts and resources in childhood matter for health and well-being at older ages. A life course perspective highlights “linked lives” across life stages, the importance of early family experiences for lifelong health, and the significance of family ties and transitions throughout adulthood for health trajectories. No single theoretical paradigm dominates research of the past decade; however, a consistent theoretical strand across studies is attention to stress (either imposed on families or arising within families) and the associated accumulation of advantage or disadvantage in health through intersecting biological, psychological, and social pathways.

In this review, we focus on relationships with parents in childhood and relationships with intimate partners in adulthood, reflecting the primary areas of research on family ties and health over the past decade. We recognize the importance of other family ties, including children, siblings, and grandparents, but a detailed analysis of these areas is beyond the scope of this review and is addressed in other articles in this volume (see MS#6776, 2020 ; MS#6759, 2020 ). Life course approaches further emphasize the importance of social position—as patterned by gender and sexuality, race and ethnicity, and socioeconomic status—in shaping family ties and life course experiences that influence health. Social position matters in at least two important ways. First, some groups are exposed to more adverse family circumstances (e.g., higher rates of incarceration among minority families, lack of access to marriage for same-sex couples historically). Second, the effects of family circumstances on health may vary by social position (e.g., gender differences in effects of relationship stress on health). We call attention to such diversity throughout this review while recognizing that the complexity associated with each of these systems of stratification warrants fuller discussion than we can provide.

An exciting advance in research has been growing theoretical and empirical sophistication in clarifying the intersecting biosocial pathways through which family ties and social conditions influence health ( Repetti, Robles, & Reynolds, 2011 ). The increasing availability of quality biomarker data (i.e., medical indicators that can be measured objectively, accurately, and reproducibly, such as blood pressure and C-reactive protein) has yielded significant insights into how and when families impact health, even prior to any specific diagnosis. This work emphasizes the effect of family stress on physiological systems: for example, family stress activates cardiovascular arousal and inflammatory and immune responses that undermine health in childhood and have the potential to increase chronic disease risk with advancing age (see a review in Miller, Chen, & Parker 2011 ).

In this review, we focus first on family ties and child health and then on family ties and health in adulthood. We address the broad themes of: (a) family structure and transitions (e.g., marital status, divorce) and (b) family relationship quality and dynamics (e.g., emotional support and conflict in family ties). We then turn to innovations in data and methods that undergird research advances over the past ten years. In conclusion, we identify significant directions for future research and emphasize the critical value of this research for informing policies that affect families and their health.

Families and Child/Adolescent Health

A significant theoretical advance over the past decade has been the placement of research on family ties’ consequences for child health squarely within a life course perspective. This research has shown that family experiences early in the life course have the potential to launch trajectories of mental and physical health that extend beyond childhood (e.g., Gaydosh & Harris, 2018 ). Whereas past research on childhood tended to “stay in childhood,” life course scholarship shows that childhood experiences shape the accumulation of health-related advantage or disadvantage throughout life ( Avison, 2010 ). For example, exposure to social resources in childhood can add to cumulative advantage in health over time. For children, family contexts and relationships are the starting point of early-life exposure to both stress and resources, with implications for both later-life family relationships and later-life health ( Umberson et al., 2014 ). We first focus on recent work that considers family stress in relation to the health of children and adolescents and then turn to family resources that may protect children’s health. We conclude by discussing the impact of stressful family conditions in childhood on health in adulthood.

Childhood and the Stress Universe

The past decade of research on children’s health has advanced the perspective that family (structure) instability, stressful family dynamics, and family social position are inextricably linked. A key life course concept is stress proliferation—the idea that stressors often occur in tandem and one stressor triggers another, leading to a pileup of stressors that can be emotionally and physically overwhelming ( Pearlin et al. 2005 ). Avison (2010) has called for more attention to the “stress universe” of children, including family stress. Before turning to recent research that sheds light on major childhood family stressors that contribute to child health, we briefly describe how child health is typically assessed and discuss recent research on the pathways that link family stress to child health.

Child Health Measures

In the following review, we define health broadly. Most studies of children and adolescents focus on internalizing and externalizing symptoms as indicators of health and well-being. Internalizing symptoms include bodily complaints, social withdrawal, depression, and anxiety; externalizing symptoms include delinquent and aggressive behaviors. These measures typically rely on parent reports for younger children and self-reports for older children and adolescents, but some studies also consider reports from teachers (e.g., Early Childhood Longitudinal Study; https://nces.ed.gov/ecls/ ). The focus on emotional and behavioral symptoms reflects current concerns about mental health in the early life course; about 21 percent of children aged 2 to 17 have a diagnosed behavioral or psychological condition, and trend data indicate increasing rates of depressive symptoms and suicidal thoughts and behaviors among youth ( The Annie E. Casey Foundation, 2016 ). There have also been sharp rises in childhood obesity, asthma, bronchitis, and hay fever ( Delaney & Smith, 2012 ), and much of the influential research on childhood family environments and health focuses on these outcomes (e.g., Bair-Merritt, et al, 2015 ; Schreier & Chen, 2013 ).

Family Structure and Instability

Research on children and families focuses on varying levels of stability and stress within families as a major influence on children’s health. Overall, studies suggest that children of married parents have better mental and physical health than children of cohabiting parents ( Cavanagh & Fomby, 2019 ). The key explanation for this finding is the tendency of married couples’ families to feature less instability (i.e., disruption and change in family structure); instability contributes to parenting strain and distress, creates new economic strains, and disrupts children’s ongoing family relationships and routines. These strains and disruptions result in increasing stress for children, especially when there are multiple family transitions (e.g., parental divorce, re-partnering and remarriage, new half-siblings, and step-families; Lee & McLanahan, 2015 ), and this increasing stress reduces children’s health and well-being ( Cavanagh & Fomby, 2019 ).

However, recent work suggests two caveats regarding family instability. First, stability can be found in nontraditional family structures. For example, Reczek and colleagues (2016b) show that children’s health benefits from living with married same-sex as well as different-sex parents but that cohabiting parents (whether in same- or different-sex unions) do not provide the same health benefits because cohabiting unions tend to be less stable (e.g., more likely to dissolve). Second, the growing literature on family instability points to the need to clarify predictive and mediating factors that make family instability more (or less) harmful for children’s health. Fomby and Osborne (2017) emphasize the importance of family-level stressors in mediating the impact of both family instability and parents’ multi-partner fertility on children’s externalizing behavior. Also important is the timing of events and stress levels both preceding and following those events. For example, a father’s departure from the home seems to have less impact on adolescent delinquency if the departure occurs earlier in childhood ( Markowitz & Ryan, 2016 ). We need more work on the complex interrelationships between associated stressors, mediating factors, and timing of the family transitions that put children at risk, as well as protective factors that promote children’s resilience and health.

Growing evidence suggests that family transitions and instability characterized by the loss of a family member are particularly damaging to children. Stable attachment to family members is essential to child development and well-being, and loss may be a uniquely traumatic stressor. The death of a parent in childhood or adolescence has adverse effects on health that last into young adulthood ( Amato & Anthony, 2014 ; Gaydosh & Harris, 2018 ), and other studies show that early parental death increases health and mortality risk even into mid- and later life ( Guldin, 2015 ). Given the extent of mass incarceration in the United States, some of the most significant research of the past decade has addressed the impact of parental incarceration , another type of parent loss, on children’s health and well-being (e.g., Turney, 2014 ). Children of incarcerated parents are embedded in a dense constellation of risk associated with disadvantage before the parent’s incarceration, disadvantage associated with losing access to a parent, and stress proliferation that results from having an incarcerated parent ( Wakefield & Uggen, 2010 ). Much like incarceration, immigration status has taken on greater significance in the United States as family separation has become a greater threat to children ( Landale et al., 2015 ). Family separation due to military deployments has also been negatively linked to child health ( Paley, Lester, & Mogil, 2013 ). Notably, race, ethnicity, and social class are associated with the risk of parental loss through death ( Umberson, 2017 ), incarceration ( Wakefield & Uggen, 2010 ), and immigration policies ( Landale et al., 2015 ). Given the clear importance of family stability for children, future research should identify the mechanisms through which family separation and loss affect child health, sources of resilience, and later health into and throughout adulthood.

Parent Characteristics and Family Stress

Recent research has advanced understanding of how stress and health spread between family members and has directed attention to stressful family dynamics for children associated with parents’ financial resources, health problems, relationship problems, and aggression. Inadequate financial resources are a major source of children’s stress, and financial strain and poverty contribute to family instability and many of the specific family stressors described below. Child poverty rates have remained high (about 20 percent) since the 1970s ( Chaudry & Wimer 2016 ). Children in families of lower socioeconomic status are in poorer health for many reasons, including having more stressed/distressed parents and caregivers, more chaotic family routines, more conflict in family relationships, greater family embeddedness in poor neighborhoods and schools, and significantly higher levels of family instability ( Raver, Roy and Pressler 2015 )—all sources of childhood stress. Family socioeconomic status operates through multiple pathways to influence children’s health behaviors, psychological states, and physiological processes; low socioeconomic status undermines health by decreasing access to helpful resources while increasing exposure to harmful stressors ( Schreier & Chen, 2013 ).

Parents’ poor health, which often co-occurs with poverty ( Hardie & Landale, 2013 ), also has a negative impact on children’s health, indicating that these should be studied together and in relation to family instability in order to best assess risk to children’s health. Most studies of parental health problems have focused on the negative impact of mothers’ depression and have shown that the effect on child health is mediated by family instability and financial stress ( Turney, 2011 ). But parents’ physical health and health behaviors also matter for children’s health, sometimes through reciprocal pathways; for example, one study found that a parent’s drinking was associated with child and adolescent externalizing behaviors, which in turn exacerbated the parent’s drinking ( Zebrak & Green, 2016 ; see review in Shreier & Chen, 2013 ). Mothers’ health limitations may matter more for children’s well-being than father’s health limitations, and the life course timing of parental health problems may also contribute to heterogeneity in children’s responses; for example, Hardie and Turney (2017) consider children up to age nine and find that parental health problems have a greater impact when they occur in middle childhood than at older or younger ages.

Recent research on why divorce appears to negatively affect children’s well-being indicates that harmful effects on children are better explained by parents’ strained relationship dynamics, mental health problems, and lower socioeconomic status (all of which contribute to the risk of divorce) prior to divorce than by the divorce event itself ( Amato & Anthony, 2014 ). Parents’ relationship quality is dynamic, and the timing, persistence, and trajectory of parents’ relationship problems clearly matter for children’s well-being. For example, Bair-Merritt and colleagues (2015) link mothers’ exposure to intimate partner violence to their children’s cortisol reactivity and asthma problems. Marital conflict is especially detrimental for children’s externalizing behaviors if conflict is frequent and escalating ( Madigan, Plamondon, & Jenkins, 2016 ). Future research should identify other pre–family transition factors that protect children’s health or increase vulnerability following family transitions.

A substantial literature shows that child neglect and abuse activate biosocial processes that take a lasting toll on health, and numerous studies over the past decade have gone further to show that parents’ more routine patterns of hostility and aggression also affect children (see MS#6811, 2020 ; MS#6755, 2020 for more detailed discussion of this point). Miller and Chen (2010 : 854) find that “even mild exposure to a risky family in early life can shift the developmental trajectory toward a proinflammatory phenotype” evident in adolescence. There is also a growing consensus that spanking, widely used as a form of discipline by parents, is a significant stressor in the lives of children, with adverse short- and long-term effects on health and well-being that are consistent across social and cultural contexts ( Gershoff et al., 2018 ).

Family Resources for Children

The focus of most research has been on family factors that create disadvantages for children’s health, but several research themes identify ways that families protect children’s health. First, family practices that promote stability and routine and minimize physical punishment ( Cavanagh & Fomby, 2019 ; Gershoff et al., 2018 ; Schreirer & Chen, 2013 ) can benefit youth. Second, parents’ good health reduces the stress of parenting and contributes to family stability ( Hardie & Turney, 2017 ). Third, close and cohesive family relationships protect children and adolescents ( Maimon, Browning, & Brooks-Gunn, 2010 ). On this last point, emerging research suggests that parental support can mitigate stress for children and adolescents at high risk due to discrimination based on race ( Benner, et al., 2018 ), sexual orientation or gender identity ( Thomeer, Paine, & Bryant, 2018 ), and immigration status ( Mood, Jonsson, & Låftman, 2016 ). Additionally, close relationships with siblings may protect adolescents from family stress ( Waite et al., 2011 ). Future research should expand understanding of family contexts that protect children’s health and how these resources are unequally distributed in the population (e.g., by socioeconomic status).

Family financial resources are highly correlated with many other family resources that benefit youth (e.g., parents’ mental and physical health, safe neighborhoods), and it is possible that the key intervention to improve child well-being is to improve parents’ financial resources ( MS#6827, 2020 ). Critiques of policy programs that seek to improve children’s health and well-being by improving parents’ marital quality point out that the more effective path to improving both parents’ relationships and children’s health is to lift children out of poverty ( Turney, 2011 ). Financial resources may also alleviate parental stress and promote family stability, rendering these protective family factors more accessible. Financial resources further reduce family members’ risk of incarceration and death, both of which are highly stressful for youth. A family’s financial resources can mitigate the effects of stress on children and add to their cumulative advantage in mental and physical health beyond childhood ( Schreier & Chen, 2013 ).

The Long Arm of Family Ties in Childhood

In line with a cumulative disadvantage perspective, childhood family ties have consequences for health in adulthood. This occurs in part because stressful family environments in childhood activate physiological (e.g., cardiovascular reactivity), psychological (e.g., emotional reactivity), behavioral (e.g., self-medication with drugs, alcohol), and social (e.g., educational attainment) processes that affect health both directly and indirectly by increasing the risk of social isolation and relationship strain and instability throughout life ( Miller, Chen, & Parker, 2011 ; Repetti, Robles, & Reynolds, 2011 ). When activated early in life, these intersecting processes influence lifelong patterns in family relationships and psychological and physiological systems, which in turn create an increasing disadvantage for health ( Umberson et al., 2014 ).

In particular, studies using biomarkers provide a way to examine the same outcome at different stages of the life course, which makes it possible to unpack how family ties and health are linked as people age. There are theoretical reasons to expect family structures and processes to affect health differently at different ages, and researchers should assess these measures over time, and develop theories of why we might see this variation. For example, some family dynamics may be more important for health in the early life course (e.g., due to sensitive periods of development in childhood), whereas others may be more important in later life (e.g., as individuals become more physically fragile or vulnerable). These details are essential to understanding how early-life family experiences affect mid- to later life health disparities. Researchers have increasingly asked how family ties in childhood matter for health at older ages (e.g., Umberson et al., 2014 ), but most studies of connections between family relationships and health in adulthood continue to exclude discussion of the health impact of early life family ties. Future research can fill this gap by addressing these key life course linkages.

Family Ties and Adult Health

In the following discussion of family ties and health in adulthood, we describe advances in research on union status/transitions and health in adulthood, partner dynamics and intersecting pathways that affect health, and intertwined union status/parental status trajectories over the life course.

Union Status, Union Transitions, and Health

Decades of research have addressed the link between intimate partnership status and health. Over time, although the quality of data and methods has improved and research better reflects the diversity of people’s relationships and their movement in and out of these relationships, many basic findings regarding union status and health remain unchanged. The preponderance of the evidence suggests that the married are in better health than the unmarried, cohabitors are in better health than the unmarried but worse than the married, and men benefit from marriage more than women do ( Rendall et al., 2011 ). There are two primary explanations for these patterns. First, through selection, people who are healthier and wealthier are more likely to marry and remain married, making it appear that marriage benefits health when it is actually health that predicts marriage ( Tumin & Zhang, 2018 ). Second, the married enjoy certain resources that promote health, including pooled economic assets, greater access to emotional and social support, and the spouse’s encouragement and coercion of healthy behaviors (i.e., social control; Rendall et al., 2011 ). While the never married and cohabitors may have fewer of these resources, transitions out of marriage through divorce or widowhood are especially detrimental to health, because these transitions trigger a wide array of new stressors and diminished resources that combine to undermine health and well-being ( Dupre, 2016 ; Roelfs, 2012 ).

Men seem to benefit more than women from marriage because women typically provide more emotional support, social control of health behaviors, and caregiving to their spouses than men do; in addition to lower benefits, women may experience more costs associated with their relatively high levels of care work ( Glauber & Day, 2018 ). Health disparities by relationship status may be greater for those with higher household incomes and more educational attainment than for their lower-income and less educated peers ( Roxburgh, 2014 ). Such disparities may also be greater for white adults than black adults ( Roxburgh, 2014 ); for example, Dupre (2016) found that divorced white adults have a much higher risk of stroke than married white adults but found no difference between married and divorced black adults. More research is needed to unpack how and why the benefits of marriage and costs of dissolution vary by race, gender, class, and other sociodemographic factors.

Research over the past decade has innovated in two key areas concerning union status/transitions and health. First, this work has gone beyond the traditional focus on heterosexual relationships to include same-sex couples, leading to new ways of thinking about gendered dynamics within relationships. Second, scholars increasingly recognize that health is the outcome of accumulated experiences, including the unique relationship biographies that individuals form over the course of their lives. These biographies may include intertwined intimate relationship and parenting histories, as well as longer periods of singleness and social isolation, both of which may vary by systems of social stratification.

Same-sex Unions

An explosion of research over the past decade has focused on same-sex unions and health. In a significant historical shift, the United States extended constitutional protection for marriage equality in 2015, with proponents of this expansion arguing that same-sex marriage recognition could improve the health of sexual minority adults and their children and that restriction from marriage was discriminatory and negatively impacted health. MS#6668’s article in this issue provides a comprehensive overview of LGBTQ families (see also Thomeer, Paine, & Bryant, 2018 ); here, we briefly highlight findings related to same-sex union status and health. Theoretical work on minority stress and gender-as-relational perspectives undergirds much of the influential research in this area. Minority stress theory points to the unique stressors and stigma associated with sexual minority status ( LeBlanc, Frost, & Bowen, 2018 ), and gender-as-relational perspectives emphasize the different patterns that men’s and women’s partner interactions follow depending on whether they are in a same- or different-sex union ( Umberson et al., 2016 ).

Some of the first evidence to rely on nationally representative data emerged in 2013, when two studies concluded that same-sex cohabiting couples’ health is worse than different-sex married couples’ but better than that of unpartnered adults, and that same-sex and different-sex cohabitors report similar levels of health once socioeconomic status is taken into account ( Denney, Gorman, & Barrera, 2013 ; Liu, Reczek, & Brown, 2013 ). Although few studies have compared same-sex married couples to same-sex cohabiting couples, research suggests that greater legal recognition (i.e., marriages, civil unions, and registered domestic partnerships versus no legal status) is associated with better health and that same- and different-sex couples receive similar health benefits from marriage ( LeBlanc, Frost, & Bowen 2018 ; Reczek et al., 2016b ).

Notably, because most large-scale data collections have included only heterosexual couples, these prior studies on same-sex marriage have had to rely on cross-sectional data and smaller samples. Longitudinal data on same-sex couples is needed to better assess the long-term impact of marriage access on both overall health and health disparities. Future research should also focus on how these experiences may differ by class, race/ethnicity, and sexual identities beyond the heterosexual and gay/lesbian dichotomy (e.g., bisexual people). Gender differences have been a major theme of past research on union status and health for different-sex couples, and gendered patterns in relationships may unfold differently depending on whether one has a same- or different-sex partner. For example, compared to men, women in both same- and different-sex unions provide more care to a spouse during serious illness, but this care work is much more likely to be reciprocated and appreciated when women are in same-sex unions ( Umberson, et al., 2016 ). Given the current political environment, continued discrimination, and the disadvantage that the privileging of marriage may create for single adults, marriage’s availability to same-sex couples does not automatically translate into improved health for members of diverse sexual minority populations ( Thomeer, et al., 2018 ).

Transgender and gender-nonconforming partners.

Over the next decade, family scholars should consider relationship status and health for couples in which at least one partner is transgender or gender nonconforming, including variations by class, race, and ethnicity. Current research in this area is limited: most studies have focused on transgender men partnered with cisgender women and have relied on cross-sectional, non-probability samples. Despite these limitations, emerging evidence shows that an intimate partner relationship is a source of social support that can reduce perceived levels of discrimination for transgender people ( Liu & Wilkinson, 2017 ; Pfeffer, 2016 ), suggesting potential health benefits, although this remains to be tested. Moving outside the gender binary will provide new opportunities for understanding gendered health dynamics across intimate partnerships.

Marital Biography, Singleness, and Absence of Family Ties

Relationship histories are becoming increasingly complex as adults live longer, are less likely to marry and more likely to marry later, spend fewer years married, experience remarriages and stepfamilies, cohabit rather than marry, and express more sexual and gender fluidity as norms and stigma around sexual and gender identity shift (see MS#6668, 2020 and MS#6760, 2020 this issue). At the same time, research has documented the accumulation of health benefits and risks over the life course. One advance of the past decade is research on how complex marital biographies—with variability in number, duration, type, and timing of unions and transitions—shape later health. For example, Reczek and colleagues (2016a) analyzed dyadic longitudinal data from the Health and Retirement Study (HRS; http://hrsonline.isr.umich.edu/ ) to look at individual- and couple-level trajectories of heavy alcohol use in relation to personal histories of marital status and transitions. Marriage and remarriage were associated with less drinking from mid- to later life for men but not women, and divorce increased men’s heavy drinking while leading women to drink less.

