Family Practice O Oxford University Press 1992

Vol. 9, No. 2 Printed in Great Britain

Problems and Issues in Family Medicine Psychosocial Research JACK H MEDALIE AND STEPHEN J ZYZANSKI Medalie JH and Zyzanski SJ. Problems and issues in family psychosocial research. Family Practice 1992; 9: 222-230. The authors believe that, despite their complexity, psychosocial factors should be included with biological variables in family medicine research. To aid this process, this article reviews some problems and issues in selected areas of psychosocial research relevant to family medicine. Basic background material, dimensions, models, intra-individual, intra-familial physiological mechanisms of transmission, and factors related to stress, support and coping, are discussed. This is followed by methodological issues that include research design, psychometric properties of measures, data collection, quantitative and qualitative methods, family assessment problems and techniques, and analytic procedures. The latter includes scoring problems, global versus specific questions, and statistical analyses issues. Finally, a discussion of biological relationships and potential biological markers for psychosocial processes or variables concludes this review.

INTRODUCTION Every experienced family physician can relate clinical vignettes in which there seems to be little doubt that psychosocial factors precipitated sudden death of patients, the onset of specific diseases, or played other important roles in their patients' condition. Clinical practice examples include the sudden death of a middle-aged father upon learning of the accidental death of his only son; the death of apparently healthy people within hours or days of the death of their spouses; and the onset of severe arthritis in women following the death of their spouses. In today's health care environment, the recognition and treatment of disease is only part of a physician's job. Today's physician also must be concerned with the prediction and prevention of disease. It is not enough, therefore, to recognize that psychosocial factors can have a significant effect on health status, we must also try to predict who is likely to be affected and in what way. Thus, today's family physicians may find themselves trying to answer questions such as: "How do we show that these incidents are not just coincidences?" "How do we predict which people will develop disease and who will remain healthy following prolonged stress or a sudden crisis?"

Research into the relationship between psychosocial factors and health is complicated. In this paper we review some problems and issues in the major areas of psychosocial research in family medicine. Our main purpose is to sensitize the reader to the broad set of issues and problems confronting family medicine researchers interested in psychosocial aspects. It is not our intent to discuss individual issues in detail but rather to provide, in one place, a general overview of the relevant issues so the interested researcher can grasp the larger picture. DIMENSIONS OF PSYCHOSOCIAL FACTORS Psychosocial factors have been described as having three dimensions. The first is the psychic or internal dimension which embraces both cognitive and affective processes. The cognitive process (the intellectual feature) includes perceptual reasoning, judgment and memory; the affective process embodies the dimensions of feeling and emotion such as anger, fear and anxiety. Most activities, however, integrate both cognitive and affective processes. The second or social dimension encompasses relationships with people, sociocultural institutions and geophysical surroundings—for example, lead poisoning in its extreme form can lead to severe mental retardation. The third dimension of psychosocial factors is the relationship with biological processes. For example, genetics plays a vital role, not only in race and sex distribution, but in its control of the chemical substances in the body that

Department of Family Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA. Address correspondence to Dr Medalie, Dorothy Jones Weatherhead Professor, Department of Family Medicine, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4950, USA.

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FAMILY MEDICINE PSYCHOSOCIAL RESEARCH determine many of our psychosocial reactions such as depression. Psychosocial Models Based on these dimensions, family physicians have adapted certain models for use in the discipline. Models are descriptions of belief systems or concepts developed to help us understand and visualize the principles by which we function. The determinants of the model used include where in the medical care system the patient is seen (primary physician's office or tertiary care hospital), the type and severity of the illness, the age of the patient and the physician's training and attitude. However, no single model adequately represents the multiple activities inherent in the practice of family medicine. Therefore, a number of models are commonly used, including the biomedical, the biopsychosocial, the developmental, the systems and the epidemiological models.1 The models on which a research project is based usually determines the specific goals and objectives of the project and will thus influence which of the many psychosocial variables will be used in a particular investigation. Some variables such as socioeconomic status and anxiety are used in many studies, while others like 'locus of control' and 'self-efficacy' are used less commonly. The definitions and items used sometimes vary from model to model and thus are not often comparable across studies.

