INTRODUCTION

Families are a universal phenomenon, present in all human societies and live in constant adaptation to social changes to fulfill their role of protecting and maintaining their values and beliefs^1,2. The family structure has different arrangements, organized with the union of individuals linked by the desire to support each other, without necessarily biological ties². In this way, the roles of the members are socially determined and are linked to the personal and psychosocial identity of each individual^3,4.

Family development cycles, on the other hand, are natural events that cause changes in the arrangement and determine the patterns of interaction⁴, for example, in situations of stress, the family can support or change certain behavior that will provide growth or destabilization of the family system. However, the different cultural, behavioral, spiritual characteristics, and values are preserved and passed on through generations^2,4.

In this way, the family operates as an open system and its health is influenced by the elements in interaction, allowing its members to act with the objective of maintaining the internal homeostasis (self-regulation) of its subsystems in constant internal interaction and in maintaining the congruence or feeling of harmony with the outside environment².

The assessment of how structural and developmental factors influence family functioning is important in the nurse's practice, as experiences with families have shown that some had greater ability to deal with situations of stress or uncertainty⁵. Therefore, it is considered that the understanding of the plurality of arrangements, the uniqueness of each developmental cycle and their possible influences on family functioning can increase the possibilities of identifying strengths and allow nurses to safely intervene with the family system², in the development of their skills to promote, maintain, restore and strengthen the health of the family unit⁴.

Aiming to assess health or family functioning, the instrument ASF-E/Brazil was adapted to Brazilian Portuguese and validated for use with Brazilian families⁶, the original of which was developed in the United States by Nurse Marie Luise Friedemann, called The Assessment of Strategies in Family-Effectiveness (ASF-E)⁴, is supported by the framework of systemic organization². This instrument was chosen for being supported by a consistent theoretical framework, for its ability to measure the functionality of the family and because it is freely accessible⁷. Experiences with this instrument in other countries such as Colombia^8-14, Mexico^15-17, Finland¹⁸, Germany and Switzerland¹⁹ highlighted its validity and reliability in assessing family health or functioning. However, the literature evidenced the absence of studies evaluating the correlation between family effectiveness, the type of arrangement and the family development cycle^7,20. Therefore, there are the necessity to know the influence of family arrangements and development cycles on family functionality. This allows creating hypotheses that family arrangements will have a significant difference in the assessment of the instrument's subscales. Its results can favor a nursing approach by analyzing arrangements, life cycles and functionality and allow nursing to develop real goals with the family to improve the family's health. Thus, this study aimed to assess the influence of structural and developmental factors on family functioning.

MATERIAL AND METHOD

This was an analytical and cross-sectional study with families within the cover of four Basic Health Units with a Family Health Strategy in the municipality of Pelotas, State of Rio Grande do Sul, Brazil.

The sample size was 200 people from 100 families, selected by non-probabilistic, convenience sampling, with two individuals per family^6,20,21. Participants were recruited based on the indication of community health, in the area covered by the in primary health care units, in Pelotas, southern Brazil. The sample instrument size, at least, was defined following the sample item's instrument size (n= 200). This number was used to meet the criteria for evaluating the reliability and validation of the instrument, with 10 respondents each item, totaling 200 participants. In all, visits were made to 100 families, with two pairs, each data were collected from October 2017 to March 2018. The inclusion criteria of the study were: being over 18 years old; know how to read in Portuguese; and the possibility of participation of two family members belonging to the area covered by the study. The exclusion criteria adopted were: not being able to verbally communicate to answer the sociodemographic questionnaire. A total of 223 families were approached, of which around 10.0% did not meet the inclusion criterion "possibility of participation of two family members" ⁶.

The approach to families occurred during a home visit, by the researcher, accompanied by community health agents and/or a nursing undergraduate student. On this occasion, the objectives of the study were presented and the type of participation was made explicit. After acceptance to participate, the Free and Informed Consent Form (ICF) was read and signed in two copies, one for the researcher and the other for each participant.