A marital biography focus also advances understanding of how time spent unpartnered shapes health. This research has focused on divorce and widowhood and has found that years spent divorced or widowed add to subsequent health risk whereas years spent married are protective ( McFarland, Hayward, & Brown, 2013 ). Moreover, there may be race and other population group differences in these patterns; Dupre (2016) found that stroke risk was increased more for white than black respondents with a history of marital dissolution. Marital biography studies have primarily addressed transitions in and out of marriage, but recent evidence points to the importance of other types of unions by showing that cohabitation breakups can affect health similarly to divorce ( Kamp Dush, 2013 ). The health effects of periods of social isolation and lack of family ties are also important features of a marital biography and need more attention in future research.

A life course approach emphasizes the linked lives of family members beyond the marital relationship. Studies using a relationship biography approach have innovated by studying the interdependent effects of parenthood and partnership histories on health. For example, Williams and colleagues (2011) found that women who were unmarried at the time of their first birth experienced worse health, more chronic disease, and higher mortality risk by age 40, yet this effect was attenuated for white women (but not black women) who eventually married and remained married to the child’s father. Future research should weave together the different strands of family biographies that coalesce to uniquely shape health, perhaps differently for different groups.

Loss of family ties may contribute to racial disparities in family and health disadvantage. Black Americans are more likely than white Americans to experience the death of a child, sibling, parent, and spouse over their lifetime and to experience these losses earlier in the life course, potentially adding to social isolation, caregiving burdens, strains within families, and cumulative disadvantage in health ( Umberson, 2017 ). Mass incarceration and current immigration policies also sever family ties and increase social isolation; these experiences affect health and are disproportionately common for racial and ethnic minorities in the United States. ( MS#6752, 2020 ; Wakefield & Uggen, 2010 ). Family scholars should identify who is most likely to lack and lose family ties, the duration of and reasons for socially isolated periods of the life course, the extent of loneliness in relation to social isolation, and variations in these experiences’ consequences for health across and within diverse socioeconomic, racial, and ethnic communities.

Relationship Processes and Adult Health

Research over the past decade has illuminated the processes through which family ties affect adults’ health by highlighting the dynamics and quality of adults’ intimate partnerships. We call attention to innovation in two main aspects of the relationship between health and the dynamics and quality of social ties: (a) the impact of relationship quality (e.g., strain, support) on health, and (b) the role of social contagion (i.e., the spread of health across individuals within social networks).

Relationship Quality

Recent research shows that the quality of an intimate relationship can affect health more than marital status per se ( Miller, Chen, & Parker, 2013 ). Over the past decade, family scholars have expanded understanding of how relationship quality matters for health by taking advantage of longitudinal and dyadic data, including biomarkers as mediators and outcomes, and innovating methodologically to identify key mechanisms linking relationship quality to health. Longitudinal data have made it possible to draw on multiple waves of data collection covering twenty or more years. This research has made significant advances by demonstrating that changes in marital quality are related to changes in health over time and that this link is likely causal as well as bidirectional ( Robles et al., 2014 ). These studies show that marital quality is more salient for health at older ages than at younger ages and that negative marital interactions (e.g., conflict, demands) have stronger effects on health than do positive interactions (e.g., support, closeness; Miller et al. 2013 ). The growing availability of longitudinal data that follow individuals and couples over decades will provide rich opportunities for research over the next decade. For example, the National Longitudinal Study of Adolescent to Adult Health Study (Add Health; https://www.cpc.unc.edu/projects/addhealth ) began collecting data from children when they were in grades 7–12 in 1994–95, and they have continued data collection since then, providing unique opportunities to study health and family relationships starting in adolescence and aging into midlife. The collection of longitudinal data is difficult, given that it takes many decades before data can be analyzed; alternative strategies include cohort studies (e.g., multiple age cohorts followed over shorter periods of time).

Like research on families and childhood health, research on the biological pathways through which relationships impact adult health has advanced significantly over the past decade ( Kiecolt-Glaser & Wilson, 2017 ). This research has shown how multiple dimensions of relationship quality (e.g., strain, support, closeness, satisfaction) shape biomarkers. For example, recent studies find that relationship quality is inversely associated with inflammation across multiple markers (e.g., interleukin‐6 and C‐reactive protein; Bajaj, et al., 2016 ). Biomarkers reveal complex and interrelated physiological responses to marital dynamics and suggest that women’s physiological responses to marital stress are stronger than men’s ( Kiecolt-Glaser & Wilson, 2017 ).

Relationship quality studies have also benefited from dyadic data that has made it possible to analyze the perspectives and experiences of both members of a couple. Dyadic studies allow researchers to identify how gender operates within intimate relationships and better test theories related to “his and hers” marriages in relation to each partner’s health ( Iveniuk et al. 2014 ; Thomeer, Umberson, & Pudrovska, 2013 ). Researchers are also beginning to move beyond the “his and hers” model to queer notions of intimate relationships. These studies use dyadic methods to critically examine whether the assumptions we make about relationship quality and health in heterosexual couples apply to same-sex couples ( Umberson et al., 2016 ). However, due to a lack of longitudinal and nationally representative data, dyadic studies of relationship quality in same-sex couples lags far behind research on different-sex couples—an important data challenge that needs to be addressed in the next decade.

Another important advance in studies of relationship dynamics involves social contagion—the idea that health can “spread” across relationships or “spill over” from one family member to another. Over the past decade, longitudinal studies have shown that the depressive symptoms of one spouse—especially the wife in a different-sex couple—influence the other spouses’ depressive symptoms over time (e.g., Thomeer et al., 2013 ). Similarly, health behaviors such as alcohol use and unhealthy eating can also “spread” within a couple ( Reczek et al., 2016a ); for instance, a study found that when one spouse became obese, the other spouse’s risk of obesity almost doubled over a 25-year period ( Cobb et al. 2015 ). Recent work considers how biomarkers spread within couples. For example, a recent study found that spouses have more similar gut microbiota (i.e., microbe population in the intestine) than siblings, but only if spouses report having a close relationship ( Dill-McFarland et al., 2019 ).

Health contagion between partners is due partly to assortative mating but also to shared resources, environments, and life events—including shared stressors—and mutual influence between spouses (e.g., one spouse’s mood spreading to the other spouse and vice versa; see Kiecolt-Glaser and Wilson 2017 for an overview). Future research can use longitudinal data, qualitative data, biomarker data, and mixed methods approaches to unpack the many mechanisms that help explain processes of contagion. The gut microbiotas are a key pathway through which a couples’ shared stressors, emotions, lifestyles, and routines may get “under the skin” in ways that jointly influence the couple’s health ( Kiecolt-Glaser, Wilson & Madison, 2018 ). There is also evidence of cortisol synchrony in long-term couples, such that partners’ levels of physiological arousal become linked over time—a phenomenon that has implications for both partners’ health ( Timmons, Margolin & Saxbe, 2015 ).

Advances in Data and Methods

Overall, research on families and health has generally followed the methodological innovations of relationship quality research, owing in large part to the greater availability of nationally representative longitudinal data, inclusion of biomarker data and explanatory mechanisms, and novel smaller-scale data collection efforts. We highlight three key advances: (a) biosocial processes linking family to health, (b) dyadic and family-level analysis, and (c) strategies for addressing selection and causal inference. We also identify areas for future research.

Biosocial Mechanisms Linking Family to Health

Research over the past decade has made important contributions to understanding the mechanisms through which family structures and dynamics are related to health throughout the life course. These innovations have progressed in large part due to increased commitments to interdisciplinary partnerships and collection of biomarker data in large-scale and longitudinal datasets. Advances in data and analysis of biosocial mechanisms has been especially influential in clarifying how physiological functioning is impacted by social conditions (e.g., family structures and dynamics) in ways that impact health. Even studies that do not explicitly discuss these biosocial pathways often build their arguments on an understanding that family experiences somehow “get under the skin” to shape both specific health outcomes and overall health. For example, family stress is theorized to increase a person’s allostatic load (i.e., cumulative “wear and tear” on the body across multiple health systems including immune, cardiovascular, and metabolic systems), thus contributing to symptoms across multiple health domains ( Miller, Chen, & Parker, 2011 ; Repetti, Robles, & Reynolds, 2011 ). Our understanding has benefited from the inclusion of biomarkers within study designs, especially longitudinal designs with repeated measures of specific biomarkers. Yet few studies that consider biomarkers theorize about why family ties would affect some biomarkers but not others.

A theoretically driven selection of biomarkers and other specific health outcomes will provide new insights into the complex and intersecting behavioral, psychological, social, and biological mechanisms through which families matter for health from childhood through later life. Inclusion of multiple biomarkers and health outcomes allows for a more robust understanding of how family ties affect overall health and especially how these outcomes might be connected to one another or cluster together ( Kiecolt-Glaser & Wilson, 2017 ; Repetti, Robles, & Reynolds, 2011 ). Future research should seek to disentangle the complex interconnections among the multiple pathways that are most predictive of specific health outcomes and identify how these interconnections vary depending on social contexts and genetic vulnerabilities.

Dyadic and Family-Level Analysis

Carr and Springer (2010) called for more dyadic and family-level data to address the failure of individual-level data “to capture the complexities of family life, including the possibility that two romantic partners, siblings, or co-parents experience their relationship (and the health consequences thereof) in starkly different ways” (p. 755). Dyadic, family-level analysis has advanced significantly over the past decade and has been featured in more than fifty studies in JMF alone. Dyadic and family-level methods allow researchers to more effectively study linked lives over the life course. For example, studies of sexual behavior such as condom use and oral sex that rely on dyadic data (e.g., Cordero-Coma & Breen, 2012 ) allow us to consider the perspectives and experiences of both partners in relation to their sexual encounters. Quantitative dyadic studies typically use Actor-Partner Interdependence Models (APIM) and adopt special protocols when individuals within dyads are indistinguishable such as same-sex couples or same-sex siblings ( Kroeger and Powers 2019 ). But qualitative dyadic studies have also emerged (e.g., Reczek & Umberson, 2016 ), and blended methods have the potential to spur new insights into dyadic processes that influence health.

Dyadic data offer three significant innovations for family research. First, studies of discordance and concordance within a dyad promote a fuller understanding of the couple’s dynamics and the health consequences of the two members’ discordance or concordance. Second, dyadic data tell us how one partner influences the other by drawing on information that each member provides independently. Third, data can be collected from both members of the dyad at the same time to develop a holistic narrative about the dyad and their interactions ( Thomeer et al. 2018 ). This is a common approach in experimental studies, including Kiecolt-Glaser and Wilson’s (2017) research on couple interactions (e.g., marital conflict), which combined observational data with biomarker assessments of the physiological consequences of the interactions for both partners. Some family-level studies move beyond the dyad to include more family members (e.g., children, siblings, parents). Like dyadic data, family-level methods give researchers access to different family member perspectives, which enhances understanding of what may be going on within the family. Ethnographic studies can also provide rich examples of family-level data. For example, the Three-City Study ethnography project ( http://web.jhu.edu/threecitystudy/index.html )—which also collects survey and interview data—followed 256 low-income mothers and their children over a six-year period to understand the unfolding processes of childhood illness, family comorbidities, and domestic violence in families and communities ( Burton, Purvin, & Garrett-Peters, 2015 ). Over the next decade, family and health studies would benefit from more studies that include multiple family members and blend ethnographic inquiry with quantitative data (e.g., Bair-Merritt et al., 2015 ; Burton, Purvin & Garrett-Peters, 2015 ) to assess the complex ways that families and health are related.

Causal Inference

Decades of research make it clear that family ties and health are closely linked, but questions remain about the extent to which these linkages reflect selection versus causation. Selection bias is likely an important driver in many of the observed differences in health among people with different family structures and family dynamics. For example, prior research finds a strong association between parental divorce and children’s poor health. It is difficult to claim that this link is causal, however, because many of the same factors that predispose people to divorce (e.g., poverty, mental disorders) also negatively impact children’s health ( Amato & Anthony, 2014 ). Recent methodological innovations have allowed for better disentanglement of the processes that link family ties and dynamics to health and specifically enable researchers to address the role of selection. For example, researchers increasingly use matching techniques, which reduce imbalance, model dependence, and the influence of confounding variables and provide insight into long-assumed causal family-health linkages. Tumin and Zheng (2018) used a composite of demographic, economic, and health characteristics to generate propensity scores for estimating the likelihood of marriage and found that once these propensities for marriage were taken into account, married adults were only modestly healthier than unmarried adults both physically and mentally. Other techniques to address causal inference, such as fixed-effect models, placebo regressions, and inverse‐probability‐weighted estimation of marginal structural models, are also gaining popularity in family and health studies ( Gangl, 2010 ). Each of these techniques has key limitations, however, including limitations related to unobserved heterogeneity despite attempts to eliminate this issue.

Going forward, two approaches are particularly likely to spur innovation and new insights into causal processes. First, quantitative behavior-genetic designs may allow researchers to better understand causal paths and the role of selection by ruling out possible confounding genetic factors ( Oppenheimer, Tenenbaum, & Krynski, 2013 ). For example, the quality of the parent-child relationship is associated with child-adjustment outcomes, but it may be that these links reflect gene-environment interplay effects ( Oppenheimer, Tenenbaum, & Krynski, 2013 ). Genetically informed studies over the past decade have interrogated whether the well-documented associations between marital status or marital quality and health may be artifacts of genetic and/or shared environmental selection; many of these studies have used population-level twin samples (e.g., Dinescu, et al., 2016 ). Studies with a behavior-genetics design can also provide insight into why some people’s health is more sensitive than others’ to family dynamics. Second, natural experiments in which people are exposed to either the experimental or the control condition by an external force (e.g., natural disaster, public policies) are a useful way to test causal inferences about family and health ( Craig, et al., 2017 ). For example, Everett and colleagues (2016) compared depressive symptoms before and after the passage of an Illinois law recognizing same-sex civil unions. They found that this supportive social policy benefited the health of sexual minority women, especially sexual minority women of color. Regardless of the specific approach, any research attempting to make causal claims about family ties and health must recognize methodological limitations and carefully interpret findings within the context of rich theoretical frameworks and critical descriptive research.

Research on families and health is thriving. It is moving in exciting, new directions and offers great potential to inform efforts to improve population health and reduce health disparities, especially those connected to the family. Many of the major research advances over the past decade were made possible by innovative and novel sources of data and methods, particularly high-quality longitudinal data, dyadic and multiple-family-member reporting, inclusion of underrepresented populations (e.g., sexual and gender diverse populations, children in nontraditional families), and the increasing sophistication of biomarker measures to help explain the impact of family ties on health from childhood through adulthood. Significant advances include: (a) growing evidence that family structures and dynamics in childhood have lasting effects not only into adolescence and early adulthood but throughout the life course, even affecting later life risk for chronic diseases and mortality; (b) biosocial approaches that take into account multiple levels of analysis to show how family experiences activate psychological, physiological, behavioral, and social pathways that intersect and cascade to influence health from childhood through adulthood; (c) attention to reciprocity and contagion to show how family members influence each other’s health and well-being over time; and (d) increased recognition and understanding of sociodemographic variability and the role of selection bias in the linkages between family ties and health.

Future research on families and health should extend these accomplishments by more fully addressing the complexity of family structures and dynamics over the entire life course and expanding knowledge about the factors and mechanisms that protect and promote the health of multiple family members. The lifelong health consequences of childhood family environments point to the need to bridge the literature on family ties and child health with that on family ties and adult health—now two largely separate literatures. This will require long-term investment in longitudinal data collections that follow individuals from childhood into later life and inclusion of wide-ranging explanatory mechanisms and health outcomes. Typically, researchers analyze very different outcomes when they study health at different ages. For example, studies of children and adolescents rely heavily on measures of externalizing behaviors, mental health, asthma, and obesity, but studies of older adults primarily consider mortality, disability, and cognitive decline. Longitudinal studies—together with a strong theoretical foundation and richly textured biosocial measures that can be assessed across the lifespan—can further clarify how family and health are connected and how explanatory biosocial mechanisms unfold over time (e.g., family stress in childhood might contribute to asthma which leads to midlife inflammation and later-life chronic conditions). Similar consideration should be given to measures of family dynamics across the life course; for example, a life course approach to family and health would benefit by comparing types and degree of support and conflict between adolescent children and their parents to support and conflict those same children have with their parents in midlife. Across these areas, research should attend to diversity in family and health experiences associated with race, ethnicity, gender and sexuality, and socioeconomic status, as well as the health effects of the absence of family ties and socially isolated periods over the lifespan.

Recent advances in research on family instability in childhood ( Cavanagh & Fomby, 2019 ) and marital biographies in adulthood ( McFarland, Hayward, & Brown, 2013 ) take into account life course relationship experiences that accumulate over time to predict health. These advances suggest the usefulness of developing a family biography approach to promote and synthesize future research advances. A family biography would take into account family experiences throughout childhood (e.g., timing and sequencing of major transitions and periods of instability); document subsequent family structures and transitions as individuals grow older (e.g., intimate partnerships, parenthood, unpartnered periods); consider how childhood family experiences are linked to subsequent family ties; assess how the entire family biography coalesces to protect or undermine health (including both specific health outcomes/causes of death and overall health and mortality risk), and address how these processes vary across diverse populations. A family biography approach could serve as an organizational tool for future research on families and health and would be useful across theoretical perspectives and methods. Indeed, richer theoretical and methodological breadth at any point in the family biographical timeline would enrich our understanding of when, how, and for whom family ties shape health trajectories and turning points over the lifespan. A life course approach that addresses childhood through adulthood also provides a framework for clarifying the transmission of family dynamics and health across generations.

Research over the next decade should be designed with attention to policy and practice. Growing attention to the lifelong consequences of childhood family experiences highlights the potential lifelong reach of early-life interventions and policies that support families and children. Yet family ties and transitions throughout adulthood also offer opportunities to promote health and well-being across diverse populations. To successfully support the health of individual family members, intervention strategies and policies must be based on sound evidence. For example, Gershoff and colleagues (2018) rally substantial empirical evidence pointing to the need to better educate parents about the adverse short- and long-term effects of spanking on the health and well-being of children and to implement social policies and laws that prohibit physical punishment of children. Such policies offer the opportunity to reduce stress and promote childhood health. Research specifically designed to assess the efficacy of policies and interventions is also needed. For example, studies conducted over the past decade establish the potential population health benefits of marriage equality for same-sex couples ( Denney, et al., 2013 ; Liu, et al., 2013 ). Yet LeBlanc and colleagues (2018) show that legal changes do not fully address the negative mental health effects of institutionalized discrimination against same-sex couples. These studies underscore the need for nuanced and methodologically sophisticated research that will generate the evidence needed to design effective policies and interventions and to evaluate their effectiveness and consequences.

ACKNOWLEDGEMENTS:

This work was supported in part by grant P2CHD042849, awarded to the Population Research Center at The University of Texas at Austin by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and grant R01 AG054624 (PI, Debra Umberson) awarded by the National Institute on Aging.

Contributor Information

Debra Umberson, Population Research Center, University of Texas at Austin, 305 E 23 rd Street, Austin TX.

Mieke Beth Thomeer, Department of Sociology, University of Alabama at Birmingham.

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Articles on Families

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Family, culture, and communication.

• V. Santiago Arias V. Santiago Arias College of Media and Communication, Texas Tech University
•  and  Narissra Maria Punyanunt-Carter Narissra Maria Punyanunt-Carter College of Media and Communication, Texas Tech University
• https://doi.org/10.1093/acrefore/9780190228613.013.504
• Published online: 22 August 2017

Through the years, the concept of family has been studied by family therapists, psychology scholars, and sociologists with a diverse theoretical framework, such as family communication patterns (FCP) theory, dyadic power theory, conflict, and family systems theory. Among these theories, there are two main commonalities throughout its findings: the interparental relationship is the core interaction in the familial system because the quality of their communication or coparenting significantly affects the enactment of the caregiver role while managing conflicts, which are not the exception in the familial setting. Coparenting is understood in its broader sense to avoid an extensive discussion of all type of families in our society. Second, while including the main goal of parenting, which is the socialization of values, this process intrinsically suggests cultural assimilation as the main cultural approach rather than intergroup theory, because intercultural marriages need to decide which values are considered the best to be socialized. In order to do so, examples from the Thai culture and Hispanic and Latino cultures served to show cultural assimilation as an important mediator of coparenting communication patterns, which subsequently affect other subsystems that influence individuals’ identity and self-esteem development in the long run. Finally, future directions suggest that the need for incorporating a nonhegemonic one-way definition of cultural assimilation allows immigration status to be brought into the discussion of family communication issues in the context of one of the most diverse countries in the world.

• parental communication
• dyadic power
• family communication systems
• cultural assimilation

Introduction

Family is the fundamental structure of every society because, among other functions, this social institution provides individuals, from birth until adulthood, membership and sense of belonging, economic support, nurturance, education, and socialization (Canary & Canary, 2013 ). As a consequence, the strut of its social role consists of operating as a system in a manner that would benefit all members of a family while achieving what is considered best, where decisions tend to be coherent, at least according to the norms and roles assumed by family members within the system (Galvin, Bylund, & Brommel, 2004 ). Notwithstanding, the concept of family can be interpreted differently by individual perceptions to an array of cultural backgrounds, and cultures vary in their values, behaviors, and ideas.

The difficulty of conceptualizing this social institution suggests that family is a culture-bound phenomenon (Bales & Parsons, 2014 ). In essence, culture represents how people view themselves as part of a unique social collective and the ensuing communication interactions (Olaniran & Roach, 1994 ); subsequently, culture provides norms for behavior having a tremendous impact on those family members’ roles and power dynamics mirrored in its communication interactions (Johnson, Radesky, & Zuckerman, 2013 ). Thus, culture serves as one of the main macroframeworks for individuals to interpret and enact those prescriptions, such as inheritance; descent rules (e.g., bilateral, as in the United States, or patrilineal); marriage customs, such as ideal monogamy and divorce; and beliefs about sexuality, gender, and patterns of household formation, such as structure of authority and power (Weisner, 2014 ). For these reasons, “every family is both a unique microcosm and a product of a larger cultural context” (Johnson et al., 2013 , p. 632), and the analysis of family communication must include culture in order to elucidate effective communication strategies to solve familial conflicts.