MECHANISMS OF PSYCHOSOCIAL PROCESSES Prior to delving into methodological issues of psychosocial research, we need to review the basic science and behavioural mechanisms of how psychosocial processes affect the organ systems of the individual, and how these are transmitted to primary groups, usually the family. An important and appropriate question is, how does a particular psychosocial variable affect the health of the individual from a physiological point of view? For example, evidence exists to show that chronic anxiety or family problems leads to higher rates of angina pectoris or duodenal ulcer. Other studies have revealed higher mortality rates in the first year following bereavement of a spouse.2-3 Stressful life events, with low levels of social support, are associated with increased attacks of upper respiratory infections and the development of chronic diseases.4 Religious people have a significantly lower incidence of myocardial infarction and cancer than the non-religious.3'6 The last decade has seen advances in our understanding of physiology so we are better able to understand the processes involved whereby psychosocial variables are transformed into medical conditions. Physiological Mechanisms The meaning of events or stimuli from the environment is processed in the cortex which then activates

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neurotransmitters (via receptors) to the brain stem, limbic system and hypothalamus (Figure I). 7 The latter is the centre in which psychological stress is transduced into physiological functioning. The hypothalamus contains three types of nuclear groups: the first is related to the autonomic nervous system; the second regulates the psychoimmune responses (cellular and humoral); and the third is connected to the neuroendocrine nuclei of the pituitary and thus to the other endocrine glands. At all levels there are feedback loops to both the previous and higher level of functioning which help control the amount and velocity of the transmissions. The foregoing processes are the mechanisms by which perceptions are transmitted via biological processes to the end organ systems, but what exactly happens when the body is in a chronic state of anxiety or persistent/prolonged stress? Looking at the cardiovascular effects of chronic stress reveals that it leads to an activation of the pituitary-adrenocortical system with an increase in corticotropin and corticosterone. This is followed by an increase of platelet mass, cholesterol, potassium excretion, hypertension, and an increased sensitivity to catecholamines. This process sets the stage for the acute physiological response that activates the sympathetic-adrenal medullary system, leading to increased levels of catecholamines and testosterone, as well as to increased cardiac output and peripheral resistance. These changes can lead to a rise in systolic and diastolic blood pressure, an increase in platelet aggregation, coronary vasospasm, and a decrease in ventricular fibrillation threshold, thus setting the stage for a possible acute cardiovascular dysfunction.8 Mechanisms of Transmission Within the Family Having seen how psychosocial factors are related physiologically to the functioning of the individual, the next questions are how does the attitude, belief or behaviour of one person develop in a family, and how are these characteristics transmitted to the other family members. Not only are these characteristics transmitted to the current family, but often to the next generation as well. The major transmission occurs through three interrelated areas within the context of the family matrix. These areas are love and nurturance, identification processes and learning activities.9 Love and nurturance is needed by every individual not only in infancy and childhood but throughout life. In this context, love appears to be a condition in which the feelings of two people are closely interwoven, and the sense of well-being and satisfaction of one is dependent to a large extent on the well-being and satisfaction of the other. Some of the processes that contribute to love and nurturance are: physical contact from the symbiotic relationship between mother and child in pregnancy and infancy; in caressing, stroking, holding hands and sexual contact; meeting the other person's needs; and giving emotional and other types of support when necessary.9

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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL Cerebral Cortex=meaning of stress is processed Activates (neurotransmitters)

Brain stem

Umbic System -

Hypothalamus

contains 3 types of nuclear groupings •

1. autonomic N.S. in brain stem, spinal cord and peripheral ganglia directly to:

2. neuroendocrine nuclei

I

3. regulate psychoimmune responses via cellular and humoral systems to body systems

Pituitary

-tissues and organs

I 2 kinds of hormones

a. tropic e.g. adrenocorticotropic-

voluntary nervous system • endocrine glands

b. hormones e.g proJactin act directly on peripheral tissue

I muscles etc

(Modified from Rieser) (7)