The average duration of the visit was one hour, which included the time to explain the objectives of the study, reading the ICF, collecting sociodemographic data and the time for the families to self-complete the instrument ASF-E/Brazil was 20 minutes. The sample was composed predominantly of female individuals, adults, married or in a stable relationship and Catholics (Table 1).

For the structural, developmental and functional assessment of families, data were collected by a sociodemographic questionnaire, applied by the researcher to the participants. Information regarding gender, age, number of children, main role in the family and the classification of the family life cycle were used to assess the family structure (roles and arrangements) and the family's development (stage of the development cycle).

Table 1 Sociodemographic characteristics of the participants (n = 200), Pelotas, Brazil, 2020. 

The classification of family arrangements considered the configurations described as follows: a) nuclear family: formed by two generations with biological children; b) extended family: formed by three or four generations; c) temporary foster family: may have a temporary character; d) biracial or multicultural foster family; e) single-parent families: headed by the father or mother; f) family of separated couples: formed by one of the parents, the father or the mother, and by his/her child(ren) not yet adults; g) homoaffective/homoparental family: formed by homoaffective couples with or without children; h) reconstituted family: formed by a couple in which one or both parties have a child(ren) from previous relationships; i) family without legal ties: formed by people who live together, with mutual commitment, without legal ties²².

The instrument used to assess family functioning was The Assessment of Strategies in Family-Effectiveness (ASF-E/Brazil), developed by nurse Marie-Luise Friedemann, professor and researcher in the United States⁴, based on the framework of systemic organization®. The ASF-E/Brazil was adapted to the Brazilian Portuguese language and validated for application with Brazilian families⁶. It is a self-administered instrument and its 20 items measure the level of family health or functioning.

A field diary was used for notes and observations regarding the perceptions of the nurse/researcher regarding the individual characteristics and the organization of the structure (roles and members of coexistence) of the family group, developed after the home visit. As well as the home environment and the participants' reports about the relationship with external systems (school, health service, work). Family arrangements were classified and described in terms of the overall structure/dynamics, marital and parental relationship, because it can contribute to the creation of standards of health of the person and the family^2,4,22.

Data were organized in Word documents and in Excel spreadsheets and analyzed using R statistical software. For the analysis, descriptive and correlational statistics and theoretical concepts of systemic organization were used^2,4,6. Socio-demographic characteristics and the effectiveness of family functioning were analyzed descriptively, for each question, the value observed in the sample (n) and percentage (%) was expressed. For the analysis of the instrument ASF-E/Brazil, each of the 20 items has three alternatives for each item. The effectiveness in family functioning is considered high when the alternative chosen is number 3, medium to alternative 2 and low to alternative 1. As for example, the options in item 1 of the instrument and their respective options: There is anger or sadness in our family (1); People in our family do not express their feelings much (2); Our family is happy, in general (3). The total value of the instrument is 60 points, results between 48 - 60 points are considered high effectiveness of family functioning, between 34 and 47 are considered intermediate and between 20 and 33 points are defined as low.

The 20 items correspond to the strategies to prevent the deterioration of the family system, and are classified according to four dimensions of coherence (1,10,15,18), individuation (3,5,7,12), System Maintenance (4,8,13,17,19) and System change (2,6,9,11,14,16,20). This aims to achieve target (subscales), called: stability, growth, control and spirituality^2,4,6.

Descriptive statistical analysis was performed using non-parametric methods. To assess the correlation between family arrangements, the development cycle and the effectiveness in family functioning, Spearman correlation (p) with significance of (p <0.05) was applied. The choice for the Spearman correlation (p) was based on the indication in the normality test (Kolmogorov-Smirnov) that the data were non-parametric. In addition to Cronbach's a, the Intraclass correlation coefficient (ICC), calculated as previously mentioned, and the Spearman correlation (p) (p<0.05) were used to complement the instrument's reliability investigation (ASF-E/Brazil). Cronbach's a and ICC were calculated for the total instrument, separately, for each factor of the AFE and also for each dimension and goal of the instrument (ASF-E/ Brazil) Spearman's coefficient (p) (p<0 .05) was calculated by correlating the scale total with the dimension values²¹.