In addition, to analyze familial communication patterns, it is important to address the most influential interaction with regard to power dynamics that determine the overall quality of family functioning. In this sense, within the range of family theories, parenting function is the core relationship in terms of power dynamics. Parenting refers to all efforts and decisions made by parents individually to guide their children’s behavior. This is a pivotal function, but the quality of communication among people who perform parenting is fundamental because their internal communication patterns will either support or undermine each caregiver’s parenting attempts, individually having a substantial influence on all members’ psychological and physical well-being (Schrodt & Shimkowski, 2013 ). Subsequently, parenting goes along with communication because to execute all parenting efforts, there must be a mutual agreement among at least two individuals to conjointly take care of the child’s fostering (Van Egeren & Hawkins, 2004 ). Consequently, coparenting serves as a crucial predictor of the overall family atmosphere and interactions, and it deserves special attention while analyzing family communication issues.

Through the years, family has been studied by family therapists, psychology scholars, and sociologists, but interaction behaviors define the interpersonal relationship, roles, and power within the family as a system (Rogers, 2006 ). Consequently, family scholarship relies on a wide range of theories developed within the communication field and in areas of the social sciences (Galvin, Braithwaite, & Bylund, 2015 ) because analysis of communication patterns in the familial context offers more ecological validity that individuals’ self-report measures. As many types of interactions may happen within a family, there are many relevant venues (i.e., theories) for scholarly analysis on this subject, which will be discussed later in this article in the “ Family: Theoretical Perspectives ” section. To avoid the risk of cultural relativeness while defining family, this article characterizes family as “a long-term group of two or more people related through biological, legal, or equivalent ties and who enact those ties through ongoing interactions providing instrumental and/or emotional support” (Canary & Canary, 2013 , p. 5).

Therefore, the purpose of this article is to provide an overview of the most relevant theories in family communication to identify frustrations and limitations with internal communication. Second, as a case in point, the United States welcomes more than 50 million noncitizens as temporary visitors and admits approximately 1 million immigrants to live as lawful residents yearly (Fullerton, 2014 ), this demographic pattern means that nearly one-third of the population (102 million) comes from different cultural backgrounds, and therefore, the present review will incorporate culture as an important mediator for coparenting, so that future research can be performed to find specific techniques and training practices that are more suitable for cross-cultural contexts.

Family: Theoretical Perspectives

Even though the concept of family can be interpreted individually and differently in different cultures, there are also some commonalities, along with communication processes, specific roles within families, and acceptable habits of interactions with specific family members disregarding cultural differences. This section will provide a brief overview of the conceptualization of family through the family communication patterns (FCP) theory, dyadic power theory, conflict, and family systems theory, with a special focus on the interparental relationship.

Family Communication Patterns Theory

One of the most relevant approaches to address the myriad of communication issues within families is the family communication patterns (FCP) theory. Originally developed by McLeod and Chaffee ( 1973 ), this theory aims to understand families’ tendencies to create stable and predictable communication patterns in terms of both relational cognition and interpersonal behavior (Braithwaite & Baxter, 2005 ). Specifically, this theory focuses on the unique and amalgamated associations derived from interparental communication and its impact on parenting quality to determine FCPs and the remaining interactions (Young & Schrodt, 2016 ).

To illustrate FCP’s focus on parental communication, Schrodt, Witt, and Shimkowski ( 2014 ) conducted a meta-analysis of 74 studies (N = 14,255) to examine the associations between the demand/withdraw family communication patterns of interaction, and the subsequent individual, relational, and communicative outcomes. The cumulative evidence suggests that wife demand/husband withdraw and husband demand/wife withdraw show similar moderate correlations with communicative and psychological well-being outcomes, and even higher when both patterns are taken together (at the relational level). This is important because one of the main tenets of FCP is that familial relationships are drawn on the pursuit of coorientation among members. Coorientation refers to the cognitive process of two or more individuals focusing on and assessing the same object in the same material and social context, which leads to a number of cognitions as the number of people involved, which results in different levels of agreement, accuracy, and congruence (for a review, see Fitzpatrick & Koerner, 2005 ); for example, in dyads that are aware of their shared focus, two different cognitions of the same issue will result.

Hereafter, the way in which these cognitions are socialized through power dynamics determined socially and culturally by roles constitutes specific interdependent communication patterns among family members. For example, Koerner and Fitzpatrick ( 2006 ) provide a taxonomy of family types on the basis of coorientation and its impact on communication pattern in terms of the degree of conformity in those conversational tendencies. To wit, consensual families mostly agree for the sake of the hierarchy within a given family and to explore new points of view; pluralistic families allow members to participate equally in conversations and there is no pressure to control or make children’s decisions; protective families maintain the hierarchy by making decisions for the sake of achieving common family goals; and laissez-faire families, which are low in conversation and conformity orientation, allow family members to not get deeply involved in the family.

The analysis of family communication patterns is quintessential for family communication scholarly work because it influences forming an individual’s self concept in the long run. As a case in point, Young and Schrodt ( 2016 ) surveyed 181 young adults from intact families, where conditional and interaction effects between communication patterns and conformity orientation were observed as the main predictors of future romantic partners. Moreover, this study concluded that FCPs and interparental confirmation are substantial indicators of self-to-partner confirmation, after controlling for reciprocity of confirmation within the romantic relationship. As a consequence, FCP influences children’s and young adults’ perceptions of romantic behavior (e.g., Fowler, Pearson, & Beck, 2010 ); the quality of communication behavior, such as the degree of acceptation of verbal aggression in romantic dyads (e.g., Aloia & Solomon, 2013 ); gender roles; and conflict styles (e.g., Taylor & Segrin, 2010 ), and parental modeling (e.g., Young & Schrodt, 2016 ).

This suggests three important observations. First, family is a very complex interpersonal context, in which communication processes, specific roles within families, and acceptable habits of interactions with specific family members interact as subsystems (see Galvin et al., 2004 ; Schrodt & Shimkowski, 2013 ). Second, among those subsystems, the core interaction is the individuals who hold parenting roles (i.e., intact and post divorced families); the couple (disregarding particular sexual orientations), and, parenting roles have a reciprocal relationship over time (Le, McDaniel, Leavitt, & Feinberg, 2016 ). Communication between parenting partners is crucial for the development of their entire family; for example, Schrodt and Shimkowski ( 2013 ) conducted a survey with 493 young adult children from intact (N = 364) and divorced families (N = 129) about perceptions of interparental conflict that involves triangulation (the impression of being in the “middle” and feeling forced to display loyalty to one of the parents). Results suggest that supportive coparental communication positively predicts relational satisfaction with mothers and fathers, as well as mental health; on the other hand, antagonist and hostile coparental communication predicted negative marital satisfaction.

Consequently, “partners’ communication with one another will have a positive effect on their overall view of their marriage, . . . and directly result[ing in] their views of marital satisfaction” (Knapp & Daly, 2002 , p. 643). Le et al. ( 2016 ) conducted a longitudinal study to evaluate the reciprocal relationship between marital interaction and coparenting from the perspective of both parents in terms of support or undermining across the transition to parenthood from a dyadic perspective; 164 cohabiting heterosexual couples expecting their first child were analyzed from pregnancy until 36 months after birth. Both parents’ interdependence was examined in terms of three variables: gender difference analysis, stability over time in marriage and coparenting, and reciprocal associations between relationship quality and coparenting support or undermining. The findings suggest a long-term reciprocal association between relationship quality and coparenting support or undermining in heterosexual families; the quality of marriage relationship during prenatal stage is highly influential in coparenting after birth for both men and women; but, coparenting is connected to romantic relationship quality only for women.

Moreover, the positive association between coparenting and the parents’ relationship relates to the spillover hypothesis, which posits that the positive or negative factors in the parental subsystem are significantly associated with higher or lower marital satisfaction in the spousal subsystem, respectively. Ergo, overall parenting performance is substantially affected by the quality of marital communication patterns.

Dyadic Power

In addition, after analyzing the impact of marital interaction quality in families on marital satisfaction and future parental modeling, it is worth noting that marital satisfaction and coparenting are importantly mediated by power dynamics within the couple (Halstead, De Santis, & Williams, 2016 ), and even mediates marital commitment (e.g., Lennon, Stewart, & Ledermann, 2013 ). If the quality of interpersonal relationship between those individuals who hold parenting roles determines coparenting quality as well, then the reason for this association lies on the fact that virtually all intimate relationships are substantially characterized by power dynamics; when partners perceive more rewards than costs in the relationship, they will be more satisfied and significantly more committed to the relationship (Lennon et al., 2013 ). As a result, the inclusion of power dynamics in the analysis of family issues becomes quintessential.

For the theory of dyadic power, power in its basic sense includes dominance, control, and influence over others, as well as a means to meet survival needs. When power is integrated into dyadic intimate relationships, it generates asymmetries in terms of interdependence between partners due to the quality of alternatives provided by individual characteristics such as socioeconomic status and cultural characteristics such as gender roles. This virtually gives more power to men than women. Power refers to “the feeling derived from the ability to dominate, or control, the behavior, affect, and cognitions of another person[;] in consequence, this concept within the interparental relationship is enacted when one partner who controls resources and limiting the behavioral options of the other partner” (Lennon et al., 2013 , p. 97). Ergo, this theory examines power in terms of interdependence between members of the relationship: the partner who is more dependent on the other has less power in the relationship, which, of course, directly impact parenting decisions.

As a case in point, Worley and Samp ( 2016 ) examined the balance of decision-making power in the relationship, complaint avoidance, and complaint-related appraisals in 175 heterosexual couples. Findings suggest that decision-making power has a curvilinear association, in which individuals engaged in the least complaint avoidance when they were relatively equal to their partners in terms of power. In other words, perceptions of one another’s power potentially encourage communication efficacy in the interparental couple.

The analysis of power in intimate relationships, and, to be specific, between parents is crucial because it not only relates to marital satisfaction and commitment, but it also it affects parents’ dyadic coping for children. In fact, Zemp, Bodenmann, Backes, Sutter-Stickel, and Revenson ( 2016 ) investigated parents’ dyadic coping as a predictor of children’s internalizing symptoms, externalizing symptoms, and prosocial behavior in three independent studies. When there is a positive relationship among all three factors, the results indicated that the strongest correlation was the first one. Again, the quality of the marital and parental relationships has the strongest influence on children’s coping skills and future well-being.

From the overview of the two previous theories on family, it is worth addressing two important aspects. First, parenting requires an intensive great deal of hands-on physical care, attention to safety (Mooney-Doyle, Deatrick, & Horowitz, 2014 ), and interpretation of cues, and this is why parenting, from conception to when children enter adulthood, is a tremendous social, cultural, and legally prescribed role directed toward caregiving and endlessly attending to individuals’ social, physical, psychological, emotional, and cognitive development (Johnson et al., 2013 ). And while parents are making decisions about what they consider is best for all family members, power dynamics play a crucial role in marital satisfaction, commitment, parental modeling, and overall interparental communication efficacy in the case of postdivorce families. Therefore, the likelihood of conflict is latent within familial interactions while making decisions; indeed, situations in which family members agree on norms as a consensus is rare (Ritchie & Fitzpatrick, 1990 ).

In addition to the interparental and marital power dynamics that delineates family communication patterns, the familial interaction is distinctive from other types of social relationships in the unequaled role of emotions and communication of affection while family members interact and make decisions for the sake of all members. For example, Ritchie and Fitzpatrick ( 1990 ) provided evidence that fathers tended to perceive that all other family members agree with his decisions or ideas. Even when mothers confronted and disagreed with the fathers about the fathers’ decisions or ideas, the men were more likely to believe that their children agreed with him. When the children were interviewed without their parents, however, the majority of children agreed with the mothers rather than the fathers (Ritchie & Fitzpatrick, 1990 ). Subsequently, conflict is highly present in families; however, in general, the presence of conflict is not problematic per se. Rather, it is the ability to manage and recover from it and that could be problematic (Floyd, 2014 ).

One of the reasons for the role of emotions in interpersonal conflicts is explained by the Emotion-in-Relationships Model (ERM). This model states that feelings of bliss, satisfaction, and relaxation often go unnoticed due to the nature of the emotions, whereas “hot” emotions, such as anger and contempt, come to the forefront when directed at a member of an interpersonal relationship (Fletcher & Clark, 2002 ). This type of psychophysical response usually happens perhaps due to the different biophysical reactive response of the body compared to its reaction to positive ones (Floyd, 2014 ). There are two dimensions that define conflict. Conflict leads to the elicitation of emotions, but sometimes the opposite occurs: emotions lead to conflict. The misunderstanding or misinterpretation of emotions among members of a family can be a source of conflict, as well as a number of other issues, including personality differences, past history, substance abuse, mental or physical health problems, monetary issues, children, intimate partner violence, domestic rape, or maybe just general frustration due to recent events (Sabourin, Infante, & Rudd, 1990 ). In order to have a common understanding of this concept for the familial context in particular, conflict refers to as “any incompatibility that can be expressed by people related through biological, legal, or equivalent ties” (Canary & Canary, 2013 , p. 6). Thus, the concept of conflict goes hand in hand with coparenting.

There is a myriad of everyday family activities in which parents need to decide the best way to do them: sometimes they are minor, such as eating, watching TV, or sleeping schedules; others are more complicated, such as schooling. Certainly, while socializing and making these decisions, parents may agree or not, and these everyday situations may lead to conflict. Whether or not parents live together, it has been shown that “the extent to which children experience their parents as partners or opponents in parenting is related to children’s adjustment and well-being” (Gable & Sharp, 2016 , p. 1), because the ontology of parenting is materialized through socialization of values about every aspect and duty among all family members, especially children, to perpetuate a given society.

As the findings provided in this article show, the study of family communication issues is pivotal because the way in which those issues are solved within families will be copied by children as their values. Values are abstract ideas that delineate behavior toward the evaluation of people and events and vary in terms of importance across individuals, but also among cultures. In other words, their future parenting (i.e., parenting modeling) of children will replicate those same strategies for conflict solving for good or bad, depending on whether parents were supportive between each other. Thus, socialization defines the size and scope of coparenting.

The familial socialization of values encompasses the distinction between parents’ personal execution of those social appraisals and the values that parents want their children to adopt, and both are different things; nonetheless, familial socialization does not take place in only one direction, from parents to children. Benish-Weisman, Levy, and Knafo ( 2013 ) investigated the differentiation process—or, in other words, the distinction between parents’ own personal values and their socialization values and the contribution of children’s values to their parents’ socialization values. In this study, in which 603 Israeli adolescents and their parents participated, the findings suggest that parents differentiate between their personal values and their socialization values, and adolescents’ values have a specific contribution to their parents’ socialization values. As a result, socialization is not a unidirectional process affected by parents alone, it is an outcome of the reciprocal interaction between parents and their adolescent children, and the given importance of a given value is mediated by parents and their culture individually (Johnson et al., 2013 ). However, taking power dynamics into account does not mean that adolescents share the same level of decision-making power in the family; thus, socialization take place in both directions, but mostly from parents to children. Finally, it is worth noticing that the socialization of values in coparenting falls under the cultural umbrella. The next section pays a special attention to the role of culture in family communication.

The Role of Culture in Parenting Socialization of Values

There are many individual perceived realities and behaviors in the familial setting that may lead to conflict among members, but all of them achieve a common interpretation through culture; indeed, “all family conflict processes by broad cultural factors” (Canary & Canary, 2013 , p. 46). Subsequently, the goal of this section is to provide an overview of the perceived realities and behaviors that exist in family relationships with different cultural backgrounds. How should one approach the array of cultural values influencing parental communication patterns?

An interesting way of immersing on the role of culture in family communication patterns and its further socialization of values is explored by Schwartz ( 1992 ). The author developed a value system composed of 10 values operationalized as motivational goals for modern society: (a) self-direction (independence of thought and action); (b) stimulation (excitement, challenge, and novelty); (c) hedonism (pleasure or sensuous gratification); (d) achievement (personal success according to social standards); (e) power (social status, dominance over people and resources); (f) conformity (restraint of actions that may harm others or violate social expectations); (g) tradition (respect and commitment to cultural or religious customs and ideas); (h) benevolence (preserving and enhancing the welfare of people to whom one is close); (i) universalism (understanding, tolerance, and concern for the welfare of all people and nature); and (j) security (safety and stability of society, relationships, and self).

Later, Schwartz and Rubel ( 2005 ) applied this value structure, finding it to be commonly shared among over 65 countries. Nevertheless, these values are enacted in different ways by societies and genders about the extent to which men attribute more relevance to values of power, stimulation, hedonism, achievement, and self-direction, and the opposite was found for benevolence and universalism and less consistently for security. Also, it was found that all sex differences were culturally moderated, suggesting that cultural background needs to be considered in the analysis of coparental communication when socializing those values.

Even though Schwartz’s work was more focused on individuals and societies, it is a powerful model for the analysis of the role of culture on family communication and parenting scholarships. Indeed, Schwartz et al. ( 2013 ) conducted a longitudinal study with a sample of 266 Hispanic adolescents (14 years old) and their parents that looked at measures of acculturation, family functioning, and adolescent conduct problems, substance use, and sexual behavior at five time points. Results suggest that higher levels of acculturation in adolescents were linked to poorer family functioning; however, overall assimilation negatively predicted adolescent cigarette smoking, sexual activity, and unprotected sex. The authors emphasize the role of culture, and acculturation patterns in particular, in understanding the mediating role of family functioning and culture.

Ergo, it is crucial to address the ways in which culture affects family functioning. On top of this idea, Johnson et al. ( 2013 ) observed that Western cultures such as in the United States and European countries are oriented toward autonomy, favoring individual achievement, self-reliance, and self-assertiveness. Thus, coparenting in more autonomous countries will socialize to children the idea that achievement in life is an outcome of independence, resulting in coparenting communication behaviors that favor verbal praise and feedback over physical contact. As opposed to autonomy-oriented cultures, other societies, such as Asian, African, and Latin American countries, emphasize interdependence over autonomy; thus, parenting in these cultures promotes collective achievement, sharing, and collaboration as the core values.

These cultural orientations can be observed in parents’ definitions of school readiness and educational success; for Western parents, examples include skills such as counting, recognizing letters, or independently completing tasks such as coloring pictures, whereas for more interdependent cultures, the development of obedience, respect for authority, and appropriate social skills are the skills that parents are expecting their children to develop to evaluate school readiness. As a matter of fact, Callaghan et al. ( 2011 ) conducted a series of eight studies to evaluate the impact of culture on the social-cognitive skills of one- to three-year-old children in three diverse cultural settings such as Canada, Peru, and India. The results showed that children’s acquisition of specific cognitive skills is moderated by specific learning experiences in a specific context: while Canadian children were understanding the performance of both pretense and pictorial symbols skillfully between 2.5 and 3.0 years of age, on average, Peruvian and Indian children mastered those skills more than a year later. Notwithstanding, this finding does not suggest any kind of cultural superiority; language barriers and limitations derived from translation itself may influence meanings, affecting the results (Sotomayor-Peterson, De Baca, Figueredo, & Smith-Castro, 2013 ). Therefore, in line with the findings of Schutz ( 1970 ), Geertz ( 1973 ), Grusec ( 2002 ), Sotomayor-Peterson et al. ( 2013 ), and Johnson et al. ( 2013 ), cultural values provide important leverage for understanding family functioning in terms of parental decision-making and conflict, which also has a substantial impact on children’s cognitive development.

Subsequently, cultural sensitivity to the analysis of the familial system in this country needs to be specially included because cultural differences are part of the array of familial conflicts that may arise, and children experience real consequences from the quality of these interactions. Therefore, parenting, which is already arduous in itself, and overall family functioning significantly become troublesome when parents with different cultural backgrounds aim to socialize values and perform parenting tasks. The following section provides an account of these cross-cultural families.

Intercultural Families: Adding Cultural Differences to Interparental Communication

For a country such as the United States, with 102 million people from many different cultural backgrounds, the presence of cross-cultural families is on the rise, as is the likelihood of intermarriage between immigrants and natives. With this cultural diversity, the two most prominent groups are Hispanics and Asians, particular cases of which will be discussed next. Besides the fact that parenting itself is a very complex and difficult task, certainly the biggest conflict consists of making decisions about the best way to raise children in terms of their values with regard to which ethnic identity better enacts the values that parents believe their children should embrace. As a result, interracial couples might confront many conflicts and challenges due to cultural differences affecting marital satisfaction and coparenting.

Assimilation , the degree to which a person from a different cultural background has adapted to the culture of the hostage society, is an important phenomenon in intermarriage. Assimilationists observe that children from families in which one of the parents is from the majority group and the other one from the minority do not automatically follow the parent from the majority group (Cohen, 1988 ). Indeed, they follow their mothers more, whichever group she belongs to, because of mothers are more prevalent among people with higher socioeconomic status (Gordon, 1964 ; Portes, 1984 ; Schwartz et al., 2013 ).