FIGURE 1. Psychophysiological pathways

The second area is identification processes. Freud10 defined identification as "the endeavor to mold a person's own ego after the fashion of one that has been taken as a model." Kagan" believes that identification is motivated by a desire to attain a positive goal, to master the environment, and to obtain love and affection. Identification is not an all or none process. A person may identify with some aspects of the role model but not with others, as well as with a variety of persons for different reasons. It also changes over time. Since the child's models are generally carriers and exemplars of behaviour of the culture or subculture, identification contributes to the process of socialization. Some of the types of identification that occur in families are: imitation or copying; prohibition; empathy; counter-identification, masked or hidden; and defensive identification.9 The third area of transmission occurs through learning and teaching processes. Learning is a process that brings about a relatively permanent change in an individual's repertory of responses as a result of experience or practice.12 Learning has three domains (psychomotor, effective and cognitive) and is trans-

mitted by association, motivation, perception, and reinforcement or conditioning.9 The three areas of transmission mentioned above all take place primarily within the family unit and they are strongly influenced by the relationships and atmosphere of this family matrix. This matrix is similar to the family context that Fisher and Ransom refer to in their recent excellent article.13 To conclude this section and prior to reviewing methodological issues, we include a few words on stress, support and coping. The concept of stress has been accepted for centuries but became acceptable for scientific study due to Cannon's work in the 1930s and Seyle's work on the general adaptation syndrome in the 1940s and later. Despite the large amount of work done on different aspects of stress, it is still a difficult concept to define and investigate. Although stress is regarded as a normal part of life, when it becomes overwhelming, a crisis is considered to occur. Hill14 first postulated his ABCX model where A the stressor interacts with B (family's resources) and with C (family's definition of the stressor) to produce X the crisis. This model was extended by Hill's col-

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leagues, McCubbin and Patterson, ' to become the T-Double ABCX model. This expands the original 'pre-crisis model' by adding 'post-crisis' variables on the individual, family and community levels. A task force of the Institute of Medicine used an XYZ model where X = activators or stimuli, Y = reactions, and Z = consequences, with mediators acting at all stages.17 An important dimension was added to the formulations of stress by Cassel and his colleagues4-18 who emphasized the area of social support. Ransom and Fisher13 added another dimension when they suggested that family relationships should be regarded as a primary conceptual frame for viewing the stress-health relationship. The response to stressful events is coping and it is apparent that the coping abilities of individuals and families are and will play an important part in future psychosocial research. Coping mechanisms include affective, cognitive and instrumental strategies. Items dealing with these areas need to be included in future research. METHODOLOGICAL ISSUES IN PSYCHOSOCIAL RESEARCH Having discussed important background information, we now turn to some methodological issues relevant for psychosocial research in family medicine. Research Design Despite the fact that psychosocial variables are generally more difficult to study than biological variables, the criteria for judging psychosocial studies must be as strict as for any other scientific study. In this respect, the criteria depend mainly on the strength of the research design—the plan, structure and strategy of the investigation needed to obtain answers to specific questions. This applies to descriptive, observational, analytical, quasi-experimental, or intervention studies. The key elements in the research design of any type of study are control groups and randomization, as far as these are possible. Psychometric Properties of Measures Psychometrics has been defined as methods that empirically investigate whether a test measures what it is intended to measure (validity) and yields consistent findings over time (reliability). It uses statistical methods to produce a quantitative index of reliability and validity." Zyzanski has characterized the psychometric properties of tests as consisting of the following properties: dimensionality (factors), item contribution (item analysis), reliability, validity, norms (including scoring), and replication (cross-validation).20 The two critical concepts are reliability and validity. Reliability or repeatability is concerned with the degree of consistency and has a number of types which are well-known: internal consistency or alpha, split-half, test-retest, and inter-rater. The validity of a measure is

