The family, as the smallest social institution, has responsibilities across many functions, including maintaining family health. Increases in chronic diseases and life expectancy require more family support to prevent disease and implement treatment for family members with chronic diseases. Therefore, physician involvement in not only the treatment of diseases but also their prevention and rehabilitation is required In Indonesia. Hence, a new approach for physician involvement with families is required, especially with regard to comprehensiveness. This study aimed to develop a physician involvement program with the family model for primary healthcare in Indonesia.
A two-round Delphi method with family medicine experts from 17 of the highest accredited medical faculties in Indonesia as participants was conducted, and factor analysis performed thereafter. The items were considered relevant at ≤0.8 validity content ratio. The second step of this research is survey using e-questionnaire involving 101 primary care physician from all over Indonesia. They live scattered in several provinces in the main islands of Indonesia such Sumatra, Java, Kalimantan, Sulawesi dan Bali.
Results showed an adequately measured sample and correlation for all items (Kaiser-Meyer-Olkin of sampling=0.821; Bartlett’s test <0.001). Seven dimensions were derived from results with eigenvalue of >1, and 25 items were filtered after determining the loading factor of >0.5. The Cronbach’s α for each factor varied from 0.602 to 0.829, and that for the total 25 items was 0.913, with a total variation documented as high as 66%.
A new physician involvement model with the family approach model, known as the “GENOGRAM model,” was developed, which consisted of seven dimensions and 25 items.
Family medicine is the medical specialty that provides continuing and comprehensive healthcare for a patient and their family [
Physician involvement with the family does not only involve its levels, where level 2 is higher than level 1, or level 4 is higher than level 3, and so on, but should also include the aspect of intervention. The comprehensive care aspect can also indicate a physician’s level of involvement with a family. Additionally, in a primary care setting, more activity details are required to indicate physician involvement with the family, in particular, information that encompasses more than details on global involvement levels. To address this requirement, this study aimed to develop a new approach for physician involvement with the family, particularly with regard to Indonesian family physicians implementing family-oriented primary care.
A two-round Delphi method was conducted to investigate physician involvement with the family [
Ethical approval number is 846/UN26.8/DL/2018 provided by Health Research Ethical Comission Faculty of Medicine University of Lampung. Informed consent was obtained from all individual participants included in the study.
The physician involvement with the family “GENOGRAM” model was developed from references and physician clinical practice experience, and then strengthened by family medicine experts from 17 of the highest accredited medical faculties in Indonesia. Primary care physicians throughout Indonesia and members of professional organizations were involved in the item factor analysis. This method was followed to ensure conformity between the items and actual conditions of the Indonesian primary health care field. The characteristics of experts and primary care physicians who participated in the Delphi process are presented in
The number sufficient to perform the factor analysis (Kaiser-MeyerOlkin test) was 0.832 [
Each of the 25 items selected had a minimum correlation of 0.5 in terms of their dimensions, indicating that each of the 25 selected items were validated to describe their dimension group. A Cronbach’s α of >0.6 for each dimension was also obtained, confirming that the dimensions and their items were consistent or stable. The item correlation was 0.368−0.767, demonstrating that the remaining 25 items were valid. The physician involvement with the family GENOGRAM model, consisting of seven dimensions and 25 items, was established to assess physician involvement with the family in Indonesian primary care settings. Each dimension and their items are shown in
The GENOGRAM model dimensions can be understood as a scope of strategies to engage families in healthcare. They are: family profile; family environment and lifestyle role; home visit; communication; activation and empowerment; and multilevel prevention [
The scope of physician involvement with a patient’s family is included in their dimensions (
The multilevel prevention dimension in the GENOGRAM model is also in accordance with comprehensive care [
The family profile dimension of the GENOGRAM model requires physicians to assess not only the demographic data of the nuclear family but also the history of family illness and family functions, including the social, cultural, economic, educational, and medical functions. Understanding family profiles is a way to understand patients as a part of their families holistically. In addition to risk assessment, family history information can be used to personalize health messages, which are potentially more effective in promoting healthy lifestyles than standardized health messages [
The environment and lifestyle dimension requires physicians to identify health risk factors, including family lifestyle and physical and social environment, which includes holistic care [
The role of the family dimension had a one-third total variation, the biggest proportion based on the total variation (
The home visit dimension assesses not only the physical environment but also the social and psychological environment and healthy and unhealthy family lifestyles. In this model, the home visit dimension is not associated with a specific purpose but could be affiliated to various purposes. This is indicated through the factor analysis where the home visit dimension is not related to other items, as it does not have an aggregated item (
The relay or communication dimension had almost 8% include “big 3” dimensions after the role of family and family empowerment. The relay dimension requires doctors to communicate with the family on matters related to the patient’s disease, with reference to the patient centered communication that includes family and friends to support improvement, families should understand the disease, treatment, complications, and prognosis in order to provide support properly [
The activating and empowering dimension had an approximately 10% total variation, meaning that this dimension is most predominant in this model after the role of family dimension. Activating and empowering assesses whether physicians initiate family meetings to resolve a patient’s health problem, or problems that arise because of the health problem; conduct family counselling to solve the patient’s health problems; increase the family’s skill to manage the patient’s health problems; increase the family’s knowledge to manage the patient’s health problems; assess family coping; and identify the impact of the patient’s illness on the family. Broad evidence from a systematic review of family empowerment on several health problems shows significantly better outcomes from solutions such as fruit and vegetable consumption [
This model is the first scope of physician involvement developed in an Indonesian setting. Physicians are required to be more involved with families in the scope of involvement, regarding promotive, preventive, curative, and rehabilitative care in primary healthcare.