In an interracial marriage, the structural and interpersonal barriers inhibiting the interaction between two parents will be reduced significantly if parents develop a noncompeting way to communicate and solve conflicts, which means that both of them might give up part of their culture or ethnic identity to reach consensus. Otherwise, the ethnic identity of children who come from interracial marriages will become more and more obscure (Saenz, Hwang, Aguirre, & Anderson, 1995 ). Surely, parents’ noncompeting cultural communication patterns are fundamental for children’s development of ethnic identity. Biracial children develop feelings of being outsiders, and then parenting becomes crucial to developing their strong self-esteem (Ward, 2006 ). Indeed, Gordon ( 1964 ) found that children from cross-racial or cross-ethnic marriages are at risk of developing psychological problems. In another example, Jognson and Nagoshi ( 1986 ) studied children who come from mixed marriages in Hawaii and found that the problems of cultural identification, conflicting demands in the family, and of being marginal in either culture still exist (Mann & Waldron, 1977 ). It is hard for those mixed-racial children to completely develop the ethnic identity of either the majority group or the minority group.

The question of how children could maintain their minority ethnic identity is essential to the development of ethnic identity as a whole. For children from interracial marriage, the challenge to maintain their minority ethnic identity will be greater than for the majority ethnic identity (Waters, 1990 ; Schwartz et al., 2013 ) because the minority-group spouse is more likely to have greater ethnic consciousness than the majority-group spouse (Ellman, 1987 ). Usually, the majority group is more influential than the minority group on a child’s ethnic identity, but if the minority parent’s ethnicity does not significantly decline, the child’s ethnic identity could still reflect some characteristics of the minority parent. If parents want their children to maintain the minority group’s identity, letting the children learn the language of the minority group might be a good way to achieve this. By learning the language, children form a better understanding of that culture and perhaps are more likely to accept the ethnic identity that the language represents (Xin & Sandel, 2015 ).

In addition to language socialization as a way to contribute to children’s identity in biracial families, Jane and Bochner ( 2009 ) indicated that family rituals and stories could be important in performing and transforming identity. Families create and re-create their identities through various kinds of narrative, in which family stories and rituals are significant. Festivals and rituals are different from culture to culture, and each culture has its own. Therefore, exposing children to the language, rituals, and festivals of another culture also could be helpful to form their ethnic identity, in order to counter problems of self-esteem derived from the feeling of being an outsider.

To conclude this section, the parenting dilemma in intercultural marriages consists of deciding which culture they want their children to be exposed to and what kind of heritage they want to pass to children. The following section will provide two examples of intercultural marriages in the context of American society without implying that there are no other insightful cultures that deserve analysis, but the focus on Asian-American and Hispanics families reflects the available literature (Canary & Canary, 2013 ) and its demographic representativeness in this particular context. In addition, in order to acknowledge that minorities within this larger cultural background deserve more attention due to overemphasis on larger cultures in scholarship, such as Chinese or Japanese cultures, the Thai family will provide insights into understanding the role of culture in parenting and its impact on the remaining familial interaction, putting all theories already discussed in context. Moreover, the Hispanic family will also be taken in account because of its internal pan-ethnicity variety.

An Example of Intercultural Parenting: The Thai Family

The Thai family, also known as Krob Krua, may consist of parents, children, paternal and maternal grandparents, aunts, uncles, grandchildren, in-laws, and any others who share the same home. Thai marriages usually are traditional, in which the male is the authority figure and breadwinner and the wife is in charge of domestic items and the homemaker. It has been noted that Thai mothers tend to be the major caregivers and caretakers in the family rather than fathers (Tulananda, Young, & Roopnarine, 1994 ). On the other hand, it has been shown that Thai mothers also tend to spoil their children with such things as food and comfort; Tulananda et al. ( 1994 ) studied the differences between American and Thai fathers’ involvement with their preschool children and found that American fathers reported being significantly more involved with their children than Thai fathers. Specifically, the fathers differed in the amount of socialization and childcare; Thai fathers reported that they obtained more external support from other family members than American fathers; also, Thai fathers were more likely to obtain support for assisting with daughters than sons.

Furthermore, with regard to the family context, Tulananda and Roopnarine ( 2001 ) noted that over the years, some attention has been focused on the cultural differences among parent-child behaviors and interactions; hereafter, the authors believed that it is important to look at cultural parent-child interactions because that can help others understand children’s capacity to socialize and deal with life’s challenges. As a matter of fact, the authors also noted that Thai families tend to raise their children in accordance with Buddhist beliefs. It is customary for young Thai married couples to live with either the wife’s parents (uxorilocal) or the husband’s parents (virilocal) before living on their own (Tulananda & Roopnarine, 2001 ). The process of developing ethnicity could be complicated. Many factors might influence the process, such as which parent is from the minority culture and the cultural community, as explained in the previous section of this article.

This suggests that there is a difference in the way that Thai and American fathers communicate with their daughters. As a case in point, Punyanunt-Carter ( 2016 ) examined the relationship maintenance behaviors within father-daughter relationships in Thailand and the United States. Participants included 134 American father-daughter dyads and 154 Thai father-daughter dyads. The findings suggest that when quality of communication was included in this relationship, both types of families benefit from this family communication pattern, resulting in better conflict management and advice relationship maintenance behaviors. However, differences were found: American fathers are more likely than American daughters to employ relationship maintenance behaviors; in addition, American fathers are more likely than Thai fathers to use relationship maintenance strategies.

As a consequence, knowing the process of ethnic identity development could provide parents with different ways to form children’s ethnic identity. More specifically, McCann, Ota, Giles, and Caraker ( 2003 ), and Canary and Canary ( 2013 ) noted that Southeast Asian cultures have been overlooked in communication studies research; these countries differ in their religious, political, and philosophical thoughts, with a variety of collectivistic views and religious ideals (e.g., Buddhism, Taoism, Islam), whereas the United States is mainly Christian and consists of individualistic values.

The Case of Hispanic/Latino Families in the United States

There is a need for including Hispanic/Latino families in the United States because of the demographic representativeness and trends of the ethnicity: in 2016 , Hispanics represent nearly 17% of the total U.S. population, becoming the largest minority group. There are more than 53 million Hispanics and Latinos in the United States; in addition, over 93% of young Hispanics and Latinos under the age of 18 hold U.S. citizenship, and more than 73,000 of these people turn 18 every month (Barreto & Segura, 2014 ). Furthermore, the current Hispanic and Latino population is spread evenly between foreign-born and U.S.-born individuals, but the foreign-born population is now growing faster than the number of Hispanic children born in the country (Arias & Hellmueller, 2016 ). This demographic trend is projected to reach one-third of the U.S. total population by 2060 ; therefore, with the growth of other minority populations in the country, the phenomenon of multiracial marriage and biracial children is increasing as well.

Therefore, family communication scholarship has an increasing necessity to include cultural particularities in the analysis of the familial system; in addition to the cultural aspects already explained in this article, this section addresses the influence of familism in Hispanic and Latino familial interactions, as well as how immigration status moderates the internal interactions, reflected in levels of acculturation, that affect these families negatively.

With the higher marriage and birth rates among Hispanics and Latinos living in the United States compared to non-Latino Whites and African American populations, the Hispanic familial system is perhaps the most stereotyped as being familistic (Glick & Van Hook, 2008 ). This family trait consists of the fact that Hispanics place a very high value on marriage and childbearing, on the basis of a profound commitment to give support to members of the extended family as well. This can be evinced in the prevalence of extended-kind shared households in Hispanic and Latino families, and Hispanic children are more likely to live in extended-family households than non-Latino Whites or blacks (Glick & Van Hook, 2008 ). Living in extended-family households, most likely with grandparents, may have positive influences on Hispanic and Latino children, such as greater attention and interaction with loving through consistent caregiving; grandparents may help by engaging with children in academic-oriented activities, which then affects positively cognitive educational outcomes.

However, familism is not the panacea for all familial issues for several reasons. First, living in an extended-family household requires living arrangements that consider adults’ needs more than children’s. Second, the configuration of Hispanic and Latino households is moderated by any immigration issues with all members of the extended family, and this may cause problems for children (Menjívar, 2000 ). The immigration status of each individual member may produce a constant state of flux, whereas circumstances change to adjust to economic opportunities, which in turn are limited by immigration laws, and it gets even worse when one of the parents isn’t even present in the children’s home, but rather live in their home country (Van Hook & Glick, 2006 ). Although Hispanic and Latino children are more likely to live with married parents and extended relatives, familism is highly affected by the immigration status of each member.

On the other hand, there has been research to address the paramount role of communication disregarding the mediating factor of cultural diversity. For example, Sotomayor-Peterson et al. ( 2013 ) performed a cross-cultural comparison of the association between coparenting or shared parental effort and family climate among families from Mexico, the United States, and Costa Rica. The overall findings suggest what was explained earlier in this article: more shared parenting predicts better marital interaction and family climate overall.

In addition, parenting quality has been found to have a positive relationship with children’s developmental outcomes. In fact, Sotomayor-Peterson, Figueredo, Christensen, and Taylor ( 2012 ) conducted a study with 61 low-income Mexican American couples, with at least one child between three and four years of age, recruited from a home-based Head Start program. The main goal of this study was to observe the extent that shared parenting incorporates cultural values and income predicts family climate. The findings suggest that the role of cultural values such as familism, in which family solidarity and avoidance of confrontation are paramount, delineate shared parenting by Mexican American couples.

Cultural adaptation also has a substantial impact on marital satisfaction and children’s cognitive stimulation. Indeed, Sotomayor-Peterson, Wilhelm, and Card ( 2011 ) investigated the relationship between marital relationship quality and subsequent cognitive stimulation practices toward their infants in terms of the actor and partner effects of White and Hispanic parents. The results indicate an interesting relationship between the level of acculturation and marital relationship quality and a positive cognitive stimulation of infants; specifically, marital happiness is associated with increased cognitive stimulation by White and high-acculturated Hispanic fathers. Nevertheless, a major limitation of Hispanic acculturation literature has been seen, reflecting a reliance on cross-sectional studies where acculturation was scholarly operationalized more as an individual difference variable than as a longitudinal adaptation over time (Schwartz et al., 2013 ).

Culture and Family Communication: the “so what?” Question

This article has presented an entangled overview of family communication patterns, dyadic power, family systems, and conflict theories to establish that coparenting quality plays a paramount role. The main commonality among those theories pays special attention to interparental interaction quality, regardless of the type of family (i.e., intact, postdivorce, same-sex, etc.) and cultural background. After reviewing these theories, it was observed that the interparental relationship is the core interaction in the familial context because it affects children from their earlier cognitive development to subsequent parental modeling in terms of gender roles. Thus, in keeping with Canary and Canary ( 2013 ), no matter what approach may be taken to the analysis of family communication issues, the hypothesis that a positive emotional climate within the family is fostered only when couples practice a sufficient level of shared parenting and quality of communication is supported.

Nevertheless, this argument does not suggest that the role of culture in the familial interactions should be undersold. While including the main goal of parenting, which is the socialization of values, in the second section of this article, the text also provides specific values of different countries that are enacted and socialized differently across cultural contexts to address the role of acculturation in the familial atmosphere, the quality of interactions, and individual outcomes. As a case in point, Johnson et al. ( 2013 ) provided an interesting way of seeing how cultures differ in their ways of enacting parenting, clarifying that the role of culture in parenting is not a superficial or relativistic element.

In addition, by acknowledging the perhaps excessive attention to larger Asian cultural backgrounds (such as Chinese or Japanese cultures) by other scholars (i.e., Canary & Canary, 2013 ), an insightful analysis of the Thai American family within the father-daughter relationship was provided to exemplify, through the work of Punyanunt-Carter ( 2016 ), how specific family communication patterns, such as maintenance relationship communication behaviors, affect the quality of familial relationships. Moreover, a second, special focus was put on Hispanic families because of the demographic trends of the United States, and it was found that familism constitutes a distinctive aspect of these families.

In other words, the third section of this article provided these two examples of intercultural families to observe specific ways that culture mediates the familial system. Because one of the main goals of the present article was to demonstrate the mediating role of culture as an important consideration for family communication issues in the United States, the assimilationist approach was taken into account; thus, the two intercultural family examples discussed here correspond to an assimilationist nature rather than using an intergroup approach.

This decision was made without intending to diminish the value of other cultures or ethnic groups in the country, but an extensive revision of all types of intercultural families is beyond the scope of this article. Second, the assimilationist approach forces one to consider cultures that are in the process of adapting to a new hosting culture, and the Thai and Hispanic families in the United States comply with this theoretical requisite. For example, Whites recognize African Americans as being as American as Whites (i.e., Dovidio, Gluszek, John, Ditlmann, & Lagunes, 2010 ), whereas they associate Hispanics and Latinos with illegal immigration in the United States (Stewart et al., 2011 ), which has been enhanced by the U.S. media repeatedly since 1994 (Valentino et al., 2013 ), and it is still happening (Dixon, 2015 ). In this scenario, “ask yourself what would happen to your own personality if you heard it said over and over again that you were lazy, a simple child of nature, expected to steal, and had inferior blood? . . . One’s reputation, whether false or true, cannot be hammered, hammered, hammered, into one’s head without doing something to one’s character” (Allport, 1979 , p. 142, cited in Arias & Hellmueller, 2016 ).

As a consequence, on this cultural canvas, it should not be surprising that Lichter, Carmalt, and Qian ( 2011 ) found that second-generation Hispanics are increasingly likely to marry foreign-born Hispanics and less likely to marry third-generation or later coethnics or Whites. In addition, this study suggests that third-generation Hispanics and later were more likely than in the past to marry non-Hispanic Whites; thus, the authors concluded that there has been a new retreat from intermarriage among the largest immigrant groups in the United States—Hispanics and Asians—in the last 20 years.

If we subscribe to the idea that cultural assimilation goes in only one direction—from the hegemonic culture to the minority culture—then the results of Lichter, Carmalt, and Qian ( 2011 ) should not be of scholarly concern; however, if we believe that cultural assimilation happens in both directions and intercultural families can benefit both the host and immigrant cultures (for a review, see Schwartz et al., 2013 ), then this is important to address in a country that just elected a president, Donald Trump, who featured statements racially lambasting and segregating minorities, denigrating women, and criticizing immigration as some of the main tenets of his campaign. Therefore, we hope that it is clear why special attention was given to the Thai and Hispanic families in this article, considering the impact of culture on the familial system, marital satisfaction, parental communication, and children’s well-being. Even though individuals with Hispanic ancentry were in the United States even before it became a nation, Hispanic and Latino families are still trying to convince Americans of their right to be accepted in American culture and society.

With regard to the “So what?” question, assimilation is important to consider while analyzing the role of culture in family communication patterns, power dynamics, conflict, or the functioning of the overall family system in the context of the United States. This is because this country is among the most popular in the world in terms of immigration requests, and its demographics show that one out of three citizens comes from an ethnic background other than the hegemonic White culture. In sum, cultural awareness has become pivotal in the analysis of family communication issues in the United States. Furthermore, the present overview of family, communication, and culture ends up supporting the idea of positive associations being derived from the pivotal role of marriage relationship quality, such that coparenting and communication practices vary substantially within intercultural marriages moderated by gender roles.

Culture is a pivotal moderator of these associations, but this analysis needs to be tethered to societal structural level, in which cultural differences, family members’ immigration status, media content, and level of acculturation must be included in family research. This is because in intercultural marriages, in addition to the tremendous parenting role, they have to deal with cultural assimilation and discrimination, and this becomes important if we care about children’s cognitive development and the overall well-being of those who are not considered White. As this article shows, the quality of familial interactions has direct consequences on children’s developmental outcomes (for a review, see Callaghan et al., 2011 ).

Therefore, the structure and functioning of family has an important impact on public health at both physiological and psychological levels (Gage, Everett, & Bullock, 2006 ). At the physiological level, the familial interaction instigates expression and reception of strong feelings affecting tremendously on individuals’ physical health because it activates neuroendocrine responses that aid stress regulation, acting as a stress buffer and accelerating physiological recovery from elevated stress (Floyd & Afifi, 2012 ; Floyd, 2014 ). Robles, Shaffer, Malarkey, and Kiecolt-Glaser ( 2006 ) found that a combination of supportive communication, humor, and problem-solving behavior in husbands predicts their wives’ cortisol and adrenocorticotropic hormone (ACTH)—both physiological factors are considered as stress markers (see 2006 ). On the other hand, the psychology of individuals, the quality of family relationships has major repercussions on cognitive development, as reflected in educational attainment (Sohr-Preston et al., 2013 ), and highly mediated by cultural assimilation (Schwartz et al., 2013 ), which affects individuals through parenting modeling and socialization of values (Mooney-Doyle, Deatrick, & Horowitz, 2014 ).

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January 7, 2021

Good news for families in 2021.

• Five research findings we published at the Institute for Family Studies in 2020 that might offer hope and direction for families in 2021 and beyond. Tweet This
• Marriage buffers against pandemic stress, more family time strengthens teen mental health, divorce is declining, and more good news to take into 2021. Tweet This

A new year is supposed to be about a fresh start—the hope and promise of doing and being better as we put the old year behind us. Barely a week in to 2021, however, we are still facing rising COVID infection rates, increasing political turmoil, a disappointing vaccine rollout, the threat of further lockdowns in some areas, and more uncertainty about the future. But as Sarah Coyne  pointed out  on these pages, it is possible to turn a traumatic event (or year) into a period of growth by finding meaning through the crisis. This involves looking back at what we learned through the hardships we faced. As we face whatever 2021 might hold, it is helpful to take a quick look back at five important research findings we published at the Institute for Family Studies last year.   What did we learn in 2020 that might offer some much-needed hope and direction for families in the new year and beyond?

1. Married individuals generally weather pandemic-related stress better. 

The relationship between marriage and better mental, emotional, and physical health is well established, but the COVID-19 pandemic really brought these benefits into focus for many people. In an analysis of AEI’s survey of parents last summer, IFS senior fellow W. Bradford Wilcox and AEI’s Peyton Roth  found  that married individuals were less likely to experience feelings of loneliness during the lockdowns. Lyman Stone  echoed these findings  in his September 2020 research brief on loneliness, where he showed that married parents were the least lonely Americans. Additionally, married individuals reported being less stressed  during the lockdowns and better able to endure financial challenges. In a review of the COVID Impact Survey, Roth and Wilcox found that “married men, women, and families are less likely to experience hunger, to be less dependent on public assistance, and to be better prepared to cover unexpected expenses during this pandemic, when compared with single adults and families headed by single parents.” 

All of this makes sense, considering the wide body of research linking marriage to overall well-being, including a lower likelihood of suicide and early death. Tyler VanderWeele of Harvard's Human Flourishing Program detailed some of this research  here at IFS  a few years back, noting that the “contribution of marriage to human flourishing is substantial” with married individuals enjoying better life satisfaction, better overall health, and longer lives than divorced or single individuals.

2. More family time is good for teen mental health .

One positive outcome of 2020 was more time together at home for families—which turns out to be a mental health booster for teens. A first-of-its-kind IFS/Wheatley Institution report,  Teens in Quarantine , which was based on a May-July 2020 survey, found that teen depression and loneliness was actually lower in 2020 than in 2018. Teens in two-parent families fared the best, reporting higher levels of mental health than teens in single-parent families. One of the main reasons for the improvement in teen mental health cited in the report is that teens are spending more time with their parents and siblings, “which might have mitigated the negative effects of the pandemic.” Specifically, 56% of teens said they were talking to their parents more than before the pandemic, 54% said their families ate dinner together more often, and 68% said their families were closer. As the report notes, “it appears that one of the primary foundations for teen resilience during the pandemic is family support and connection.”  

3. Divorce is declining.

Perhaps the most important research we published on the IFS blog in 2020, which was also our most  popular post of the year , is that marriage in the United States is more stable today. As Wendy Wang reported, the divorce rate is at its lowest point in 50 years. While early media reports cited a possible increase in divorce filings during the pandemic, Lyman Stone  analyzed data   from five states to show that divorce actually declined in 2020 .  These findings were confirmed in new  research  from Bowling Green University’s Center for Family and Demographic Research. Furthermore, the most recent  American Family Survey  found that the pandemic has brought some couples closer rather than driving them apart, with 58% saying the pandemic created a deeper appreciation for their spouse. Also, Wilcox predicted that marriage will become more stable in the future because the "soulmate model" of marriage will die due the global pandemic and its economic consequences. "In facing new trials and tribulations, married men and women will be less focused on their own emotional fulfillment and more focused on meeting the basic financial, social, and educational needs of their children, themselves, and their parents," he wrote. 

Unfortunately, the U.S. marriage rate also reached an all-time low in 2019, and, as Wang pointed out in a recent research brief, the  share of never-married Americans  is rising. The marriage gap between less-educated and higher-educated Americans also continues to widen. This means that unless something changes, fewer Americans and their children will reap the benefits of marriage highlighted above.

4. Religious schooling is strongly associated with healthier family formation for students . 

Throughout this pandemic, parents with children in private schools have benefited from more in-person instruction for their children compared to parents with kids in public schools. While the academic benefits of private schooling for kids are well known,  our recent report  with AEI highlights a lesser-known outcome of religious schooling: healthier future family lives for students.  The Protestant Family Ethic , which compared public and private school students, found that those who attended private schools were more likely to be in a stable marriage as adults and to have their children inside marriage compared to public-school attendees. This association was stronger among students who attended religious schools, especially Protestant private schools. In reflecting on the reasons for the association between attending private school and healthier family life outcomes, the authors point to a more supportive peer environment and stronger traditional messaging from school leaders about the value of marriage and of having and raising children within marriage. As we think about how best to promote marriage to young people who are increasingly delaying or forgoing marriage, especially those from at risk communities , we should consider the key role of private, and particularly religious, education.