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the extent to which it measures what it was designed to measure. Three basic types of validity include content, criterion-related and construct. There is an important quantitative relationship between reliability and validity. The degree to which an independent measure can correlate with an outcome measure is limited by its own reliability and that of the outcome.20 Therefore, a valid test must have a fair degree of reliability- However, the reverse may not be true: even if measures were perfectly reliable, the validity might still be zero, because it does not really measure what it was intended to measure. Who Provides the Data? Different types of data can be provided by an insider (patient or subject) the patient's family, a caretaker, or by an outsider. The latter is an observer or examiner who is not part of the subject's intimate primary group. The response by the insiders is subjective whether they are interviewed or answer through selfreport questionnaires. Their answers are their opinions, views and judgments related to their own or their family's attitudes, functioning, etc. The outsider's response is usually regarded as objective because they are not emotionally involved with the possible answers to the testing procedure. However, their subjective feelings and cultural background often enter the picture when the observer has to make judgments or ratings of the subject or family. Clinically, how often have these thoughts been voiced: "How can this nice person be an alcoholic or a drug abuser?" This means that the accuracy of the data collected is affected by the process of data collection (self-report, observation, etc.). Perhaps a more relevant question is, which is more important—subjective or objective assessments—in relationship to specific outcome measures? Some studies, such as those by Olson and otheTS,21 which have used both insider and outsider ratings have shown a low correlation between the two, but the outsider (objective) ratings have not always provided better correlation with outcome measures. For example, Mossey and Shapiro,22 in a 10-year follow-up of elderly people, found that after controlling for factors such as objective health status, age, sex, and income, the self-rated health of the subjects (a subjective opinion) at the beginning of the study was the best predictor of shortterm (at 3 years) and long-term (at 10 years) mortality. The current recommendation appears to be that studies should use a multi-dimensional approach by utilizing data from both insiders and outsiders. An invalid data collection can occur when an instrument which has been found to be valid and reliable on a particular group of people, such as white middleclass young adults, is then used on another population type such as black, low socioeconomic group adults or white elderly. The former instrument might not necessarily be appropriate for the latter groups and it may be necessary to re-establish the instrument's psychometric properties in the new setting.20

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Quantitative/Qualitative Methods The vast majority of published and presented research work in family medicine is based on quantitative methods, which are reflections of the basic sciences of statistics, epidemiology and behavioural sciences.23 These quantitative methods are important, and more and better quantitative research needs to be done. However, some of the richness and flavour of family medicine—for example, the differing perceptions of the various cultural groups, the integration of the psychosocial phenomena with biological factors, the view of the family as a system—is often missed in quantitative methods. Because quantitative methods often fail to reflect all aspects of the area under study, there seems to be two major roles for qualitative and other research methods. The first is as an adjunct or partner of quantitative methods in developing hypotheses and the second is in explaining results, that is, at the beginning and end of quantitative research. We agree with Blake,24 and Stange et at.v who have recently stressed the importance of integrating qualitative and quantitative methods concurrently into research projects. Burkett26 recently made the point that qualitative approaches are based on theory that requires different types of knowledge and classification system as compared to the quantitative approach. Kuzel,27 quoting from Guba, believes that family medicine needs an additional research paradigm having its own theory methods and epistemiology, and suggests a new paradigm for this purpose. It is uncertain whether his suggestion is the new paradigm needed for psychosocial research, but something is certainly needed to supplement and complement the quantitative methods now used. It also needs to be emphasized that qualitative methods should be taught and learned with the same rigor and depth as quantitative methods. What health providers do in everyday practice is not sufficient training for qualitative research methods. Family Assessment Family assessment for clinical and research purposes is one of the key factors in the survival and development of family medicine as a unique academic and scientific discipline. Clinical needs of screening, in-depth diagnosis, and follow-up of families, while similar in many aspects to research needs, differ from the testing of hypotheses, answering research questions, and predicting outcomes. These research needs often demand more precision and detail than is necessary in clinical work. Some of the current major issues28'29 of family research are firstly, there is no unified theory or model of family process and/or relationships that is accepted by the various disciplines working with families. It might be that the vastly different types and functions of families make it impossible to have a unified theory, but the fact that there none makes conclusions from family research all the more difficult.28 Secondly, there