In the pre-test of the instrument, with 15 individuals from the target population, in the assessment of conceptual and semantic equivalence and in the understanding of the ASF-E instrument items for face and content validity, 89.3% agreement was obtained, CVI of 0.89, Kappa coefficient of 0.80 and ICC (95% CI) of 0.99 (0.997 - 0.999). The categorization of correlations considered as null those with magnitude between 0.0 and 0.20, low (0.21 - 0.40), moderate (0.41 - 0.60), high (0.61 - 0.80) and very high (0.81 - 1.0)²¹. The analysis of variance for independent samples (Kruskal Wallis) tested the differences between the medians of processes of the dimensions of the ASF-E/Brazil. The study had no missing data.

This research was authorized by the Municipal Health Secretariat, by the Managers of the four Basic Health Units with the Strategy in Family Health of Pelotas, State of Rio Grande do Sul, Brazil. It was submitted to the Research Ethics Committee and approved under number 2.088.36 and CAAE 68095317.3.0000.5316.

RESULTS

Participants were 200 people from 100 families. The results of the evaluation of the structure, development and functioning of the 100 families are presented in the roles, family arrangements, developmental cycles and level of effectiveness of the family functioning.

The predominant family roles were mother (42.0%), among mothers, 71.0% were married and the rest were divorced (12.0%), single (11.0%) or widowed (6.0%), 35.0% of the families declared to have two children and the families were categorized in three arrangements, with a predominance of nuclear families (52.0%) (Table 2).

The result of the evaluation of the effectiveness in family functioning with the instrument ASF-E/ Brazil, showed a predominance of high level (82.0%) (Table 3).

The result of the assessment of the dimensions of the instrument ASF-E/Brazil indicated a predominance of the high level in the dimensions Coherence (64%), Individuation (64%), System change (75%) and System Maintenance (77.5%) (Table 4).

The result of the evaluation of the target of the instrument ASF-E/Brazil showed high classification for the target of control (71.0%), growth (71.0%), stability (70.5%) and spirituality (64.0%) (Table 5).

The presentation of the structural, developmental and functional assessment showed a high correlation between all the arrangements and dimensions of the instrument ASF-E/Brazil and the average effectiveness of family functioning per development cycle.

The evaluation of the correlation of family arrangements and the dimensions of the instrument ASF-E/Brazil showed statistical significance in the three evaluated arrangements. In the dimensions of coherence, individuation and System change, they were classified as high for all arrangements. In the dimension of maintenance in the system, there was a very high correlation (> 0.80) in all the arrangements. Only in the arrangement of extended families (more than three generations, reconstituted families with no legal ties), the correlation with the System change was moderate (0.58) (Table 6).

Table 2 Structure of the families (n = 200), Pelotas, Brazil, 2020. 

Table 3 Classification of the effectiveness in family functioning (n = 200), Pelotas, State of Rio Grande do Sul, Brazil, 2020. 

Table 4 Classification of the dimensions of the instrument ASF-E/Brazil (n= 200), Pelotas, State of Rio Grande do Sul, Brazil, 2020. 

Table 5 Classification of family target obtained with the instrument ASF-E/Brazil (n = 200), Pelotas, State of Rio Grande do Sul, Brazil, 2020. 

Table 6 Correlation between family arrangements and the instrument ASF-E/Brazil, Pelotas, State of Rio Grande do Sul, Brazil, 2020. 

The most frequent phase of the family development cycle was the phase of "launching" the children (from the first one until the last one goes) (36.0%). Still, it was identified that 76.0% of the families were in more than one development cycle. There were no correlations between the effectiveness of family functioning and sex, age group, marital status, number of children, religion, main role in the family and phase of the family development cycle. This finding demonstrates that these characteristics did not interfere with the level of effectiveness of the functioning of the assessed families. Only the assessment of the correlation between the family development cycles and the total score of the instrument showed a statistical difference, identified in the mean values, that is, the development cycle called "Family with preschool children (older child between 30 months and 6 years old)" had the best level of effectiveness of family functioning and the lowest mean value for families with "nest without using" (Only the couple) (Table 7).