5. Faith, meaning, and acts of service can bolster individual and family resilience. 

Over the past year, we published a number of research findings on the power of faith and meaning to improve human flourishing during turbulent times. BYU professors David Dollahite and Loren Marks  explained  that simple daily religious practices, such as individual and family prayer and reading scripture together, can bolster couple and parental relationships, as well as individual health. They pointed to “a large and growing body of empirical evidence that demonstrates that faith in God and meaningful engagement in a faith community both provide tangible, measurable benefits to mental, relational, and physical health—including years of longevity.” 

IFS contributor Clay Routledge also shared findings  from his research on meaning . “Meaning in life has great motivational power,” Routledge wrote. “It gives people hope and the personal agency to take care of themselves and help others.” Indeed, the  Washington Post  recently  reported , “people who have high levels of purpose in life spend fewer nights in hospitals, have lower odds of developing diabetes & over two times lower risk of dying from heart conditions than do others." 

Finally, Dr. VanderWeele  explored  the health benefits of helping others. His recent study found that volunteering at least two hours a week was associated with higher levels of happiness, optimism, and life purpose, and lower depressive symptoms, loneliness, and physical discomfort, as well as lower rates of death. As he wrote, "Society as a whole, and each of us individually, will more fully thrive if we are continually seeking the good of others."

So how can we use these research findings to strengthen family life in 2021? We can spend more quality time with our spouse and children, embrace the power of faith and faith-based institutions, advance the message that marriage matters to well-being, and pursue more meaningful lives as we find ways to serve others in our communities. By doing these simple things, we can hopefully turn a bad beginning to 2021 into a year when more families flourish regardless of circumstances.

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Office of the Assistant Secretary for Planning and Evaluation

Research on Successful Families

U.S. Department of Health and Human Services

Maria Krysan, Kristin A. Moore and Nicholas Zill

Child trends, may 10, 1990.

PDF Version

This report was prepared under contract #HHS-100-89-0041 between HHS's Office of Social Services Policy (now the Office of Disability, Aging and Long-Term Care Policy) and Child Trends, Inc. For additional information about this subject, you can visit the ASPE home page at http://aspe.hhs.gov . The Project Officer was Gerald Silverman.

ACKNOWLEDGMENTS

The conference on successful families research and the preparation of this report were made possible by contract HHS-100-898-041 from the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, to SysteMetrics/McGraw-Hill and Child Trends, Inc. The opinions expressed in the report are not necessarily those of the Department of Health and Human Services.

What is research on successful families?

This is a body of research on families that are enduring, cohesive, affectionate, and mutually-appreciative, and in which family members communicate with one another frequently and fruitfully. They are families that raise children who go on to form successful families themselves. They are not necessarily families that are trouble-free. Some have experienced health problems, financial difficulties, and other problems. But they are adaptable and able to deal with crises in a constructive manner.

The goal of research on these families is to discover the conditions and behavior patterns that make for family success.

Who is doing research on successful families?

The study of family strengths has been pursued by researchers from a variety of disciplines, including psychology, psychiatry, sociology, social work, and marriage and family counseling. Many of the individuals involved work to assist troubled families, as well as doing research on families that function well.

Thirteen of the leading researchers in this field came together recently to describe their work in a two-day conference in Washington. This document provides a report on that conference. (Names and biographical sketches of conference participants may be found at the end of the report.)

How is research on successful families different from other research on families?

A great deal of family research focuses on families that experience problems like spouse abuse, adolescent pregnancy, divorce, alcoholism or drug abuse, welfare dependency, and child maltreatment. Research on these family-related problems is essential if society is to develop better methods of dealing with them. Studies of successful families complement problem-focused research by teaching us how negative behavior patterns may be prevented in the first place or dealt with by families themselves. Research on strong families can also teach us how families transmit positive values and encourage beneficial behavior patterns like hard work, prudent risk-taking, responsible childbearing, and community involvement. Just as good health at the individual level is more than the absence of disease, so healthy family functioning is more than a lack of obvious problems. A review of the successful families research literature, " Identifying Successful Families: An Overview of Constructs and Selected Measures ," was prepared prior to the conference and is available from the Office for Social Services Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, or from Child Trends, Inc.

What are the policy implications of research on strong families?

Society relies on families to perform a number of essential functions such as providing for the economic needs of dependents, rearing and nurturing the next generation, and caring for the frail and disabled. When families break down or malfunction, everyone pays a price. Some of the critical functions of families may be taken over by public agencies or private charities that cannot carry out these duties as efficiently as family members could, or the needs of family members may go unmet.

Problem prevention . The prevention of problems within the family tends to be less costly in every sense of the word than dealing with problems after they have developed. If the key attributes of successful families can be identified, and ways can be found to develop these characteristics among troubled families, then the costs of public health and welfare programs might be reduced. A stronger labor force and fewer social problems might also result.

Social indicators and policy appraisal . Knowing what makes families work makes it possible to develop a broader range of statistical indicators of the condition of family life in the United States. Current statistics count the number of families in the country and describe their composition but tell little about how they are functioning. We need indicators that gauge the quantity and quality of communication between family members, the depth of commitment to each other, the frequency of shared activities, the satisfaction or dissatisfaction that members feel about how the family is operating, the division of labor within the family, and the extent of cooperation with respect to ends and means. Such measures could be used in evaluation studies that appraise the effects of specific policies on the behavior and well-being of affected groups. Research findings on strong families may also give policymakers and citizens a better basis for judging whether proposed policies will be helpful or harmful to families.

Public information and encouragement of private initiatives . Research on successful families is relevant to government efforts to inform the public and encourage individual actions and organizational policies that promote family health. Some of the findings are clearly applicable to specific areas of individual choice and business policy, whereas the practical implications of other findings will become clearer as theory and empirical evidence are further developed. Dissemination of the findings may help families to identify and develop behaviors and interaction patterns that enhance family functioning and may help foster a climate of public opinion that is more favorable to families.

What are the characteristics of strong, healthy families?

Based on various assumptions about what a strong family does, researchers have developed lists of structural and behavioral attributes that characterize successful families. In spite of differences in discipline and perspective, there seems to be a consensus about the basic dimensions of a strong, healthy family. The following constructs, which are often interrelated and complex, will be identified, defined, and described briefly as they exist in strong, healthy families:

• communication
• encouragement of individuals
• expressing appreciation
• commitment to family
• religious/spiritual orientation
• social connectedness
• ability to adapt
• clear roles
• time together

The presence of effective communication patterns is one of the most frequently mentioned characteristics of strong families. Researchers characterize the communication patterns of strong families as clear, open, and frequent. Family members talk to each other often, and when they do, they are honest and open with each other (Stinnett and DeFrain, 1985; Lewis, 1979; Epstein, 1983; Olson, 1986).

The encouragement of individual members encompasses a range of affective dimensions related to mutual support, recognition, and respect. Strong families cultivate a sense of belonging to a family unit, but also nurture the development of individual strengths and interests. Members enjoy the family framework, which provides structure but does not confine them.

Stinnett describes commitment to the family as follows: "Commitment goes in two directions. Each family member is valued; each is supported and sustained. At the same time they are committed to the family as a unit. They have a sense of being a team; they have a family identity and unity. When outside pressures (work, for example) threaten to remove family from its top priority, members of strong families take action and make sacrifices if necessary to preserve family well-being" (Stinnett, prepared statement to the Select Committee on Children, Youth, and Families, 1986, pg. 48).

"Delivering a high level of positive reinforcement to family members, day in and day out, doing things that are positive from the other person's perspective, just for their sake, not merely as a strategy for 'buying their love,' etc." is Schumm's (1986) description of appreciation as an important characteristic of strong families. Related to this, W. Robert Beavers and others stated that a sense of "delight" with the child is important to his or her successful development. Similarly, Olson summed up that it is important, when studying a family, to emphasize the delight, liking, warmth, and humor that family members share, which are all aspects of this construct and which distinguish some families from others.

A religious or spiritual orientation is identified by many researchers as an important component of strong families. Indeed, Beavers noted that all studies have found some aspect of religiosity or spirituality as a component of strong families. However, as described below, there is disagreement over which aspects of religion are most critical to family functioning.

A family's ability to adapt to stressful and potentially damaging events as well as to predictable life cycle changes, has also been identified as an important characteristic of strong families. Beavers noted that strong families are those with an ability to absorb stress and cope. The more rigid a family system, the more disturbed. Olson equates adaptability with flexibility, which he describes as the capacity of a family system to change the power structure, roles, and rules within the family. Healthy families change; unhealthy families remain stuck. Researchers note that ability to adapt is contingent upon a number of other characteristics common to strong families such as effective communication, affective involvement, external resources, etc. In addition, two of the other characteristics of strong families (social connectedness and clear definition of roles) are linked closely to this adaptability dimension.

Successful families are not isolated; they are connected to the wider society. One effect of social connectedness is the availability of external resources, identified by researchers as important to effective coping by families. A family's social connectedness can be measured in terms of the availability of external resources in the form of friends, family, and neighbors, as well as participation in community organizations.

Many researchers identify clear role definition as an important characteristic of family functioning, and as essential for a family's ability to adapt to changing situations. With a clear, yet flexible structure in place, family members are aware of their responsibilities in and to the family. Consequently, in the face of crises and problems, members know their roles. The nature of this aspect of family functioning is described as follows: "[it] focuses on whether the family has established patterns of behavior for handling a set of family functions... In addition, assessment of the roles dimension includes consideration of whether tasks are clearly and equitably assigned to family members and whether tasks are carried out responsibly by family members" (Epstein, et al, 1983).

Successful families spend time together , and the shared time is high in both quality and quantity. Self-report instruments assessing family functioning address this topic in terms of the number of activities done as a family and the extent to which family members enjoy spending time together. For example, questions are asked about whether "family members like to spend their free time with each other" (Olson's FACES), and about "spending time together and doing things with each other" (Stinnett and DeFrain, Family Strengths Inventory).

What methods are used to identify strong families?

Researchers have devised a number of methods to measure the characteristics of family life, and to identify the attributes of strong families. Methods include both self-report instruments, such as questionnaires and check-lists, and observational procedures in which rating scales are filled out by trained observers who are present with the family in their household or a laboratory, or who view and code from a videotape made of the family interacting. Observed activities include both structured tasks, such as discussing what each member would like to change about the family, and everyday pursuits, such as family meals. Assessments range in scope from measures of overall family functioning to measures of the individual constructs discussed above. In general, the family strengths measures employed to date are rather global and do not provide information on family behavior patterns. For example, the observer may judge how well family members communicate without specifying what is entailed in "good" communication.

What are some of the major substantive issues surrounding the area of successful families research?

Among the major substantive issues discussed at the conference were the social and economic contexts in which families operate, the implications of changing roles and behavior patterns for our notions of family health and normality, the diversity of family life and whether current research findings are applicable to minority and low-income families, the precise role that religion and religiosity play in helping to make for strong families, and whether this research can inform the debate over "family policy."

Does successful families research pay enough attention to the social and economic contexts in which families operate?

Several conference participants felt that successful families research needs to pay more attention to the social and economic conditions in which families operate. They argued that an appreciation of the environmental context was critical to any appraisal of family functioning. For example, child development expert Urie Bronfenbrenner noted that although the focus of research on successful families is on family processes, there are certain conditions under which these processes can and cannot occur. Some of these conditions are not wholly in the power of the family to create or eliminate. The availability of steady and adequately-paid employment is an example. While families can do things that increase the chances of gainful employment, there are larger economic forces at work shaping the job market. The effects of these external conditions must be considered when assessing family strengths.

Job demands and family functioning . Therapist Froma Walsh also emphasized that many family problems are contextually bound. For instance, in families that are trying to raise young children while both parents have full-time jobs, the lack of flexible and supportive work environments can create stresses and challenges that interfere with harmonious family functioning. Dual careers may also make it harder for family members to spend as much time together as they would like.

On the other hand, the work environment can be supportive of family functioning. Walter Schumm gave the example of a Major General in the U.S. Army who was the Commander of Fort Reilly. The Commander made it a policy that every Thursday afternoon after 3 P.M. was a time for soldiers to go home and spend time with their families.

Stresses and coping resources . A number of participants pointed out that in their research they did try to measure the stresses that families experienced and the resources available to them for coping with these problems. Researcher David Olson asserted that any appraisal of family strengths must incorporate an indicator of the level of stress experienced by the family. Margaret Owen said she found it worthwhile to measure both the "daily hassles" and the "daily uplifts" that parents experience. Lawrence Gary added that it was important to include a measure of racial discrimination when assessing the level of stress experienced by minority families.

It was noted that social connectedness was one of the attributes that had been repeatedly found to characterize successful families, and that better-connected families tended to have more resources available to them for coping with crises, as well as with the problems of daily living. Some families may even develop special mechanisms for bringing resources to bear on a problem. In a study of stable, black families, Lawrence Gary found that many of these families had one member who acted as a "cultural broker." The broker was a family member who had the know-how and ability to deal with social agencies, businesses, schools, and other institutions with which the family had to interact. Although relatives, friends, and colleagues often provide assistance to families, especially in times of crisis, Urie Bronfenbrenner observed that, paradoxically, social networks can sometimes be a source of stress; they are not always the social support they appear to be.

There was general agreement that future research on successful families should devote more attention to the interaction between family characteristics and community conditions, including such factors as: employment and unemployment patterns in the area; job-related demands and benefits; level and stability of family income; availability of quality child care and schooling; crime and drug problems; and community supports and resources. There was also interest in exploring the effects on families of broader social conditions, such as the intended and unintended impacts of government policies and issues of whether media influences help or hinder successful family functioning.

Definitions of family health and normality . In his comments on the conference proceedings, philosopher Robert George addressed the issue of whether changing patterns of family living, employment, sexual behavior, child care, and division of labor by gender should cause us to alter our definitions of what is normal and healthy in families. George argued that it would be a mistake to do so. He said that a thing is functioning well if it does what it is supposed to do. Thus, we should ask ourselves: What are families supposed to do? George noted that there were value questions involved here that social science alone could not resolve.

It is not a neutral, scientific position to say that ideals should shift in response to changing realities of social behavior. Non-shifting values permit a cultural critique of changing realities. To treat norms as shifting is to take a controversial, relativist view. One can argue that the prevailing value systems are corrupt or defective. But that would be moral argumentation, not social science.

George noted that after seeking alternatives to the family during the 1960s and 1970s, liberal elites have now endorsed the family as necessary for society. But they have also recognized significant deviations from traditional norms as acceptable behavior patterns. He wondered whether this was not contradictory. Are we "pushing the limits" in trying to function as a society without a commonly agreed upon set of values for families?

How well do existing research findings apply to racial and ethnic minorities and to low-income families?

A review of the successful families literature reveals that much of the research has focused on white, middle-class, two-parent families. Thus, there are questions regarding the extent to which the findings may be generalized to the population as a whole, and especially to subgroups such as racial and ethnic minorities and low-income families. Those researchers who have studied minority families have provided some important insights, and have raised issues and constructs that are not always identified by researchers studying white, middle-class families. For example, in studying strong black families, Lawrence Gary found that a sense of racial pride or consciousness was a frequent characteristic of these families. They focused on developing strong positive feelings toward their heritage, as well as talking openly about racism and teaching their children how to protect themselves against it. Of course, this construct can be extended to non-minority families as well. An understanding and appreciation of family history and cultural heritage, and the transmission of these traditions to children are probably characteristic of strong families in all racial, ethnic, and religious groups.

Gary also found a secure economic base to be important for black families, involving income that was not necessarily high but steady, and a strong work orientation . Family members showed a great deal of resourcefulness , often possessing skills and talents that could help them to produce or barter for needed goods and services. Other characteristics that Gary identified in stable black families were parallel to those recognized in research on non-minority families: a sense of family unity and cohesion; frequent displays of mutual appreciation, love, and acceptance; flexibility and adaptability in carrying out family roles; a high degree of religious or spiritual orientation; strong kinship bonds; and community involvement and concern about the climate of the neighborhood.

Research by sociologist William Vega has pointed to the unique experiences and needs of immigrant families, particularly in terms of adaptation, as well as the importance of assessing family strengths in light of a family's level of acculturation. In terms of measurement issues, Harriette McAdoo pointed to the overall need to develop scales and measures relevant to racial and ethnic minority populations, which would presumably include measures of the above constructs. Indeed, most of the instruments used to measure family strengths have been developed based on white, middle-class families.

While existing research suggests that many of the basic constructs are applicable across different racial/ethnic minority groups and income levels, the extent to which measurement instruments and cross-cultural results are valid for these populations is unclear. Further work must be done to address these concerns, as well as to identify additional constructs which may be unique to minority and low-income families.

What is the role that religion plays in helping to make for strong families?

There was extended discussion at the conference about the definition of religiosity or spirituality, and the precise role that this attribute plays in making for strong families. It was generally agreed that a religious or spiritual orientation as it manifests itself in strong families is not necessarily synonymous with frequency of church attendance. Spirituality can consist of a variety of things, such as: membership in an organized religious body, joint participation in worship or charitable activities, a shared sense of a greater purpose in life, and adherence to an explicit values system or moral code. Further research is needed on how these aspects of religion interrelate and which are most critical to successful family functioning.

Lessons from the Jewish American experience . As part of a presentation on the role of family in American Jewish culture, historian Steven Bayme noted that the divorce rate for Jewish couples is lower than that for the U.S. population at large. Among those who are affiliated with a synagogue, one-in-eight marriages end in divorce. For those not affiliated, the divorce rate is one-in-three. More orthodox congregations have lower divorce rates than less orthodox ones. However, according to Bayme, the synagogues that do best at supporting families are those that are more than just houses of worship. The successful synagogues are total communities that provide an array of services, activities, and peer-group supports to member families. "Strong communities build strong families," said Bayme.

Bayme attributed the strength of Jewish families to the central role that the family occupies in Jewish life. The family and the community are seen as closely intertwined. Marital success is important to the self-esteem of Jewish adults. Marriage provides companionship and fosters one's development as an adult. But a strong family also allows one to transcend the self and forge links with the larger Jewish culture and heritage. The family is, of course, a mechanism for reproduction and procreation. It is also the primary vehicle for the transmittal of values and the sense of Jewish identity. Judaism has a number of family-centered rituals and explicitly calls for family members to spend "quality time" together on a regular basis.

While acknowledging that the Jewish-American community has an over-representation of upper middle-class families, Bayme felt that their strength derived more from non-economic aspects of Jewish religion and culture. He felt that all groups could benefit by placing more emphasis on communication between parent and child, individual sacrifice for the sake of the family unit, a sense of family that comes from the "bottom up" , rather than being preached from the "top down", and the regular setting aside of time for shared observance of religious and cultural rituals.

Can successful families research inform the debate over "family policy"?

Patrick Fagan observed that the field of successful families research had to be developed further before it could be used as a basis for government policy. Nonetheless, there was discussion at the conference about possible policy implications of current findings. Steven Bayme noted that much of the conflict over "family policy" consisted of debate between those who advocated government policies that would provide resources and services to families in need, and those who saw the government's role as primarily one of "cultural education." Bayme felt that both groups could learn from one another.

Bayme suggested that there was a need to pay attention to the "cultural climate", and whether it was supportive of positive family functioning. It was also desirable, he felt, to strengthen communities in which families flourish, and to strive for well-integrated social policies. He defined these as ones which sought to provide assistance to dysfunctional families, but also considered the possible effects of the assistance on families that are functioning well.

Nick Stinnett presented a view of current social conditions and trends that captured the concerns of many conference participants. He asserted that current societal values emphasize the importance of work and career and de-emphasize the importance of family. There has been a loss of primary relationships and an increase in secondary relationships. More people lead hectic lives with chronically high levels of stress. In addition, there are generally no clear avenues for the transmission of values to young people, such as those which exist within the Jewish culture.

All of this leads, according to Stinnett, to families that are often too busy and fragmented to provide the warm, repetitive interactions, the irrational commitment of parent to child, and the mutual delight in one another that all humans must have. The lack of these developmental supports can lead, in turn, to social problems such as drug abuse, violence, domestic abuse, teen suicide" and runaways. The challenge for successful families research, noted Patrick Fagan, is to provide information that can help develop programs and policies that might reverse the negative trends described by Stinnett and help to strengthen families that are now in jeopardy.

What are some of the important methodological concerns?

Many issues related to measurement technique were raised during the conference. Among these were the advantages and disadvantages associated with self-report and observational techniques. The lower financial and time investment for self-report measures is a major advantage for this technique. There was consensus among the researchers that if observation techniques were impossible for reasons of time and/or cost, self-report measures were preferable to dropping a given construct. Owen identified conflict, adaptability, cohesion, and communication as constructs best measured through observation. John DeFrain noted that time together, community involvement, and values/religion are best assessed with questionnaires.

Several participants noted the importance of measuring family characteristics and processes using information from more than one family member. Doing so, however, creates a variety of analysis problems. For example, multiple perspectives from several members of the same family are rarely highly correlated. Schumm noted that he has developed some statistical techniques for handling problems caused by score discrepancy among family members. Also, Olson cautioned that researchers cannot assume that results obtained using self-report measures will correlate with results based on observation techniques. Indeed, in some of her research, Owen found that the predictive power of interaction observations could be reduced by the inclusion of self-report data into the analysis.

One of the most salient methodological issues to surface during the conference was the problem of small and unrepresentative samples that characterizes much of the existing research on successful families. The review of the literature prepared prior to the conference reveals that much of the work in this field has focused on white and/or middle class families. Often, the samples used are self-selected. This has obvious implications for the ability to generalize the findings to the population as a whole, as well as to subgroups such as minorities and low-income families. An informal survey of conference participants identified the following populations as research priorities: black families, dual-worker families, and single parent families. Applying family strengths measures to a national probability sample of families is critical at this stage of successful families research in order to test the generality of the findings obtained to date.

What are the next steps for successful families research?