is no widely acceptable method of linking the different theories with specific measurement techniques. Thirdly, there is difficulty in linking methods of measurement with types of analysis. Fourthly, the all-encompassing influence of the family on the individual has not been sufficiently emphasized in research. Ransom and Fisher13 argue that the family is 'the medium through which the links between stress from various sources and personal health can be understood.' Lastly, these issues are further compounded by the difficulty of defining the unit of analysis, of what is meant by family, and how to score family data. In everyday clinical practice we are faced with different primary intimate relationships and the problem of what constitutes the family. In essence, in family medicine we deal with at least four types of families. The biological family includes both the family of orientation and the family of procreation. This is depicted by the family tree or genogram, which usually covers several generations. The household consists of the people living in the same residence as the index patient and may include members of the patient's biological family as well as non-related people. The current household is usually depicted by a dotted line on the family tree. The household becomes important in monitoring transmission of infectious diseases, resources readily available, and sometimes clarifying intepersonal relationships. The functional family or group in day-to-day living deals with everyday problems such as who helps with the child care, grocery shopping, car pooling, etc. This includes what Carol Stack30 calls 'fictive kin ties', a group of reliable friends who are accepted and function as 'family'. The fourth type or crisis family (group) consists of relatives and non-relatives who become available to help out during a crisis. This often means siblings or children who live a long way away. These participants are usually a small core of people who do not change; together with others who vary, depending on the nature of the crisis—health matter, divorce, business failure, sudden death. In addition to the four primary types of families, other primary intimate groups may be involved in health and other activities. These people may include co-workers, club members, religious associates, school mates, and gang members. Family Assessment Research Techniques The multitude of family theories, models, and types of families has led to a number of different methods of family assessment for clinical and research purposes. Family assessment research techniques include observational techniques, self-report measures, protective techniques, experimental tasks, and structured or semi-structured interviews. Observational techniques are performed by people outside the family system and are regarded as objective and relatively unbiased. These techniques include both family interaction coding schemes and rating procedures.

FAMILY MEDICINE PSYCHOSOCIAL RESEARCH Family interaction coding schemes are coding schemes used for assessing family interactions. These observational techniques may be aided by videotapes and computer analysis which yield quantitative indices of interaction. Examples include the family interaction code and family interaction scales. Rating procedures involve a judgment by an outside observer with regard to placement of an individual, dyad or family on some psychological dimension. Examples of these include the Beavers-Timberlawn family scale and the McMaster rating scale. Some potential sources of bias in rating scale measurement relate to the observer. The latter needs to have thorough training and must guard against errors of central tendency, a leniency-severity effect and the carrying over of global impressions to specific items (the halo effect). Although replete with methodological challenges, family rating scales at this time may be the family assessment research method of choice.28 Self-report measures such as family functioning measures and measures of stress, use standardized questionnaires and are the most commonly employed method, both in clinical and research work. Two types of family functioning measures frequently used in our discipline are Smilkstein's Family APGAR31 and Olson's Faces III.21 There are many others but it is often difficult to compare different instruments because even though the constructs are the same or similar, they have different meanings. An example of this is expressiveness, which meant hugging and touching in one instrument and an open discussion of problems in another. Care must be taken, both in the administration and analyses of these self-report measures, to consider certain tendencies by the respondant. The latter often wishes to appear in a positive light so will answer as he thinks the investigator wants (social desirability). We have found that some people, especially the elderly, have a tendency to acquiescence throughout a questionnaire; while others want to be different so they answer negatively (deviation). Projective techniques include the family circle, a well-known technique that has many useful applications in clinical and educational activities.32 In research, the family Rorschach, family sculpture, and mapping techniques such as the ecomap and sentence completion tests have been used. To date, none of these has been sufficiently validated for research purposes. Experimental tasks are those given to families under direct observation to assess their coping, problemsolving and decision-making abilities. An example is the simulated family activity measure. These tasks are often unlike those which families commonly deal with and more work needs to be done to document the correlation between these results and how families solve problems in their own environment. Structured or semi-structured interviews of whole families may have future research application if some of the outstanding clinical skills of family therapists