Table 7 Family development cycle (n = 200) and mean values of the effectiveness in family functioning with the instrument ASF-E/Brazil, Pelotas, Brazil, 2020. 

There was no statistical significance, therefore, there was no correlation between families in one or more development cycles and the level of family functionality.

DISCUSSION

The novelty of this study is the presentation of the results obtained with the instrument ASF-E/ Brazil in determining the effectiveness in family functioning. It is essential the knowledge of family development and the structural configuration for the assessment and planning interventions with families. In this study, the main role was that of mother. This characteristic can be related to the female role, caring for children, the elderly and responsibility for other tasks, called domestic. Such assignments contribute to work overload, overlapping roles and responsibilities assumed daily by women²³.

In addition to Brazil, these characteristics were identified in studies that evaluated the effectiveness of family functioning in Finland¹⁸, because they bring with them a range of symbolisms and attributions of the female gender that can influence the family health level.

The families studied follow the worldwide phenomenon of fertility decline, with a predominance of the number of 1 to 2 children, in the family configuration. This characteristic corroborates the recent trend in Brazilian families of a sharp drop in the fertility rate, especially observed in poorer women with less education in all regions of Brazil^24,25. This reality can be linked to social changes such as economic and cultural changes, access to information and health services, which allowed families to get closer to the number of children they really want.

Still in the structural evaluation, there was a predominance of families in nuclear arrangements, formed, in general, by a heterosexual couple and child(ren). This traditional arrangement is characteristic of the modern family and was observed in studies that assessed the effectiveness of family functioning in Colombia^9,12,13 and Mexico^15,17. However, it has been losing space for arrangements of homosexual or single-parent families, less frequent even in this study, but a characteristic of contemporary families²⁶.

The expanded families, the second most frequent arrangement, are composed of three or more generations (with or without biological ties). In this study, reconstituted families and members without legal ties were grouped in this classification. Such a configuration may be related to factors ranging from the desire to share and live with other generations to financial need, due to economic factors, to support the family in chronic health conditions, as observed in home visits. This arrangement is characterized by the ability to receive, by relating not only with their children, but with other members, arising from different situations, with whom they share the feeling of belonging.

Still, as for unions, as described in the characterization, more than 60.0% participants declared themselves as married or in unions without legal recognition. The marriage is a social construction®, and this characteristic has been observed in Latin America¹².

In this study, the predominance of Catholic families may be related to cultural characteristics, especially in the southern region of Brazil²⁷. From a systemic perspective, spirituality and religiosity can have the same meaning as a feeling of belonging, connection, security, where they find comfort in difficult times, or be an individualized practice, or the sharing of life ideals². Therefore, beliefs have an important influence on the way we deal with events, due to their strong relationship with human subjectivity¹, it is related to the construction of meaning of human existence²⁸. As a result, it has the power to improve people's quality of life²⁹.

In the development of the family, marked by life cycles that are the phases in which the transmission and strengthening of values and beliefs take place; as well as building new family systems as cycles change. In this study, the most frequent development cycle was that of "families in the phase of "launching" their children (from the first one until the last one goes)", followed by "families with teenagers (older child between 13 and 20 years)". It is noteworthy that most families were in more than one development cycle, and since adaptation to the new cycle is characterized by the fragility of the unknown, it is emphasized, the importance of the nurse to prepare and accompany the family in adapting to the new cycle, as changes in family dynamics trigger periods of stress and, consequently, break with congruence (or harmony)².

In view of the results obtained with the instrument ASF-E/Brazil, Brazilian families showed high effectiveness in family functioning. Studies with similar results have shown that congruence can be a protective factor for family health². Despite the evaluation in specific populations with the instrument ASF-E, it has been revealed that the higher the effectiveness of family functioning, the lower the risk of intrafamily violence¹¹, this does not characterize that Brazilian families do not face such problems.