Throughout the course of the two-day conference, numerous suggestions for future research were proposed which would move the field of successful family research forward, as well as provide useful information to policymakers, practitioners, and individuals interested in helping families. The following suggestions were offered:

Research on more varied populations. In addition to assessing family strengths in a national probability sample of families, there is a need to conduct studies about other populations such as racial/ethnic minorities, dual-worker families, rural families, families with a member who has a chronic disease, single-parent families, blended families, and families with low or no religious involvement.

A need to conduct longitudinal studies across the life cycle of the family, with particular attention to families with aging parents.

The development of a survey module comprised of measures derived from the successful families literature that could be used in other surveys. This would allow incorporation of items to assess family strengths in large sample surveys that can address questions such as the number of strong families in the total society and their demographic and economic characteristics.

The study of successful families from a process perspective. Conference participants identified the following processes as research priorities: role of the father in the process; process of racial, cultural, and/or family of origin identification; the process by which family strengths are developed; and identifying the community characteristics which help nurture family strengths.

The development of measures to assess the effect of the family on the development, functioning, and well-being of its adult members.

The integration of the findings of successful families research into intervention and prevention strategies, as well as public policy. This could be facilitated by the creation of a clearinghouse of studies on family strengths, making the findings more readily available to counselors, teachers, and policymakers as well as other researchers.

The integration and comparison of the family strengths literature with other sociological and psychological theories of the family, such as social capital theory, and with theories of deviance and delinquency that focus on negative behaviors, such as drug use.

The development of prevention and intervention programs based on the findings of successful families research, and rigorous evaluations of these programs. In order to develop such programs, the family strengths constructs, which are now stated in rather general terms, need to be developed more fully. This will make it possible to identify specific skills that can be transmitted to families who are experiencing problems.

The study of the relationship between individual strengths and family strengths.

The study of the relative importance of different family strengths and the interrelationships among them.

The incorporation of measures of family stress levels into studies of successful families, with attention to racial discrimination as a stressor for minority families.

The conference and literature review made it clear that a substantial body of theory and research exists on the topic of successful families. With encouragement to further develop the methods and constructs employed to study successful families, a mature literature could be developed. This would be of great use in understanding what makes families work well and how to help more families become strong.

RESEARCHERS ATTENDING THE SUCCESSFUL FAMILIES CONFERENCE

Steven Bayme, PhD, directs the Jewish Communal Affairs Department at the American Jewish Committee. He is an historian who has done research on the Jewish family in American society.

W. Robert Beavers, MD, is a psychiatrist and the founder and research director of the Southwest Family Institute. He approaches the study of families from a systems perspective and has developed a number of family assessment tools, including the Beavers-Timberlawn Family Evaluation Scale, an observational rating technique.

Urie Bronfenbrenner, PhD, is an emeritus professor in the Department of Human Development and Family Studies at Cornell University. He is a psychologist who approaches the study of human development from an ecological perspective.

John DeFrain, PhD, is a researcher, teacher, and marriage and family counselor at the University of Nebraska-Lincoln Department of Human Development and the Family. He has published a number of articles in the field of family strengths, and co-authored the book Secrets of Strong Families .

Lawrence Gary, PhD, is a researcher in the Mental Health Research and Development Center at the Institute for Urban Affairs and Research at Howard University. He was principal investigator for a study of the characteristics of stable black families.

Robert George, PhD, is a United States Supreme Court Fellow on leave from the Department of Philosophy at Princeton University.

Harriette Pipes McAdoo, PhD, Dean of the School of Social Work at Howard University, has researched and written extensively on black families. Her current research focuses on the inter-generational transmission of values.

David Olson, PhD, Professor of Family Social Science at the University of Minnesota, has designed a number of self-report inventories to assess family characteristics, including the widely used Family Adaptability and Cohesion Evaluation Scales (FACES). His book, Families: What Makes Them Work , outlines the Circumplex Model, and the findings of a cross-sectional study of intact families.

Margaret Owen, PhD, a member of the Research Staff at the Timberlawn Psychiatric Research Foundation, is involved with their Young Family Project. This longitudinal study of psychological health and family well-being has been following families from before the birth of their first child using a variety of psychological assessments, questionnaires and videotaped sessions.

Walter Schumm, PhD, an Associate Professor in the Department of Human Development and Family Studies at Kansas State University, does research on the interrelation of family strengths, and has developed short self-report measures of family and marital satisfaction.

Nick Stinnett, PhD, a professor of Human Development at the University of Alabama, has authored and co-authored a number of books and professional articles on family relationships, including The Secrets of Strong Families . He has also co-edited a number of books based on a series of conferences on family strengths held at the University of Nebraska, Lincoln.

William Vega, PhD, is a sociologist at the University of Miami. His research interests include Mexican American families, with a particular focus on social networks, cohesion, adaptability, and depression factors, especially among recent immigrant families.

Froma Walsh, PhD, is a clinical psychologist, and an associate professor at the School of Social Service Administration and the Department of Psychiatry at the University of Chicago. Recent research and publications have addressed normal family processes, healthy functioning in divorced and remarried families, and the role of women in families, particularly as it relates to models of family therapy.

INVITED RESEARCHERS WHO WERE UNABLE TO ATTEND THE SUCCESSFUL FAMILIES CONFERENCE

Carolyn Pape Cowan, PhD, is a clinical psychologist in the Department of Psychology at the University of California, Berkeley, where she co-directs. the "Becoming a Family Project." This is a longitudinal study of couples' transition to parenthood.

Jerry M. Lewis, MD, is a senior research psychiatrist at the Timberlawn Psychiatric Hospital and the Timberlawn Psychiatric Research Foundation, and has been involved with research on healthy families, including one study focusing on well-functioning working class black families. He recently published The Birth of a Family , based on findings from the Young Family Project, a longitudinal study of families.

Hamilton McCubbin, PhD, Dean and Professor at the School of Family Resources and Consumer, Sciences at the University of Wisconsin, Madison, is co-author of the book Family Types and Strengths: A Life Cycle and Ecological Perspective , based on results from a large survey of families across the life cycle. He developed a number of the self-report inventories used to assess family dimensions for this study.

Rudolf Moos, PhD, holds appointments at the Social Ecology Lab at Stanford University and the Veteran's Administration Medical Centers in Palo Alto. He is a clinical psychologist whose research focuses on the family environment and factors relating to stress. He developed a widely used self-report instrument which assesses a number of dimensions of the family environment (the Family Environment Scale).

AGENCY & ORGANIZATION REPRESENTATIVES ATTENDING THE SUCCESSFUL FAMILIES CONFERENCE

Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health & Human Services Patrick Fagan, PhD, Deputy Assistant Secretary for Social Services PolicyWilliam ProsserAnn SegalGerald Silverman

Child Trends, Inc. Maria KrysanKristin A. Moore, PhDNicholas Zill, PhD

Nabers Cabaniss, Office of Public Affairs, Department of Health & Human Svcs.

Linda Eischeid, Office of Human Dev. Services, Department of Health & Human Svcs.

Jeff Evans, PhD, JD, Demog. & Beh. Sci. Branch, National Institute of Child Health & Human Development

Harold Himmelfarb, Office of Research, Department of Education

Larry Guerrero, Div. of Program Analy. & Eval., Department of Health & Human Svcs.

Wade Horn, PhD, Admin. for Children, Youth, and Family, Department of Health & Human Svcs.

Patricia Langley, Family Service America

Kate O'Beirne, JD, Heritage Foundation

Theodora Ooms, American Association for Marriage & Family Therapy

Courtney Pastorfield, Subcommittee on Children, Family, Drugs and Alcoholism, U.S. Senate

Jerry Regier, Department of Justice

Mike Schwartz, Free Congress Research & Education Foundation

Catherine Deeds, Select Committee on Children Youth, and Families, U.S. House of Representatives

Mark Souder, Hon. Dan Coats' Office, U.S. Senate

Beau Weston, PhD, Office of Education Research Improvement, Department of Education

Bayme, Steven. 1990. "The Jewish family in American culture." New York: The American Jewish Committee.

Beavers, W. Robert. 1977. Psychotherapy and growth: A family systems perspective . New York: Brunner/Mazel.

Bronfenbrenner, Urie. 1979. The ecology of human development . Cambridge, MA: Harvard University Press.

Epstein, Nathan B., Lawrence M. Baldwin, & Duane S. Bishop. 1983. "The McMaster Family Assessment Device." Journal of Marital and Family Therapy 9(2): 171-180.

Gary, Lawrence E., Lula A. Beatty, Greta L. Berry, et al. 1983. Stable black families: Final report . Washington, DC: Mental Health Research & Development Center, Institute for Urban Affairs & Research, Howard University.

Lewis, Jerry M. 1989. The birth of a family . New York: Brunner/Mazel.

Lewis, Jerry M. 1979. How's your family? A guide to identifying your family's strengths and weaknesses . New York: Brunner/Mazel.

Lewis, Jerry M., W. Robert Beavers, John Bossett, et al. 1976. No single thread: Psychological health in the family system . New York: Brunner/Mazel.

Lewis, Jerry M., & John G. Looney. 1983. The long struggle: Well-functioning working class black families . New York: Brunner/Mazel.

Lewis, Jerry M., Margaret Tresch Owen, & Martha J. Cox. 1988. "The transition to parenthood, III. Incorporation of the child into the family." Family Process 27: 411-421.

McAdoo, Harriette P. (ed.). 1981. Black families . Beverly Hills, CA: Sage Publications.

Mellman & Lazarus, Inc. 1990. MassMutual American family values study. Results of focus group and survey research . Washington, DC: Mellman & Lazarus.

Moos, Rudolf H., & Bernice S. Moos. 1986. Family environment scale manual (Second edition). Palo Alto, CA: Consulting Psychologists Press.

Morgan, Elizabeth A. 1987. "Pioneer research on strong, healthy families." Washington, DC: Family Research Council.

Olson, David H. 1986. Prepared statement before the House Select Committee on Children, Youth, and Families. In: The diversity and strength of American families . Washington, DC: US Government Printing Office.

Olson, David H., Hamilton I. McCubbin, Howard Barnes, et al. 1983. Families: What makes them work . Beverly Hills, CA: Sage Publications.

Olson, David H., Hamilton I. McCubbin, Howard Barnes, et al. 1982. Family inventories: Inventories used in a national survey of families across the family life cycle . St. Paul, MN: University of Minnesota.

Olson, David H., Candyce S. Russell, & Douglas H. Sprenkle (eds.). 1989. Circumplex model: Systemic assessment and treatment of families . New York: Haworth Press.

Schumm, Walter R. 1986. Prepared statement before the House Select Committee on Children, Youth, and Families. In: The diversity and strength of American families . Washington, DC: US Government Printing Office.

Schumm, Walter R. 1985. "Beyond relationship characteristics of strong families: Constructing a model of family strengths." Family Perspective 19(l): 1-9.

Stinnett, Nick. 1986. Prepared statement before the House Select Committee on Children, Youth, and Families. In: The diversity and strength of American families . Washington, DC: US Government Printing Office.

Stinnett, Nick, & John DeFrain. 1985. Secrets of strong families . Boston: Little, Brown & Co.

Swihart, Judson. 1988. "Characteristics of strong families." Unpublished paper, International Family Center, Logos Research Institute.

U.S. House of Representatives Select Committee on Children, Youth, and Families, 99th Congress, 2nd Session. February 25, 1986. The diversity and strength of American families . Washington, DC: US Government Printing Office.

Vega, William A., Thomas Patterson, James Sallis, et al. 1986. "Cohesion and adaptability in Mexican-American and Anglo families." Journal of Marriage and the Family 48(Nov): 857-967.

Walsh, Froma. Normal family processes . 1982. New York: Guilford Press.

Walker, Deborah Klein, & Ruth W. Crocker. 1988. "Measuring family systems outcomes." In Heather B. Weiss & Francine H. Jacobs (eds.) Evaluating family programs . Hawthorne, NY: Aldine de Gruyter.

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Top Five Family Formation Research Findings in 2021

Posted by Daily Citizen Staff | Dec 31, 2021 | Family

2020 was certainly a rough year and we were glad to see it fade in the rear-view mirror. But that annual turn of the calendar into 2021 brought more unexpected challenges to life.

It’s worth asking, “How has the family fared this year? How has it gotten stronger? Has it weakened? What new knowledge did we gain?”

Amid the pandemic, scholars have continued studying the family and its fascinating dynamics. As we put a satin bow on the year, let’s look at some of the most important developments in family research in 2021.

#5 – COVID Strengthened Marriage in Important Ways

As The Daily Citizen reported in early June, two leading sociologist of the family from Bowling Green State University’s  Center for Family and Demographic Research  provided what they describe as “our first opportunity to assess how the pandemic may have influenced both marriage and divorce levels” across the United States. Their  research  explained that, compared with data from 2018 and 2019, disruptions from the pandemic brought “about 21,000 fewer marriages and 16,000 fewer divorces” in five states (Arizona, Florida, Missouri, New Hampshire, and Oregon).

Research-based evidence demonstrated the COVID pandemic brought married couples closer. Sociologists at the Institute for Family Studies  found  that even though American couples felt increased life-strain, they also reported the trials helped their marriages in many ways, allowing them to develop a growing appreciation for each other. These scholars discovered “the share of married people who said their marriage is in trouble”  fell during the pandemic. They add, “While there is no question that some couples are struggling, the evidence generally points in the opposite direction.”

The rate of married couples, aged 18-55, who stated their marriage was in trouble declined markedly from 40% in 2019 to 29% in 2020. In light of these findings, the lead researcher on this project, Professor W. Bradford Wilcox of the University of Virginia, told  The Daily Citizen , “As the pandemic fallout unfolded, we are seeing many husbands and wives are turning, not away from one another, but towards one another.” He adds, “They are seeking more practical and emotional support from one another.” Specifically, Wilcox contends, “From what I see, I think the people who are currently married will generally emerge from all of this trial and tribulation stronger in their marriages.”

#4 – Just 18% of American Households Are Families with Married Parents

While marriages appear to be strengthening during the pandemic years, marriage as a foundational institution is sadly declining. In late 2021, demographers at the U.S. Census Bureau discovered that fewer than 20% of American families are founded and maintained by married parents.

In raw numbers, there are 23.1 million American homes with nuclear families (married mother and father raising their own children) out of 130 million households. The Census Bureau explains this number “ is  the fewest since 1959.”

This means only 17.8% of U.S. households are established on the healthy bedrock of a husband and wife raising their kids together. This is down from 18.6% in 2020, and down even more drastically over previous decades. In 1970, 40% of U.S. households consisted of a married mother and father with children. This year, that number has been more than halved.

Accounting for the decline between 2020 and 2021, the reasons given for the drop include the pandemic delaying marriage and a continued decline in birth rate.

Given the rich, research-based benefits of marriage for adults and children, this decline is a tragedy. And it leads us to our next major research discovery for 2021.

#3 – Marriage Continues to Dramatically Boost All Important Measures of Human Well-Being

The Daily Citizen reported in April just how profoundly the best, university-based medical, psychological, and social science research continues to demonstrate that marriage is far more than just a sacred or sentimental institution. It makes a real demonstrable difference in all of the most important measures of human thriving for women, men, children, and society at large.

Harvard Medical School  explains ,

[T]here is fascinating — and compelling — research suggesting that married people enjoy better health than single people. For example, as compared with those who are single, those who are married tend to

– live longer

– have fewer strokes and heart attacks

– have a lower chance of becoming depressed

– be less likely to have advanced cancer at the time of diagnosis and more likely to survive cancer for a longer period of time

– survive a major operation more often.

Our April article offered four reasons for improved health among married couples. 

First  is that married people tend to have better immune function. Marriage seems to actually improve disease resistance.  Second , married people take fewer risks, eat better, and maintain generally healthier lifestyles than those in other relational categories.  Third , married people tend to have better emotional support systems that contribute to improved health and healing.  Finally , married people tend to be healthier prior to marriage and stay that way.

Thus, fighting for and working toward a more pro-marriage culture is essential and an effort all genuine social justice sectors should engage in.

#2 Cohabitation Still Linked to Increased Divorce

Professor Scott Stanley from the University of Denver is a long and valued friend of Focus on the Family. He is one of the leading scholars in a very small but distinguished group who carefully study the nature and consequences of unmarried cohabitation. It has long and consistently been established that living together before marriage is related to a significant host of negative relational outcomes and habits, including increased infidelity, physical and verbal abuse, relational manipulation, unequal sharing of income and household chores, as well as increased likelihood of divorce.

Stanley published a very important and influential article in 2021 showing how the best data continues to demonstrate that cohabitation is still related to increased divorce. Despite this, more than 70% of marriages today are preceded by living together. The elevated risk of divorce is true for those who cohabit with or without their eventual spouse, but to varying degrees. Stanley explains, “Most people believe cohabitation should improve one’s odds of marital success. [One recent study] suggests this may only be true very early in marriage. Otherwise, not so much. As ever on this subject, questions abound.” Stanley adds, “One of the most intriguing questions remains: why is there any association with risk?”

In the work Stanley has done with his colleagues, he leans strongly in the direction that the act of cohabiting, and its defined lack of commitment and relational clarity, actually trains couples to interact with each other and future partners in increasingly unhealthy ways. Cohabitation is still not a wise way to test a relationship.

#1 – Divorce Rate Continues to Drop and Active Faith Reduces Divorce

It has been well-established among family demographers that the divorce rate in America has been declining over the last few decades. For every 1,000 marriages in the last year, only 14.9 ended in divorce, according to the newly released American Community Survey data from the Census Bureau. This is the lowest rate seen in 50 years. It is even slightly lower than 1970, when 15 marriages ended in divorce per 1,000 marriages. And all indications point to this trend continuing into 2022.

This is great news for Americans who are married. It means their marriages will likely be more stable, and their children more likely to grow up with two married parents, which provides them the best chance for success later in life.

And finally, two leading family scholars, and men of deep faith, just published original research showing that young people who grow up with an active faith are significantly less likely to face divorce when they do marry. As these scholars explain, “religiosity is associated with a markedly higher likelihood of going directly from singleness to a married union without cohabiting ahead of time, and generally at younger ages.” Broken down by faith groups, the data on likelihood of marrying  without  having ever cohabited looks like this…

They add, “Our results also suggest that religion fosters relationship stability by pushing young adults away from cohabitation, which is highly unstable, and toward marriage, which is much more stable.”

These scholars conclude, “The upshot of all this is that the religious model of marriage and family appears to boost the odds that young adults can marry before 30 without increasing their risk of landing in divorce court.”

These new findings mean science  continues  to show that couples, young and old, who have a serious connection to their faith,  enjoy markedly lower risk of divorce.

The entire staff at The Daily Citizen looks forward to continuing to track important research findings on the family into 2022. We invite you to join us as faithful partners in this vital work.

Photo from Shutterstock .

About The Author

Daily Citizen Staff

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Living on the edge - key findings, longitudinal study on post-covid-19 impact assessment among low-income households in kuala lumpur.

This study is a continuation of the Families on the Edge (FOE) project. During the COVID-19 pandemic, UNICEF and UNFPA conducted a four-phase mixed methods longitudinal study undertaken during various periods of the COVID-19 pandemic and post-pandemic to measure the impact of the pandemic on women and children in low-income families in Kuala Lumpur.

This study focuses on a survey undertaken post-pandemic, conducted from October 14, 2023, to November 16, 2023, with data collected from a total of 755 low-income households living in sixteen low-cost public housing in Kuala Lumpur.

The key findings and factsheets are available for download in English and Malay.

Kajian ini adalah kesinambungan daripada projek Keluarga di Pinggiran (FOE). Semasa pandemik COVID-19, UNICEF dan UNFPA menjalankan kajian longitudinal kaedah campuran empat fasa semasa dan selepas pandemik. Kajian itu bertujuan mengukur kesan pandemik ke atas wanita dan kanak-kanak dalam keluarga berpendapatan rendah di Kuala Lumpur.

Kajian ini bertumpu pada tinjauan yang dibuat selepas pandemik, yang dijalankan dari 14 Oktober 2023 hingga 16 November 2023.

Penemuan utama dan helaian fakta boleh dimuat turun dalam Bahasa Inggeris dan Melayu.

Files available for download

Related topics, more to explore.

Living on the Edge: Increased cost of living adds pressure on low-income urban familiess

Snakes and ladders: navigating uncertainty in the new normal

As Malaysia entered MCO 2.0, many low-income urban families were already close to breaking point

Partial, uneven, and uncertain: Families on the Edge report chart recovery among low income families post-MCO

• Open access
• Published: 05 May 2024

The quality of life of men experiencing infertility: a systematic review

• Zahra Kiani   ORCID: orcid.org/0000-0002-4548-7305 1 ,
• Masoumeh Simbar   ORCID: orcid.org/0000-0003-2843-3150 2 ,
• Farzaneh Rashidi   ORCID: orcid.org/0000-0001-7497-4180 3 ,
• Farid Zayeri   ORCID: orcid.org/0000-0002-7791-8122 4 &
• Homayoon Banaderakhsh   ORCID: orcid.org/0000-0001-8982-9381 5  

BMC Public Health volume  24 , Article number:  1236 ( 2024 ) Cite this article

414 Accesses

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Metrics details

Men experiencing infertility encounter numerous problems at the individual, family, and social levels as well as quality of life (QOL). This study was designed to investigate the QOL of men experiencing infertility through a systematic review.

Materials and methods

This systematic review was conducted without any time limitation (Retrieval date: July 1, 2023) in international databases such as Scopus, Web of Science, PubMed, and Google Scholar. The search was performed by two reviewers separately using keywords such as QOL, infertility, and men. Studies were selected based on inclusion and exclusion criteria. The quality of the articles were evaluated based on the Newcastle-Ottawa Scale. In the initial search, 308 studies were reviewed, and after removing duplicates and checking the title and abstract, the full text of 87 studies were evaluated.