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could be captured in a systematic way. However, this seems a long way from fruition, at this time. The content areas of family assessment is a subject unto itself and varies as much as the techniques. Suffice it to say that family assessment in family medicine means more than family functioning and should include the following areas: structure (sociodemographic variables), development (history and data base), functioning, and health status. ANALYTICAL ISSUES/PROBLEMS The objective of this section is to sensitize the reader to some of the issues or problems that arise in the analytical stage of projects. Being aware of these often means that provisions can be made in the planning stage so that the analysis will be more valid. Psychosocial variables are acceptable as relevant if the analyses show that the psychosocial predictor variables are related to the outcome, independent of other risk factors; or that psychosocial variables, in a synergistic form, increase the significance or predictive value of the known variables. Many good examples of these associations exist in the literature. ''2i33 Another methodological issue is scoring; severity ranking is one of the problems. To illustrate this issue, assume the answers to a self-report questionnaire on the severity of each of 20 life events are scored 0-4: no life event (0), mild effects (1), moderately severe (2), severe (3), very severe (4). The first respondent checks three life events each in the moderately severe category ( 3 x 2 points; total score of 6). The second respondent only had one life event that devastated him so he marked it as very severe, giving him a score of 4. The first person with 6 points is graded as having a higher total stressful life event score than the second respondent with 4. Without interviewing the two persons involved (a qualitative process), we will probably never know if this is a valid ranking. Global questions pose another problem. Some investigators have tried to shorten their questionnaires by asking a few global questions instead of many specific ones. Whether you ask one global question about your patient's social support, as Blake,34 general satisfaction with your sexual relationship, as Schein,35 or whether you ask detailed questions about specific problems within the larger subject, such as questions about sexual desire, arousal and orgasm instead of the global sexual satisfaction,35 will depend on the objective of your research and the measurement properties of the questions. Single or a few global questions might be appropriate for screening purposes but rarely help when more details are necessary. At the other extreme, microanalysis in certain situations, such as the physician-patient interview, does not always give the observer what is desired. How do we score the family? What is a family index? A summary or composite score is often dependent on how family data are classified and in this respect Fisher's scheme36 is most helpful. A modification

FAMILY PRACTICE—AN 228 of his scheme leaves us with this classification of family data: the individual's view of the family; aggregate of responses using a mean (which often does not reflect the variability); a sum (if adults are 1, then are children 1/2?) or a discrepancy score (relational); the whole family (one answer from whole unit); and direct observation of family interactions (transactional). A concordant/divergent score is useful for working with couples in certain situations. Unfortunately, a couple with concordant opinions might not necessarily be better off than a couple with divergent opinions who can discuss their differences in an open manner. Statistical analysis issues are also a problem. We have previously questioned whether qualitative research can be, or should be, analysed by statistics developed for quantitative studies. However, even in the quantitative field there are a number of problems. The lack of variance and skewness in some of the responses to certain psychosocial questionnaires is important because they determine the reliability and, to a certain extent, the validity of the instrument. Most of the statistical techniques we use are based on traditional assumptions about linearity. These techniques, however, are generally not appropriate for assessing curvilinear relationships in the data. For example, Olson's cohesion and adaptability dimensions are conceptualized as U-shaped distributions with 'normal' being in the middle. Another non-linear example is a family system where one person's relationships and responses to the others is heavily influenced by the interaction between the others and their response or feedback to the first individual. Linear statistics do not capture these interactions. Path and non-linear analyses, which some geneticists and behavioral scientists favour, are improvements but not the complete answer. An additional statistical issue is how to deal with changes in the independent variables in a longitudinal study. Changes over time occur in nearly all aspects of life. Whether it is height, weight, blood pressure, cholesterol level, or sexual functioning, there tends to be changes. Similarly, certain psychosocial properties, such as coping skills, also change with time and maturity. However, besides the statistical issues involved, we must remember that the instruments we use to measure these properties may not be sensitive to change. For example, in a group of pregnant women surveyed five times over a 1-year period, Reeb et al. found that scores on Hudson's Index of Family Relationships and an abbreviated Olson's cohesion measure did not change with time, whereas scores on an abbreviated Olson's adaptability measure and the Family APGAR did change.37 Therefore, in measuring changes over time, it is important that the measuring instrument selected is the appropriate one: this depends on whether you want to measure a stable trait or a labile state.