According to the systemic organization, a family will be healthy insofar, as a system, it reaches its objectives, in the target of growth, stability, control and spirituality. These target can be achieved through strategies of the dimensions System change, System Maintenance, coherence and individuation².

In the evaluation of the scores of the dimensions of the instrument ASF-E/Brazil, the results obtained in the System Maintenance stand out, for which 77.5% of the families had a high level. This was the dimension with the best overall result and very high correlation with all family arrangements. This is an indication that Brazilian families use their best strategies, understood as collective actions in which members participate, take responsibilities in activities, make collective decisions, negotiate problems, establish rituals and traditions. A similar result was reported for Colombian^8-10,13 and Mexican families¹⁵.

Also, in the dimension of System Maintenance, 26.0% families were classified at the intermediate level due to item 14 of the instrument ASF-E/ Brazil. According to the systemic organization, this is an indication of difficulty in decision making, definition of roles, communication standards, norms, values, financial management and approach to the future in order to maintain family harmony and provide a sense of security and autonomy².

In the individuation dimension, 64.0% families had a high level. However, 47.0% families were classified at the intermediate level, due to item 5 of the instrument ASF-E/Brazil, is related to family pride and can be strengthened with the recognition of the image created of the family unit. As noted, in the correlation of the coherence dimension, it was identified that single-parent families had lower results, which may be related to the lower pride of their families, due to the economic vulnerability and/or stigma of the patriarchal culture, which may influence their participation in the community. Since the single-parent family may have difficulties in relating to the community due to the stereotypes present and the way the female single-parent family perceives itself in society³⁰.

The individuation dimension had a high correlation with all family arrangements; however, the highest correlation was with single-parent families and the lowest correlation, both with extended and nuclear families. These results indicate that Brazilian families support each other, thus allowing members to develop a personal identity that includes assuming roles and responsibilities to achieve particular interests and give meaning to life. In individuation, talents are reinforced, as are initiatives that allow the incorporation of knowledge to assume behaviors against personal/ family and environmental pressures².

For the dimension of System change, 64.0% families had a high level. However, the classifications at low and intermediate levels were caused by the low score obtained with item 17 of the instrument ASF-E/Brazil, related to the consultation of the family for decision making. This dimension had a moderate correlation with the arrangements of extended families and high with arrangements of nuclear and single-parent families. This result, according to the systemic organization, is related to the ability of families to incorporate new events, knowledge and assume different positions in face of a certain situation that positively or negatively affects the system, considering that their priorities change over time⁵. Therefore, extended families are less flexible to change and have less ability to support individuals' decision making. On the other hand, the nuclear and single-parent families were more sympathetic when faced with the decision making of their members. Similar result found with families of Colombian teenagers⁹.

In the coherence dimension, the results showed 63.0% families at a high level. The result of due to item 15 of the instrument ASF-E/Brazil, which is related to family opinion and can be strengthened by improving the communication in the family unit, stimulating the respect for the different opinions. This dimension had a high correlation with all family arrangements, with better results for extended families and worse for mononuclear families.

The predominance of a high level for the coherence dimension is a protective factor, as it indicates the extent to which families have the skills to establish harmonious relationships between members. It is noteworthy that the greatest correlation obtained in the coherence dimension was with the arrangement of extended families. Because it is still based on a feeling of unity of family belonging through the internalization of respect, love, concern for the other; sharing of values and beliefs that allow the creation of emotional connections necessary for the survival of the family system as a whole². Similar result found in Colombia with families of adolescents^7,9.

The control goal results from the dimensions of System change and System Maintenance; in this goal, 71.0% families were classified at a high level. This result demonstrates that Brazilian families are concerned with preventing, reducing and eliminating events that threaten family stability. Result similar to that of the families of teenagers^9,15. Since keeping the control goal high, it maintains the congruence of the system².