In conclusion, the physician involvement with the family GENOGRAM model for Indonesian family physicians in primary care settings was developed in this current study. This model consists of seven dimensions and 25 items, with a total variation score of 66% and Cronbach’s α coefficient of 0.913. This is the first time that a GENOGRAM physician involvement model of this nature has been designed in Indonesia.
No potential conflict of interest relevant to this article was reported.
This study was funded by the Ministry of Research Technology and Higher Education of Indonesia. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Additional support was received from the “International conference sponsorship of Ministry of Research Technology and Higher Education of Indonesia” for the oral presentation in Asia Pacific Regional Conference of WONCA 2019 in Kyoto, 15–18 May 2019.
We thank all family medicine experts from Medical Faculty with highest accreditation in Indonesia and all primary care physicians for their contribution.
Item validation through the Delphi method by the family medicine experts.
Item extraction with factor analysis. KMO, Kaiser-Meyer-Olkin test.
Participant characteristics in the Delphi method and factor analysis
Characteristic | 1st Delphi (N=20) | 2nd Delphi (N=22) | Physicians in factor analysis (N=101) |
---|---|---|---|
Gender | |||
Male | 9 (45) | 3 (17) | 25 (25) |
Female | 11 (55) | 19 (83) | 76 (75) |
Education | |||
MD | 0 | 6 (27) | 80 (80) |
Master/specialist | 10 (50) | 12 (55) | 19 (19) |
PhD/subspecialist | 10 (50) | 4 (19) | 2 (2) |
Occupation | |||
Full-time lecturer | 5 (25) | 6 (27) | 0 |
Lecturer and practitioner | 15 (75) | 13 (59) | 5 (5) |
Full-time practitioner | - | - | 96 (97) |
Other | - | 2 (9) | |
Age (y) | 45.9 | 39.3 | 37.8 |
Length of professional career (y) | 0 | 10 | 15 |
Time as lecturer (y) | 24 | 16 | 0 |
Values are presented as number (%) or number.
New seven dimensions formed with aggregated items, based on loading factor >0.5, total variations and indicators
Dimensions | Aggregated items | Total variation (%) | Indicators |
---|---|---|---|
Family profile | 1, 2, 3, 6 | 5.023 | (→ G) indicates identification of demographic data, history of disease in three generations of the family and family function |
Environment and lifestyle | 4, 5, 13 | 5.668 | (→ EN) indicates identification of health risk factors, including family lifestyle and physical/social environment |
Role of family | 7, 8, 9, 10, 16 | 29.870 | (→ O) indicates identification and continuing assessment of family role and support for patient, including caregiver |
Go to patient’s home (home visit) | 28 | 3.762 | (→ G) indicates physician performs home visits |
Relay (communication) | 14, 15, 19 | 7.991 | (→ R) indicates physician communicates the patient’s condition to the family, including medical condition, treatment plan, complications and prognosis |
Activating and empowering | 24, 25, 26, 27, 29, 30 | 9.359 | (→ A) indicate physician performs family activation and empowerment to manage patient problems |
Multilevel prevention | 18, 22, 23 | 4.064 | (→ M) indicates physician performs comprehensive care defined by five levels of prevention |
The items excluded from the final model were items no. 11, 12, 17, 20, 21, and 31.