Finally, 24 studies were included in the final review based on the research objectives. Based on the results, men’s QOL scores in different studies varied from 55.15 ± 13.52 to 91.45 ± 13.66%. Of the total reviewed articles, the lowest and highest scores were related to mental health problems and physical dimensions, respectively.

The reported findings vary across various studies conducted in different countries. Analysis of the factors affecting these differences is necessary, and it is recommended to design a standard tool for assessing the quality of life of infertile men. Given the importance of the QOL in men experiencing infertility, it is crucial to consider it in the health system. Moreover, a plan should be designed, implemented and evaluated according to each country’s contex to improve the quality of life of infertile men.

Peer Review reports

Introduction

Defined as the absence of pregnancy after one or two years of unprotected sexual intercourse (without the use of contraceptive methods) [ 1 ], infertility is recognized as both a medical and social issue [ 2 ]. Based on the latest Word Health Organization (WHO) report in 2023, the pooled lifetime and period prevalence of infrtility are reported as 17.5% and 12.6%, respectively [ 3 ]. In this regard, male factors play a role in 50% of infertilities [ 4 ].

Complicated treatment protocol, difficult treatment process, semen analysis, multiple ultrasounds, invasive treatments, long waiting lists, and high financial costs for the clients who seek assisted reproductive techniques have been described as psychological stresses for infertile couples [ 5 , 6 ]. Moreover, the diagnosis and treatment of infertility can have negative impact on the frequency of sexual intercourse, self-esteem, and body image [ 5 ]. However, these men usually tend to suppress or deny their problems which may diminish their quality of life (QOL) over time [ 7 ]. This decreased QOL, in turn, can have a detrimental effect on their response to treatment [ 8 ].

The function of infertile people is under the influence of society, family, and the society culture. In many societies, infertility is primarily viewed as a medical problem, often neglecting its individual and social dimensions [ 9 ]. In other words, despite having the right attitude toward infertility, infertile people sometimes cannot adapt to the problem. Thus, non-compliance during the behavioral process may lead to additional problems and impair one’s QOL [ 10 ].

The WHO describes the QOL as people’s perspective of their life circumstances in terms of the cultural systems and standards of their environment, and how these perspectives are associated with their objectives, prospects, ideals, and apprehensions [ 11 ]. Recently, the QOL of men experiencing infertility as a main subject has been carefully considered by health investigators. Furthermore, because of men’s essential role in future phases of life, their QOL can significantly affect their health at both individual and societal levels [ 12 ].

Given the significance of QOL, its precise measurement is substantially important. In this regard, various tools have been designed and used in studies to examine this concept. A systematic study used the World Health Organization Quality Of Life )WHOQOL), 36-Item Short Form Survey (SF-36 ), and general QOL questionnaires. Based on the results, the QOL of men experiencing infertility was reported to be low in two studies that had used the SF-36 questionnaire. By contrast, the QOL of these men was high in a study that used the WHOQOL questionnaire. It was noted in this systematic review that although infertility has a negative effect on the mental health and sexual relationships of couples, there is no consensus regarding its effect on the QOL of infertile couples [ 13 ].

In Almutawa et al.‘s systematic review and meta-analysis 2023, it has been shown that the psychological disturbances in infertile women are higher than in men, and this difference in couples needs further investigation [ 14 ]. Chachavomich et al. 2010 showed that women’s quality of life is more affected by infertility than men study, which was a systematic review [ 12 ], . This study was conducted 14 years ago and due to the increase in the number of articles in this field, it needs to be re-examined.Given that no systematic review had been conducted to address the QOL of men experiencing infertility and considering the significance of this issue in therapeutic responses, this study examined the QOL of men experiencing infertility in the form of a systematic review.

Search strategy

To search and review the studies, reputable international databases and sites such as Scopus, Web of Science, PubMed, and Google Scholar were used. The search was performed using keywords such as QOL, infertility, and men (Table  1 ), without time limitation (Retrieval date: July 1, 2023), and using AND and OR operators, and specific search strategies were used for each database.

The search strategy of PubMed, Web of Science, and Scopus databases is as follows:

Pubmed (retrieval date: July 1, 2023)

Male [tiab] OR Males [tiab] OR Men [tiab] OR Man [tiab] OR Boy [tiab] OR Boys [tiab] AND Quality of Life [tiab] OR Health-Related Quality of Life [tiab] AND Infertility [tiab] OR Sterility OR Reproductive [tiab] OR Reproductive Sterility [tiab] OR Subfertility [tiab] Sub-Fertility [tiab].

Web of science (retrieval date: July 1, 2023)

((TI=(male OR males OR man OR men OR boy OR boys)) AND TI=(Quality of Life OR Health-Related Quality of Life OR Health-Related Quality of Life)) AND TI=(Infertility OR Sterility OR Reproductive OR Reproductive Sterility).

Scopus (retrieval date: July 1, 2023)

TITLE ( male OR males OR men OR man OR boy OR boys ) AND TITLE (quality AND of AND life OR health-related AND quality AND of AND life ) AND TITLE ( infertility OR sterility OR reproductive).

The method of presenting the article, describing the problem, data collection, data analysis, discussion, and conclusion of the findings were based on preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 [ 15 ]. The reviews were conducted separately by two reviewers, and the third reviewer was also used in case of disagreement between them.

Inclusion and exclusion criteria

Those studies with the following criteria were included in the review: (1) Observational studies; (2) Cross-sectional data from longitudinal studies; (3) Using valid tools for measuring the QOL; (4) Studies conducted on men of infertile couples (by men experiencing infertility we mean those men whose unprotected sexual intercourse during the past year did not lead to any pregnancy); (5) Minimum sample size of 30 subjects; (6) Subjects with no chronic disease, and (7) those men of infertile couples who were within the diagnostic process for infertility and before starting infertility treatment. The search and review process for this study were conducted in English, and there were no restrictions imposed on the inclusion of open-access studies.

Exclusion criteria included: (1) Case report studies; (2) Review studies; (3) Animal studies; (4) Studies on mental syndromes; (5) Studies not written in English; (6) Lack of access to the full text of the article, and (7) Unrelated reports.

The patient, intervention, comparison, outcome, and study design (PICOS)

PICOS model was used to help break down the searchable elements of the research question into (P) participants: men experiencing infertility (primary or secondary infertility) (I) intervention/exposure: not applicable; (C) control group: not applicable; (O) outcomes: evaluate infertile men’s QOL, which was measured using standard tools such as general or specific QOL questionnaire and (S) study type: Observational studies and Cross-sectional data from longitudinal studies.

Data extraction

The two reviewers independently reviewed the titles and abstracts of the articles following the inclusion criteria, and the studies which did not have the required criteria were excluded. Then, the full text of the articles with inclusion criteria was reviewed and if appropriate, they were included in the study.

Required information, including authors’ names, year of publication, research location, sample size, QOL score, type of tool, type of infertility, mean age of men, and duration of infertility, were extracted from the studies.

Outcome measurement

The main outcome of this study was to evaluate QOL of men experiencing infertility, which was measured using standard tools such as a general or specific QOL questionnaire.

Quality evaluation

The Newcastle-Ottawa Scale checklist was used to assess the quality of nonrandomized studies in meta-analyses [ 16 ]. This checklist consists of 5 parts that are representativeness of the sample, sample size, non-respondents, ascertainment of anxiety, and quality of descriptive statistics reporting. Each part gets a score of zero and one. Given the fact that the checklist has 5 items, the minimum, and maximum scores are 0 and 5, respectively. Then, studies were divided into high- and low-risk groups if their scores were ≤ 3 and more than 3 [ 16 ]. The quality assessment in this study was performed by two reviewers independently, and in case of disagreement between them, the third reviewer was asked to help. The coefficient of agreement of 0.7 and more among the reviewers was acceptable.

Ethical consideration

Ethics approval was obtained from the Ethics Committee, Faculty of Pharmacy and Nursing.

Midwifery, Shahid Beheshti University (Ethical code: IR.SBMU.PHARMACY.REC.1400.214). All methods were carried out in accordance with relevant guidelines and regulations.

After reviewing the title, abstract, and text of the articles in different stages (Fig.  1 ), finally, 24 articles were reviewed based on the inclusion criteria and research objectives and the coefficient of agreement among the reviewers was K = 0.81 (Table  2 ).

Flowchart for selection of studies

The smallest and largest sample size were 30 [ 19 ] and 1,000 [ 40 ], respectively. Seven studies were conducted in low- and middle-income countries, two studies in upper-middle-income, and 15 studies in high-income countries. High-income countries had a higher quality of life score compared to low- and middle-income countries countries. In all studies, QOL scores were calculated based on 100, and the highest score (91.45 ± 13.66%) obtained from the Fertility quality of life (FertiQoL) questionnaire in South Korea as a high-income country [ 25 ]. Most of the studies showed that education, family income and proper marital relations improved the quality of life of infertile men. Out of 24 reviewed articles, 12 articles used the FertiQoL questionnaire, 7 articles SF-36, and 6 articles WHOQOL-BREF. One study [ 36 ] used SF-36 and WHOQOL-BREF questionnaires simultaneously.

Out of the total articles reviewed, the lowest scores were attributed to different domains. Accordingly, the lowest score in 11 articles was related to mental health problems, in 8 articles it was related to social problems, and 3 articles to communication problems.Some articles did not report the scores based on the dimensions. Based on the results, men’s QOL scores in different studies varied from 55.15 ± 13.52 to 91.45 ± 13.66%. In the total reviewed articles, the lowest and highest scores were related to mental health problems and physical dimensions, respectively.

In most of the studies using the FertiQoL questionnaire, it was observed that the lowest scores belonged to the social and communication dimensions. The FertiQoL questionnaire was developed and psychometrically evaluated in a survey study conducted in the United States. FertiQoL is a 36-item scale with Six dimension: (1) Emotional; (2) Mind-body; (3) Relational; (4) Social; (5) Environment; and (6) Treatment tolerability. A 5-point Likert scale (0–4) was used in the questionnaire, and the total score was between 0 and 100, where the higher the score, the better was the QOL [ 41 ]. This questionnaire has been translated into different languages in the world and has obtained the required validity (content, face, and construct) and reliability (with Cronbach’s alpha of 0.7–0.9) in different populations [ 42 , 43 , 44 , 45 ].

In the studies where the SF-36 and WHOQOL-BREF questionnaires had been used, the lowest scores belonged to the dimensions of limitations in usual role activities because of emotional problems and social relationships. On the other hand, the highest scores in the questionnaires were related to physical dimensions. The SF-36 questionnaire has been considered for clinical investigation, health policy assessments, and surveys. The 8 dimensions of this questionnaire are as follows: Restrictions in physical activities; Restrictions in social activities; Restrictions in standard role activities; Physical pain; General mental health; Restrictions in standard role activities; Vitality; and Common health perceptions. The final scores of the questionnaire are standardized based on 100 [ 46 ]. This questionnaire has been translated into different languages in the world and has obtained validity (content and face) and reliability (Cronbach’s alpha of 0.8–0.95) in different populations [ 47 , 48 , 49 , 50 , 51 , 52 ]. The 26-item version of WHOQOL-BREF was developed in the following four dimensions: physical health, mental health, social connections, and environmental health, and two items associated with common QOL and general health [ 53 ]. The questionnaire has been translated into different languages of the world and has obtained validity (content and face) and reliability (Cronbach’s alpha of 0.74–0.88) in different populations [ 54 , 55 , 56 , 57 ].

This systematic review study investigated the quality of life of infertile men. Based on the results, men’s quality of life scores in different studies varied from 55.15 ± 13.52 to 91.45 ± 13.66%. However, men’s quality of life scores was reported to be between 70 and 80% in the majority of the studies. As one of the health indicators with a combination of each person’s knowledge in different aspects of life and performance in human, work and social relations, quality of life is essentially important for the continuation of an optimal life and well-being of the individuals. Moreover, quality of life is strongly influenced by demographic, social, economic, and cultural variables, as well as the variables related to health and disease, and its measurement is, thus, substantially important [ 58 ]. Quality of life is a reflection of the desires, hopes, and expectations of individuals regarding their current and future life situation, and is influenced by factors such as age, personal and family characteristics, socio-economic status, and time [ 59 ].

In this systematic review, the lowest scores of men’s quality of life belonged to the psychological and emotional dimensions and then to the social and communication dimensions. Although the reviewed studies had used different tools, these tools were essentially similar in these dimensions, indicating the problems of men in these areas. Fertility is highly valued in most cultures and the desire for having a child is one of the human stimuli in the continuation of life. If efforts for fertility do not lead to success, they can have adverse effects on mental health as well as family and social relationships [ 60 ].

The reviewed studies indicated that education has a significantly positive effect on the quality of life of infertile men. Higher levels of education are associated with increased awareness and better decision-making abilities [ 25 ], and improved coping strategies for dealing with infertility-related challenges [ 38 ]. Infertile men with higher education are also more likely to seek treatment, and remain hopeful that treatment will improve their quality of life [ 28 ].

The results of most studies showed the positive and significant relationship between family income and quality of life.The costs of infertility treatment and the potential need for repeated treatment can lead to concerns and anxieties among men and reduce their quality of life [ 61 ]. If men have fewer concerns about the cost of treatment, they are more inclined to pursue infertility treatment. In the International Conference on Population and Development held in Cairo in 1994, addressing the issue of infertility was emphasized as an important health priority. However, it is unfortunate that infertility problems have been overlooked not only in developing countries but also at various levels of international health management [ 62 ].

The results of the study regarding the countries’ income showed that the quality of life score of men in infertile couples residing in low-income countries was lower compared to those in high-income countries. Current infertility policies in the treatment and distribution sector are uncoordinated, which has led to improper distribution of public and private centers in low- and middle-income countery [ 63 ]. This point of view is a kind of simplistic calculation of the problem of infertility that justifies the lack of public centers, inadwquate finantial sources, specialists and affordable treatment options [ 64 ], requireing serious attention and careful planning, especially in low- and middle-income countries.

The results of the studies showed that marital relationships have a positive and significant impact on the quality of life of infertile men. Sometimes, infertile men may experience a lack of sexual attraction, and due to irrational thoughts, they might abstain from having sexual relations with their partners or try to suppress their sexual desires. Sexual desire is a significant aspect of life that can affect the quality of life [ 65 ]. Some studies have indicated that the quality of marital relations is higher among infertile couples than the fertile ones, and infertility can bring couples closer together and encourage more open communication about their concerns and plans for the future [ 33 , 66 ]. Further research is recommended to gain a deeper understanding in this area.

Infertility presents people with a new and challenging world [ 28 ]. In this regard, infertility is characterized as a long-term process that involves time-consuming treatments, fluctuations between hope and disappointment, loss of control over reproductive outcomes, inability to plan for future, and significant shifts in personal identity and worldview [ 28 , 32 , 63 ]. Long working hours, work-caused exhaustion, along with infertility, can exacerbate men’s problems. These problems affect their quality of life, though they may deny the problems [ 67 ].

Given the significance of quality of life, its accurate measurement is essentially important. In this regard, various tools have been designed to investigate this concept and have been used in several studies. The noteworthy point in this systematic review was the use of different measurement tools in various studies. In the majority of the studies, Boivin’s FertiQoL [ 41 ] was used as a specific tool for measuring the quality of life of infertile couples. Covering emotional, physical, communicational, social, environmental, and acceptability dimensions, this questionnaire has been designed for infertile couples and does not specifically assess the quality of life of infertile men. Other studies have used a general quality-of-life questionnaire (SF-36 and WHOQOL-BREF). WHOQOL questionnaire has been designed in 4 dimensions of physical health, psychological health, social relationships, and environmental health [ 53 ]. SF-36 questionnaire also has 8 dimensions of Limitations in physical activities because of health problems; 2) Limitations in social activities because of physical or emotional problems; 3) Limitations in usual role activities because of physical health problems; 4) Bodily pain; 5) General mental health (psychological distress and well-being); 6) Limitations in usual role activities because of emotional problems; 7) Vitality (energy and fatigue); and 8) General health perceptions [ 46 ]. The main drawback of these tools is that they ignore significant dimensions such as sexual and socio-economic dimensions which are important for certain groups including infertile men. Additionally, the other dimensions of the questionnaire are not sensitive enough to measure changes in the quality of life of people with various diseases [ 68 ].

Health researchers have recently paid much attention to the examination of the quality of life and the design of a questionnaire to measure this concept. This measurement can improve clinical decision-making, estimate healthcare in a particular population, perceive different health causes and consequences, and, finally, promote health policy. All of these objectives will be achieved in light of a specific tool in this regard. However, according to the review, no questionnaire has hitherto been designed to measure the quality of life in infertile men. Specific questionnaires for infertile couples or general quality of life questionnaires have been used in different studies. Given the concept of quality of life and its changes over time as well as the expansion of tool-making knowledge, there is a need to design specific tools to measure the quality of life of infertile men by using mixed methods. We hope that more attention will be given to this significant issue in future. Polit and Beck argue that one of the main applications of exploratory mixed methods is in instrument making. They maintain that when a new tool is developed to explain a health-related concept, the complexity of this concept must be carefully explained [ 69 ].

Furthermore, it seems that the concept of men’s quality of life needs more investigation and also this concept may change over time and impact on their life. Besides, the studies demonstrated specific concerns among infertile men such as decreased self-esteem, Fertility- related stress, masculinity identity, hiding the infertility problem, resistance to the treatment, and cost of treatment [ 70 , 71 ]. These concerns could be the specific items for the infertile men-related quality of life questionnaire.

Research limitations

The impossibility of meta-analysis was because of several limitations in the study: (1) Variety of tools and small sample size in each subgroup; (2) Inaccurate report of information; and (3) -heterogeneity of the studies. Other limitation in this systematic review was that the reviewed papers were confined to English literature; thus, it is possible that some relevant non-English language studies were missed.

The systematic review strategies and solutions

The quality of life of men is one of the basic issues in their life. Assessing the quality of life of men should be done during the initial evaluation of infertility, and if necessary, interventions should be made to improve their quality of life. It is recommended that researchers, using qualitative-quantitative methods, first explain the concept of the QOL of men with infertility and then design and psychometrically evaluate the QOL tool for men experiencing infertility. Based on its context, each country should design a suitable program to improve the quality of life of men.

Data availability

All data related to this review is included in the result section of the manuscript. If any further data is needed it can be accessible via the corresponding author on request.

Abbreviations

World Health Organization

The Newcastle-Ottawa Scale

Preferred reporting items for systematic reviews and meta-analyses

Not reported

The Health Survey Short Form

World Health Organization Quality of Life Instruments

The Fertility Quality of Life tool

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Kiani, Z., Simbar, M., Rashidi, F. et al. The quality of life of men experiencing infertility: a systematic review. BMC Public Health 24 , 1236 (2024). https://doi.org/10.1186/s12889-024-18758-6

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• A Majority of Latinas Feel Pressure To Support Their Families or To Succeed at Work

Expectations to excel at work and to do housework, be beautiful and start a family are top pressures

Table of contents.

• The impact of gender, Hispanic identity and skin color on the lives of Latinas
• 2. Pressures Latinas face in their lives
• 3. Life satisfaction and sources of joy for Latinas
• Acknowledgments
• The American Trends Panel survey methodology

Pew Research Center surveyed 5,078 Hispanic adults, including 2,600 Hispanic women, in an effort to better understand Latinas’ life experiences, the pressures they face and where they find joy. The survey was conducted from Nov. 6 to Nov. 19, 2023, and includes 1,524 respondents from the Center’s American Trends Panel and an additional 3,554 from Ipsos’ KnowledgePanel.

Respondents on both panels are recruited through national, random sampling of residential addresses. Recruiting panelists by mail ensures that nearly all U.S. adults have a chance of selection. This gives us confidence that any sample can represent the whole population (see our Methods 101 explainer on random sampling). For more information on this survey, refer to its methodology and questionnaire .

The terms  Hispanic  and  Latino  are used interchangeably in this report. 

The terms Latinas and Hispanic women are used interchangeably throughout this report to refer to U.S. adult women who self-identify as Hispanic or Latino, regardless of their racial identity. 

Foreign born  refers to persons born outside of the 50 U.S. states or the District of Columbia. For the purposes of this report, foreign born also refers to those born in Puerto Rico. Although individuals born in Puerto Rico are U.S. citizens by birth, they are grouped with the foreign born because they are born into a Spanish-dominant culture and because on many points their attitudes, views and beliefs are much closer to those of Hispanics born outside the U.S. than to Hispanics born in the 50 U.S. states or D.C., even those who identify themselves as being of Puerto Rican origin. 

The terms  foreign born  and  immigrant  are used interchangeably in this report. Immigrants are also considered first-generation Americans. 

U.S. born  refers to persons born in the 50 U.S. states or D.C. 

Second generation  refers to people born in the 50 U.S. states or D.C. with at least one immigrant parent.  

Third or higher generation  refers to people born in the 50 U.S. states or D.C., with both parents born in the 50 U.S. states or D.C. 

Throughout this report, Democrats are respondents who identify politically with the Democratic Party or those who are independent or identify with some other party but lean toward the Democratic Party. Similarly, Republicans are those who identify politically with the Republican Party and those who are independent or identify with some other party but lean toward the Republican Party.

More than half of Latinas say they often feel pressure to provide for their loved ones at home or succeed in their jobs, mirroring the life stressors experienced by women across the United States today.