We next turn to the work of Ransom and Fisher.38 Without discussing the finer details of their methods, they seem to be trying to integrate valid and reliable

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measurements with an in-depth look at the family. This method attempts to provide a more in-depth way of assessing how a family functions and behaves. They are also using non-linear analyses and incorporating four life domains: structure-organization, problem solving-communication, world view, and emotion expression-management, against a health domain of 14 variables. Analytical strategies include clustering techniques such as principal component and multidimensional analyses and the multivariate technique of canonical analysis for correlations among the domains.38 Their work illustrates the increasing sophistication of measurements brought to bear on family dynamics and functioning. Finally, there is a problem in the analysis of data which a recent editorial in Lancet referred to as 'subjectivity.'39 The authors refer to a number of instances in which the same data set and results were interpreted differently by different investigators or by the same investigators at different times. This seems to occur when slightly different analytical standards are used. The effect of this is very confusing to everyone, including clinicians, who are expected to apply research findings to their practices, as well as the public who receive different recommendations on the same subject from different sources. Currently, there does not seem to be an easy answer to this problem. BIOLOGICAL RELATIONSHIPS Earlier in this article we showed how perceptions by an individual are converted and transferred from the cerebral cortex to the hypothalamus. The latter affects the autonomic and endocrine systems and the immune processes. These systems play key roles in three of the major diseases that affect us: cardiovascular disease, malignancies and infections. Thus, the relationship between psychosocial factors and the major causes of morbidity and mortality has a physiological explanation. Despite the improvement in the development of instruments to measure psychosocial factors, the presence of valid biological markers would be of great assistance. A biological marker in this sense can be viewed as a substance or sign which reflects changes in response to an emotional or psychosocial reaction; for example, our pulse rate may be regarded as a biological marker of fear or anger. There are two situations in which biological markers may help. The first is by having an added means for validating our instruments. If the diagnosis of, for instance, anger, anxiety, depression, or poor functioning, had reliable biological markers, it would be an important step in the ascertainment of validity. The psychophysiologists are searching for such markers and through the advances of molecular biology, there are a number of promising chemical molecular markers on the horizon. These might be chemical substances produced by the neuroregulators, the autonomic nervous system, the endocrine system or the immune system.40

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Another use of biological markers might help us answer some other psychosocial questions. For example, there have been numerous studies of adjustment of patients and their families to cancer. Psychological questionnaires and other measures characterize the coping reactions in different ways, and often a value judgment is placed on whether a certain type of adjustment is good (healthy) or not. In some follow-up studies people with breast cancer whose adjustment was labelled as good had a far worse prognosis for mortality than the poor adjusters.41-42 Similarly, Reiss et al.43 found that high scores on family problem-solving ability and intactness predicted early death rather than survival in a sample of patients with end-stage renal disease. They called this phenomenon the paradoxical vulnerability of strong families. These results paralleled animal studies in which a dissociation between observable distress behaviour and physiological distress markers was found. Thus, there might be four adjusted-physiological marker groups: well-adjusted with normal physiological markers (the best group), well-adjusted with poor markers, poor adjusters with normal markers, and poor adjusters with poor markers (the worst group). Many studies are showing the effect of psychosocial variables such as stressful situations on well-known biochemical substances such as cholesterol and its fractions, insulin and glucose. We therefore havefiveways of measuring stress: the subject's perception and opinion; the family's reaction; an outside observer's opinion; clinical signs (blood pressure, heart rate, sweating palms); and biochemical and molecular signs (lipids, norepinephrine, T cells). Whether our aim is to validate, to undestand better or to predict, it may not be long before biological markers will be a standard part of all psychosocial studies. CONCLUSION We have attempted to give a general overview of some problems and issues related to the current status of psychosocial factors in family medicine research. It is a complex field with many unresolved methodological issues of both a quantitative and qualitative nature. However, a great deal of progress has been made in this challenging and vital field. In general, we feel that all research in family medicine should include psychosocial as well as biological factors, even though these psychosocial variables are often complex, difficult to measure and analyse. By using quantitative as well as qualitative measures and by utilizing the various techniques mentioned here, we believe family medicine should and can make its unique contribution to the academic and health care domains. ACKNOWLEDGEMENT The authors thank Karyn Schmidt for her efficiency and support.

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