The stability goal results from the dimensions of coherence and System Maintenance. In this goal, 70.5% families were classified at a high level. This result indicates that Brazilian families, according to the systemic organization, seek to have and maintain traditions and routines, which are passed on from generation to generation and promote the unity and development of values, attitudes and beliefs². A high level was also found in studies that assessed the effectiveness of the functioning of Colombian families with school-age children⁸ and adolescents¹⁰.

The growth goal results from the dimensions of individuation and System change; in this goal, 71.0% families were classified at a high level. Similar result was found with Colombian families¹⁰. These results indicate that Brazilian families respect their members and support their choices to achieve their target. Bearing in mind that, according to the systemic organization, the growth goal suggests the reorganization of the basic values that allow to assume new behaviors and/ or roles, and lead to processes of readaptation and adjustments®. Therefore, members of Brazilian families find support in the internal family system, as it influences members in their adaptation process.

The spirituality target results from the dimensions of coherence and individuation, in which 64.0% families were classified at a high level. This may be related to the results of items 5 and 7 of the instrument ASF-E/Brazil and the fact that the mononuclear families, which had the best result in the individuation dimension and the extended families with the best result in the coherence dimension, together, accounted for less than half of the sample (n= 96). This target is related to spiritual connection, feeling of inner security, belonging, acceptance, respect, wisdom and inner peace. In this way, the family can identify, accept and integrate concepts that allow dimensioning beyond the understanding, how are the processes related to life and death². It was the highest target among elderly people with chronic diseases^14,16.

As contributions to the practice, it is considered that although all family arrangements have shown a high correlation with the dimensions of the instrument, even so, the effectiveness of family functioning can be improved. To this end, it is necessary to support the nuclear and extended families to improve the result of the dimensions of System change (supporting the adaptation and implementation of actions carried out consciously by members that allow incorporating new events and/or values that positively or negatively affect the system to adapt to new situations). Likewise, these two arrangements (nuclear and extensive) can be supported to promote the result of the individuation dimension (supporting members to respect physical and intellectual activities which allow them to expand their horizons and reveal and pursue their interests and life target). Single-parent families can be supported to improve, especially the coherence dimension (supporting the strengthening of the sense of unity of the members of the family system to maintain unity and foster self-esteem and love for members) followed by the dimensions of individuation and System change.

In view of the performance of the instrument ASF-E/Brazil in assessing the effectiveness in family functioning, its use is recommended because it has proved to be practical, reliable, valid and is available to be used in different scenarios of clinical practice and research with Brazilian families healthy or in the process of becoming ill, living in Brazil or abroad.

The limitations of this study are related to the characteristics of the participants, all of them were adults and lived in urban areas. The cross-sectional design and the study location do not allow us to infer that the same social determinants of health influence the level of functionality of families. In this way, it is suggested that other studies be carried out with rural families, adolescents and the elderly, healthy and/or with chronic health conditions.

CONCLUSIONS

When assessing the influence of the arrangements and the development cycle on the effectiveness of family functioning, a very high correlation was detected in the structural assessment, for all arrangements (nuclear, extended and mononuclear families) with all dimensions of instrument the ASF-E/Brazil, especially with the System Maintenance dimension. These results allow us to infer that certain family arrangements have strategies to prevent the deterioration of the family system. Thus, the family nurse can use systematic approaches supported by the structural, developmental and functional evaluation of the family. This because this approach allows to identify recent or future stressors, such as structural changes in the formation of new arrangements or the family development cycle, which may compromise the family functionality. As well as the strengths in the dimensions and intervene to reach the goals of the families. There was no correlation between roles and life cycles, but the need to support families with children (youngest child up to 30 months) was evidenced, due to the lower average effectiveness of family functioning.

In view of the results obtained with the instrument ASF-E/Brazil, nurses are expected to feel motivated to assess the effectiveness ofthe functioning of Brazilian families and intervene in promoting or strengthening the health of the family unit.