Latinas feel cross-pressured in other ways too, as they juggle cultural expectations around gender roles rooted in Latin America and those rooted in the U.S. Majorities of Latinas say that U.S. Hispanic women face pressure to do housework, be beautiful and start families.

Despite these life pressures, 88% of Latinas are either extremely or very satisfied (56%) or somewhat satisfied (32%) with their family life. And 86% say they are extremely or very happy (43%) or somewhat happy (43%) with how things are going in their lives these days.

At 22.2 million, Latinas account for 17% of all adult women in the U.S. today. The population grew 5.6 million from 2010 to 2022, the largest increase of any major female racial or ethnic group.

Moreover, most Latina adults have recent immigrant connections, with 77% being either immigrants themselves (52%) or having at least one immigrant parent (25%). 1

Some Latinas in the U.S. grow up with traditional cultural values carried over from Latin America. This can produce pressure from family or a community to place the needs of others ahead of their own, be passive or subordinate to others, or be virtuous or chaste – characteristics related to marianismo . At the same time, some Latinas may also feel pressure to achieve success in their own right in academics or a career .

These findings emerge from Pew Research Center’s bilingual National Survey of Latinos, conducted Nov. 6-19, 2023, among 5,078 Hispanic adults. The survey explores what it’s like to be a Latina in the U.S. today.

In addition to life pressures ( Chapter 2 ), the report explores Latinas’ views on sexism against women in media, schools, family and the workplace, and their experiences with harassment and discrimination ( Chapter 1 ). Other topics include Latinas’ views of their general happiness and life satisfaction and where they find joy in life ( Chapter 3 ).

Pressures Latinas say they face at home and work

• 53% of Latinas say they often feel pressure to support their family in some way, by caring for children or elderly family members, supporting their family financially or living close to family.
• 39% of Latinas say they often feel pressure to be successful in their job or career.
• Overall, 63% of Latinas say they often feel family pressures or work pressures.

Hispanic men also feel life pressures. About half (49%) of Hispanic men say they often feel pressure to support their family in some way, and 40% say they face pressure to be successful at work. Overall, 59% of Hispanic men say they often feel pressure from family or work.

However, Latinas are more likely to say Hispanic women face pressures such as cooking and cleaning at home, being pleasant to others, and starting a family than to say this about Hispanic men. Among Latinas:

• 68% of Latinas say Hispanic women face a great deal or fair amount of pressure to cook and clean at home, compared with 19% who say the same is true for Hispanic men.
• 62% say Hispanic women face pressure to be beautiful, such as by dressing nicely, wearing makeup or doing their hair and nails. By comparison, 37% of Latinas say Hispanic men face pressure to be handsome, such as by dressing nicely or styling their hair.
• 56% say Hispanic women face pressure to get married and have children, while 36% say the same of Hispanic men.

Hispanic men generally agree that Hispanic women face more pressure than Hispanic men to do things associated with gender roles for women. For example, 57% of Hispanic men say Hispanic women face pressure to cook and clean at home, compared with 18% who say Hispanic men face this pressure.

Among Latina adults, those who are U.S. born are more likely than immigrants to say Hispanic women as a group face pressure to do things tied to idealized gender roles.

• 66% of U.S.-born Latinas say Hispanic women face a great deal or fair amount of pressure to get married and have children, compared with 47% of Latina immigrants who say U.S. Hispanic women face these pressures.
• 76% of U.S.-born Latinas say Hispanic women in the U.S. face a great deal or fair amount of pressure to cook and clean at home, compared with 59% of immigrant Latinas.
• 68% of U.S.-born Latinas say Hispanic women face a great deal or fair amount of pressure to be beautiful, compared with 56% of immigrant Latinas.

About half of Hispanic women say sexism against women is a problem in different settings, including at work and in entertainment media. Hispanic men are less likely to say so.

• 52% of Hispanic women say sexism against women is at least a somewhat big problem in the workplace, compared with 44% of Hispanic men.
• 48% of Hispanic women say sexism against women is a problem in schools, while 37% of Hispanic men say this.
• Among English speakers, 50% of Hispanic women say sexism against women is a problem in English-language music, compared with 40% of Hispanic men. 2
• Among Hispanic adults, 47% of women say sexism against women is a problem in English-language movies and TV, versus 36% of men.
• Among Spanish speakers, 46% of Hispanic women say sexism against women is a problem in Spanish-language movies and TV, compared with 36% of Hispanic men. 3

Latinas’ views vary by age on pressures, sexism and harassment

Younger Latinas are more likely than older Latinas to say:

• They often face pressure to succeed at work or live close to their family ( Chapter 2 ).
• Sexism against women is a big problem in the workplace ( Chapter 1 ).
• They have experienced harassment or discrimination in the past year ( Chapter 1 ).

For new research on the economic gains Latinas have made in the last two decades, read “ Half of Latinas Say Hispanic Women’s Situation Has Improved Over the Past Decade, Expect More Gains .”

• Latinas’ population size and growth rate from 2010 to 2022 were calculated using the 2010 and 2022 American Community Surveys through IPUMS. Latinas’ shares that are foreign born or second generation were calculated using the 2023 Current Population Survey ASEC, also through IPUMS. ↩
• Asked only of those who say they can carry on a conversation in English at least “a little.” ↩
• Asked only of those who say they can carry on a conversation in Spanish at least “a little.” ↩

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Thirty years later, the Women’s Health Initiative provides researchers with key messages for postmenopausal women

Researchers from the NHLBI-supported Women’s Health Initiative , the largest women’s health study in the U.S., published findings from a 20-year review that underscores the importance of postmenopausal women moving away from a one-size-fits-all approach to making medical decisions. Through this lens, the researchers encourage women and physicians to work together to make shared and individualized decisions based on a woman’s medical history, age, lifestyle, disease risks, symptoms, and health needs and preferences, among other factors. These findings support the concept of “whole-person health” and published in  JAMA .  After reviewing decades of data following clinical trials that started between 1993 and 1998, the researchers explain that estrogen or a combination of estrogen and progestin, two types of hormone replacement therapies, had varying outcomes with chronic conditions. The evidence does not support using these therapies to reduce risks for chronic diseases, such as heart disease, stroke, cancer, and dementia. However, the authors caution that the study was not designed to assess the effects of FDA-approved hormone therapies for treating menopausal symptoms . These benefits had been established before the WHI study began.  Another finding from the study is that calcium and vitamin D supplements were not associated with reduced risks for hip fractures among postmenopausal women who had an average risk for osteoporosis. Yet, the authors note women concerned about getting sufficient intake of either nutrient should talk to their doctor. A third finding was that a low-fat dietary pattern with at least five daily servings of fruits and vegetables and increased grains did not reduce the risk of breast or colorectal cancer, but was associated with reduced risks for breast cancer deaths. 

Media Coverage

• The Women's Health Initiative trials: clinical messages
• HRT for menopause is safe for some women, new study shows
• Major study supports safety of HRT in early menopause
• Hormone therapy for menopause doesn't reduce heart disease risk
• No need to fear menopause hormone drugs, finds major women's health study
• Researchers review findings and clinical messages from the Women’s Health Initiative 30 years after launch

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• Cardiovascular Disease Program Toolkit
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• About Heart Disease
• About Stroke
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Evaluation Basics Guide

At a glance.

This Evaluation Basics guide is helpful when evaluating heart disease and stroke prevention activities. This guide focuses on ensuring evaluation use through evaluation reporting.

Various aspects of evaluation reporting can affect how information is used. Programs should consider stakeholder needs, the evaluation purpose, and the target audience when communicating results. Evaluation reporting should identify what, when, how, and to what extent information should be shared. Evaluation reporting should also consider how information might be received and used.

Learn more about evaluation reporting and how to ensure use of evaluation findings. You can also download the complete guide .

Evaluation reporting: a guide to help ensure use of evaluation findings

Key considerations for effectively reporting evaluation findings.

These steps can help drive your intended users to action or influence someone or something based on the findings presented in your evaluation report.

Engage stakeholders

Stakeholders are people who are invested in the program or potentially affected by the evaluation. Stakeholders can play a key role by offering input throughout the evaluation process to ensure effective and useful reporting of evaluation results.

You can engage stakeholders:

• During the planning phase. Stakeholders can help determine the intended use of the evaluation findings, identify potential primary users of findings, and help develop a reporting and dissemination plan.
• Once data have been collected. Stakeholders can review interim findings, interpret data, help prepare findings, and to help develop potential recommendations.
• When developing the evaluation report. Stakeholders can help define the audience, identify any potential uses of the information, and ensure report findings meet the evaluation purpose.

Revisit the purpose of your evaluation

The purpose determines how the evaluation report and findings are used, who the users are, and the most appropriate type of reporting. There may be multiple purposes for conducting an evaluation.

Two common reasons for evaluating CDC-funded programs are to guide program improvement and to ensure program effectiveness.

• Program improvement. Program staff may want to see a dashboard report of selected indicators and receive regular brief, verbal updates at meetings to learn what midcourse adjustments to make to improve program operations and activities.
• Program effectiveness. A funding entity may ask for a detailed, comprehensive report to demonstrate whether program components contribute to expected outcomes for accountability purposes.

The evaluation's purpose can have a direct effect on how evaluation data are applied and used. Often, the desire is for evaluation recommendations and findings to inform decision making and lead to program improvement. Alternatively, evaluation results may be used to support or justify a preexisting position, resulting in little to no programmatic change.

Define your target audience

Consider and define the target audience of your evaluation report and findings.

• Who are the intended primary users or the specific stakeholders who will most likely use the findings?
• Is the target audience the funding agency of the program, people who are served by the program, or key legislators or decision makers in your local government?

Evaluation findings can be presented differently depending on the target audience and primary evaluation users. Some things to keep in mind about your audience are:

• Effective communication channels. Identify the appropriate, preferred, and commonly used channels of communicating with your audience.
• Desired action. Consider what action you want the audience to take and what is within their sphere of influence. Explore how the target audience makes decisions or decides to take action on the basis of new information.
• Technical expertise or comprehension. Reflect on the level of familiarity the audience has with the subject matter and tailor the level of language to meet their comfort level. Use plain language over more technical language.
• Cultural appropriateness. Ensure that reports are culturally appropriate for the audience.
• Perceptions and expectations. Identify the audience's interest in or expectations of the project. Evaluation results may not always be expected or favorable. Regardless of how the findings are perceived, the opportunity for use remains. Also consider how the audience perceives the evaluator and the evaluation process.
• Presentation of information. Present findings according to the audience's preference. For example, choose between written documentation and oral communication and between presenting anecdotal stories and presenting data.
• Experience and context. Consider how your audience may interpret the findings, based on their understanding and experiences. Provide context where necessary, and keep the methodology description simple.

Making evaluation reports work for you

The format you use to deliver your evaluation findings will affect how and whether the findings are used. Use these tips to help ensure your evaluation findings are used by your stakeholders.

• Use action-oriented reporting . Action-oriented reporting prompts your audience to action. This type of report is focused, simple, and geared toward a particular audience.
• Offer creative options for format of delivery , such as newsletter articles, a website, one-page fact sheets, executive summaries, and PowerPoint presentations or webinars.
• Communicate your findings in a way that the audience can easily understand . Write content to describe graphs, tables, and charts. Do not assume that your readers will look at both the displays and the narrative. Ensure that all of your graphs, tables, and charts can stand alone.
• Interpret the findings . Interpretation means looking beyond the data and asking what the results mean in relation to your evaluation questions. It is always a good idea to review the results with selected stakeholders before completing an evaluation report. This review can be accomplished by circulating an interim or draft report and meeting to discuss it together.
• Include recommendations and lessons learned . The recommendations should address specific findings and be feasible, realistic, actionable, and tailored to intended users. A report that details lessons learned is particularly useful in contributing to public health practices and reporting for accountability purposes.

Keeping it off the bookshelf—the importance of dissemination

Effective dissemination requires a plan to get the right knowledge to the right people at the right time and to help them apply it in ways that may improve a program’s performance.

Step 1: Create a dissemination plan

Your dissemination plan should answer these questions:

• Who is the target audience?
• What medium will you use to disseminate findings—hardcopy print, electronic, presentations, briefings?
• How, where, and when will findings be used?
• Who is responsible for dissemination?
• What resources are available to accomplish the work?
• What are the follow-up activities after release?
• How will follow-up activities be monitored?

Step 2: Identify a person to oversee the dissemination plan

Identify a person to lead the dissemination effort. This person makes sure that the dissemination plan is carried out. They person should have experience making information accessible and understandable to different audiences.

Step 3: Know the current landscape

Recognize that most reports have a shelf life and most findings have a “relevancy date.” Be knowledgeable about your context, and select optimal release times. For example, if there is a great deal of media coverage about a topic related to your work, such as helping families stay healthy, you may wish to be con­nected to an existing press release or press conference. If your topic has received negative publicity, on the other hand, you may wish to “plan around” this coverage.

Step 4: Consider the timing and frequency

Dissemination works best when multiple products (e.g., a full report, a summary report, an evaluation brief) and channels (i.e., print, verbal, and Web) are used.

Step 5: Stay involved

Convene follow-up discussions and facilitation as needed to ensure continued use of the report. You can take advantage of events that may help keep continued focus on your findings, such as social media, brown-bag lunches, meetings, conferences, or workshops.

Cardiovascular Disease Data, Tools, and Evaluation Resources

CDC provides public health professionals with resources related to heart disease and stroke prevention.

For Everyone

Public health.

Child Care and Early Education Research Connections

Insights from the field: strategies for growing family child care: key findings and executive summary.

Between 2021 and 2022, eleven states saw increases in the number of family child care homes, reversing a long-term national trend. This brief analyzes this trend and presents key findings from focus groups and interviews with stakeholders from three of these states, focused on strategic financial investments as well as policy and systems-level solutions viewed as important in driving this change. (author abstract)

- Related Resources

Related resources include summaries, versions, measures (instruments), or other resources in which the current document plays a part. Research products funded by the Office of Planning, Research, and Evaluation are related to their project records.

Insights from the field: Strategies for growing family child care

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Insights from the field: Strategies for growing family child care: Appendices

Voices from the field: promising family child care strategies to support children in mixed-age groups.

The independent source for health policy research, polling, and news.

Do States with Easier Access to Guns have More Suicide Deaths by Firearm?

Heather Saunders Published: Jul 18, 2022

Nearly half a million lives (480,622) were lost to suicide from 2010 to 2020. During the same period, the suicide death rate increased by 12%, and as of 2009, the number of suicides outnumbered those caused by motor vehicle accidents. Suicides are most prevalent among people who live in rural areas, males, American Indian or Alaska Natives, and White people, but they are rising fastest in some people of color, younger individuals, and people who live in rural areas. On July 16, 2022, the federally mandated crisis number, 988, will be available to all landline and cell phone users, providing a single three-digit number to access a network of over 200 local and state-funded crisis centers. While the overall number of suicide deaths decreased slightly from 47,511 to 45,979 between 2019 to 2020, the suicides involving firearms increased over the same period (from 23,941 to 24,292). The recent mass shootings in Uvalde and Buffalo have catalyzed discussion around mental health and gun policy. In the same week that the federal Bipartisan Safer Communities Act was signed strengthening background checks for young adults, adding incentives for red flag laws, and reducing access to guns for individuals with a domestic violence history, the Supreme Court struck down New York’s “proper cause” requirement for concealed carry allowances. In this issue brief, we use the Center for Disease Control and Prevention (CDC) Wonder database and the State Firearm Law Database to examine the association between suicide deaths by firearm and the number of state-level firearm law provisions.

Suicides account for over half of all firearm deaths (54%), and over half of all suicides involve a firearm (53%). Though mass shootings are more widely covered, data reveal that suicides are a more common cause of firearm-related deaths than homicide. In 2020, a little more than half (54%) of all firearm-related deaths were suicides, 43% were homicides, and 2% were accidental discharges or undetermined causes. This represents a slight decrease from 2018 and 2019, where suicides by firearms accounted for over 60% of all firearm deaths in that period. Looking at suicides, we find that guns were involved in 53% of suicides in 2020, representing the majority of all suicides.

Variation in state-level suicide rates is largely driven by rates of suicide by firearm. Suicides involving firearms vary from the lowest rate of 1.8 per 100,000 in New Jersey and Massachusetts to a high of 20.9 per 100,000 in Wyoming, representing an absolute difference of 19.1. In contrast, the rate of suicide by other means is more stable across states, ranging from a low of 4.6 in Mississippi to a high of 11.4 in South Dakota, representing an absolute difference of 6.8.

There is a wide range of firearm law provisions across states, with Idaho having the fewest at just one and California having the most at 111. Because there is no comprehensive national firearm registry and very few state registries, it is difficult to track gun ownership in the US, so estimates of gun ownership rely on survey data or measures closely related to gun ownership–such as the number of firearm laws. The State Firearm Law Database is a catalog of the presence or absence of 134 firearm law provisions across all 50 states; this analysis uses firearm laws present in 2019. Even though state laws vary widely in detail and number, there are some common themes across states. Many states restrict firearm access to those considered high-risk, including people with felony convictions (37 states), domestic violence misdemeanors (31 states), or those deemed by the court to be a danger (28 states). A number of states regulate concealed carry permits–for example, 37 require background checks for applicants and 28 require authorities to revoke concealed carry permits under certain conditions, though some concealed carry laws may be subject to change given the recent Supreme Court decision.  Other major categories of gun laws include dealer regulations, ammunition regulations and child access prevention, among others. In 2019, the average number of firearm law provisions per state was 29 and ranged from one provision in Idaho to 111 in California ( Appendix Table 1).

More than twice as many suicides by firearm occur in states with the fewest gun laws, relative to states with the most laws. We grouped states into three categories according to the number of firearm law provisions. States with the lowest number of gun law provisions (17 states) had an average of six provisions and were placed in the “least” category; states with a moderate number of laws (16 states) had an average of 19 provisions and were placed in the “moderate” category; and states with the most firearm laws (17 states) had an average of 61 provisions and were placed in the “most” firearm provisions category. Using CDC WONDER underlying cause of death data, we calculated the age-adjusted rate of suicide by firearm for each category of states. We find that suicide by firearm is highest in states with the fewest gun laws (10.8 per 100,000), lower in states with moderate gun laws (8.4 per 100,000), and the lowest in states with the most gun laws (4.9 per 100,000) (Figure 3). The analysis is not designed to necessarily demonstrate a causal relationship between gun laws and suicides by firearm, and it is possible that there are other factors that explain the relationship.

Firearms are the most lethal method of suicide attempts, and about half of suicide attempts take place within 10 minutes of the current suicide thought, so having access to firearms is a suicide risk factor. The availability of firearms has been linked to suicides in a number of peer-reviewed studies . In one such study , researchers examined the association between firearm availability and suicide while also accounting for the potential confounding influence of state-level suicidal behaviors (as measured by suicide attempts). Researchers found that higher rates of gun ownership were associated with increased suicide by firearm deaths, but not with other types of suicide. Taking a look at suicide deaths starting from the date of a handgun purchase and comparing them to people who did not purchase handguns, another study found that people who purchased handguns were more likely to die from suicide by firearm than those who did not–with men 8 times more likely and women 35 times more likely compared to non-owners.

Non-firearm suicides rates are relatively stable across states suggesting that other types of suicides are not more likely in areas where guns are harder to access. To examine whether non-firearm suicides are higher in states where guns are more difficult to access, we used the state-level firearm law provision groups described above and calculated the age-adjusted rate for each group (states with the least, moderate, and the most firearm law provisions). The results of this analysis provide insight into whether there are other factors that may be contributing to the relationship between gun laws and firearm suicides, such as whether people in states that lack easy access to firearms have higher suicide rates by other means. The rate of non-firearm suicides is relatively stable across all groups, ranging from a low rate of 6.5 in states with the most firearm laws to a high of 6.9 in states with the lowest number of firearm laws. The absolute difference of 0.4 is statistically significant, but small. Non-firearm suicides remain relatively stable across groups, suggesting that other types of suicides are not more likely in areas where guns are harder to get (Figure 3). Though we do not observe an increase of suicide death by other means in states with less access to guns, there may still be differences across states that could explain these findings.

If the suicide rate by firearm in all states was similar to the rate in the states with the most gun laws, approximately 6,800 lives may have been saved in 2020, a reduction of about 15% of all suicide-related deaths. Applying the crude rate of 5.3 per 100,000 to the total population in 2020, we estimate that nearly 6,800 suicide deaths may have been averted if rates of suicide by firearm were similar to states with the most gun control laws.

Recent federal legislation strengthens some gun control measures, but it may take several years to impact firearm mortality. In the recently passed federal legislation, the Bipartisan Safer Communities Act , there is an emphasis on strengthening some measures of gun control including background checks for young adults and reducing gun access for those who have a history of domestic violence, among other provisions. Also included in the legislation are additional funds for mental health services in schools and for child and family mental health services. Despite federal movement toward strengthening gun control, a recent Supreme Court decision struck down state legislation that placed additional restrictions on concealed carry permits. It is not known how the Supreme Court’s decision will impact the frequency of concealed carry firearms and the rate of firearm mortality. More firearm regulations are associated with fewer homicides and suicides , but the newly passed federal gun laws may take several years to reduce firearm mortality .

If you or someone you know is considering suicide, contact the National Suicide Prevention Lifeline at the new three-digit dialing code 988 or 1-800-273-8255 (En Español: 1-888-628-9454; Deaf and Hard of Hearing: 1-800-799-4889).

This work was supported in part by Well Being Trust. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

• Mental Health
• Gun Violence
• State Level

Also of Interest

• The Impact of Gun Violence on Children and Adolescents
• Child and Teen Firearm Mortality in the U.S. and Peer Countries
• A Look at the Latest Suicide Data and Change Over the Last Decade