Instrument dimension, item correlation, and loading factor of the physician involvement with the family GENOGRAM model
No. | Factor/dimension | Item indicators and numbers | Item correlation | Loading factor | Cronbach’s α |
---|---|---|---|---|---|
1 | Family profile | 1: Assess demographic information (name, birth date, occupation, religion, education, etc.) of each family member | 0.453 | 0.731 | |
2: Explore history of disease of core family members | 0.504 | 0.636 | 0.707 | ||
3: Develop family genogram (including 3-generation disease history) | 0.523 | 0.630 | |||
6: Assess family functions | 0.517 | 0.544 | |||
2 | Environment and lifestyle | 4: Identify healthy and unhealthy behaviours in family members’ lifestyles | 0.767 | 0.807 | |
5: Assess the stages of the family lifecycle | 0.749 | 0.748 | 0.834 | ||
13: Identify potential hazards in the family environment (physical, chemical, biological, psychological, ergonomic) | 0.579 | 0.532 | |||
3 | Role of family | 7: Assess family support for patient | 0.502 | 0.701 | |
8: Identify family members who act as caregivers or key health providers | 0.642 | 0.705 | |||
9: Appreciate and listen to the caregiver or key health provider’s opinions | 0.767 | 0.709 | 0.827 | ||
16: Continue family assessment | 0.678 | 0.610 | |||
10: Cooperate with family members to improve the patient’s family support | 0.547 | 0.655 | |||
4 | Communication | 14: Provide the patient’s medical information to the family | 0.755 | 0.852 | |
15: Explain the prognosis of the patient’s illness to the family, including complications | 0.726 | 0.811 | 0.816 | ||
19: Describe the patient’s treatment plan to the family | 0.546 | 0.741 | |||
5 | Activating and empowering | 24: Initiate family meetings to resolve the patient’s health, or that arise because of it | 0.511 | 0.574 | |
25: Conduct family counselling to solve the patient’s health problems | 0.686 | 0.775 | 0.831 | ||
26: Increase family skill to manage health problems | 0.667 | 0.718 | |||
27: Increase family knowledge to manage health problems | 0.613 | 0.747 | |||
29: Assess family coping | 0.578 | 0.701 | |||
30: Assess the impact of the patient’s illness on the family | 0.592 | 0.591 | |||
18: Disease prevention via intervention and family wellness plan | 0.425 | 0.667 | |||
6 | Multilevel prevention (comprehensive care) | 22: Initiate family to curative and disability limitations due to the patient’s disease | 0.368 | 0.536 | 0.602 |
23: Initiate family in disease rehabilitation | 0.439 | 0.645 | |||
7 | Home visit | 28: Visit the patient’s home (home visit) | 0.547 | 0.789 | 0.913 |
Total Cronbach’s α of 25 items=0.913.
The GENOGRAM model with all 25 item indicators
Dimension | Item indicator | Scoring based on proportion of total variation |
---|---|---|
G → Family profile | a. Assess demographic information (name, birth date, occupation, religion, education, etc.) of each family member | 1 |
b. Explore history of disease of core family members | 1 | |
c. Develop family genogram (including 3-generation disease history) | 1 | |
d. Assess family functions | 2 | |
EN → Environment and lifestyle | a. Identify healthy and unhealthy behaviours in family members’ lifestyles | 2 |
b. Assess the stages of the family lifecycle | 1 | |
c. Identify potential hazards in the family environment (physical, chemical, biological, psychological, ergonomic) | 2 | |
O → Role of family | a. Assess family support for patients | 3 |
b. Identify family members who act as caregivers or key health providers | 3 | |
c. Appreciate and listen to the caregiver or key health provider’s opinions | 3 | |
d. Continue family assessment | 10 | |
e. Cooperate with family members to improve family support for the patient | 10 | |
G → Go to patient’s home | a. Visit the patient’s home (home visit) | 3 |
R → Relay/communication | a. Provide the patient’s medical information to the family | 3 |
b. Explain the prognosis of the patient’s illness to the family, including complications | 3 | |
c. Describe the patient’s treatment plan to the family | 2 | |
A → Activating and empowering | a. Initiate family meetings to resolve the patient’s health problem, or that arise because of it | 1 |
b. Conduct family counselling to solve the patient’s health problems | 3 | |
c. Increase family skill to manage health problems | 3 | |
d. Increase family knowledge to manage health problems | 3 | |
e. Assess family coping | 1 | |
f. Assess the impact of the patient’s illness on the family | 1 | |
M → Multilevel prevention (comprehensive care) | a. Disease prevention via intervention and family wellness plan | 1 |
b. Initiate family in an effort to disable limitations due to the patient’s illness | 1 | |
c. Initiate family in disease rehabilitation | 1 | |
Total score | 65 |