The study took place in the region around Karlsruhe, a city in the southwest of Germany. Participants were recruited in schools via distributing flyers and posters after directors’ agreement and by placing a project description in an university-intern magazine. In addition, flyers were distributed in regional sports clubs. Families with at least one child between 10–16 years were included in the study. Prior to the interviews, participants got written information about the background, aims and the procedure of the study. Additionally, each family member was informed about the voluntariness of the study and the possibility to terminate at any time. Finally, each family member signed an informed consent. The study was conducted with ethics approval from the Karlsruhe Institute of Technology Research Ethics Committee.
The sample consisted of seven families comprising 22 individuals who were interviewed. Fathers’ (n = 7) mean age was 47 years (SD = 4,4). Mothers’ (n = 7) mean age was 44 years (SD = 3,7) and children’s (n = 8) mean age was 12 years (SD = 2,0). To assess the amount of time spent at home with the family, we collected also data of hours of working or lessons per week. On average, fathers spent about 42.9 (SD = 7.3) hours per week at work while mothers were at home to a greater extent and worked on average 22.9 hours per week (SD = 7.4). The mean time children spent in school was 32.2 hours per week (SD = 2,9).
Since we aimed to examine family life, we did not interview single members but the whole family at once. Interviewing the whole family provides better insights in their living environment, interaction patterns as well as experiences within the family are made possible  . Therefore, semi-structured interviews utilizing an interview guide were conducted. The interview guide comprised four topics with three to four questions per topic. Interviewers received a special training. The interviews took place at the participants’ homes in order to conduct the interviews under favourable environmental conditions [19, 20] .
All interviews were held in German. First, in the introductory part, some general questions were asked (e.g., about age, job, working hours, school). Furthermore, we asked about the amount and type of time spent together as a family. In a second part, the questions dealt with aspects concerning family health, e. g. the importance of a healthy lifestyle in the family, specific health related actions or disagreements concerning health. Participants were also asked to recall and describe specific situations in which these phenomena appeared. Third, the families were asked about their opinion on typically healthy or typically unhealthy families. In this context, participants were asked about the health status of their own family, potential for improvement and barriers they experienced. The last topic comprised questions about similarities and differences in physical activity and eating behavior in the family. We also asked for reciprocal influence on physical activity and eating behavior.
The interviews took between 55 and 85 minutes, were digitally recorded and transcribed verbatim. Transcription and data analysis were conducted using F4Analysis (dr. drehsing & pehl GmbH), a software package for qualitative analysis. Transcripts were systematically analyzed following Grounded Theory principles . Open, axial and selective coding was applied to all transcripts. Firstly, raw text data was coded and compared in order to categorize relevant information with similar meaning. While reading and coding the manuscripts, ideas were written down in memos to support the process of open, axial and selective coding. In a second step, connections between the categories within and between cases were established and checked in a circular process. Finally, selective coding involved the identification of core categories and their connections. For data analysis two researchers read and analyzed the interviews and weekly meetings were held to discuss the findings and to develop a theoretical model according to Strauss’ coding paradigm . In this process, previous theoretical knowledge and sensitizing concepts were utilized to construct empirically grounded categories  , focusing on the Family Health Climate. For presentation in this paper, quotations were translated from German to English.
We identified various factors arising from the socio-cultural and physical environment as well as individual factors that affect family life as reflected in health-related behaviors and interactions. Based on these findings, we developed a model of factors shaping the Family Health Climate (FHC) and consequences of the FHC. The model summarizes the relevant elements and their associations with regard to the FHC (see Figure 1).
The central element of the model is the family life (meso level). With regard to health, the family life comprises health-related interactions among family members that result in the Family Health Climate. These health-related interactions among family members are based on various actions of individual family members that refer to other family members. These actions are influenced by individual factors such as personal attitudes and interests, genetic predispositions, motor competences etc. However, individual behavior is also influenced by socio-cultural norms, the community and the neighborhood, workplaces and schools the individuals of a family are embedded in. Hence, actions of individual family members are affected by individual factors at the micro level and environmental factors at the macro level. While individuals’ actions are based on individual intentions (i.e. one-sided), interactions reflect reciprocal actions in dyads (i.e. two-sided) or triads etc. The sum of interactions forms the network structure of families at the meso level. Recurring family interactions such as health-related information exchange or shared activities (e.g., accompanying children to competitions) and family routines (e.g., eating dinner together) result in shared cognitions and values as reflected in the Family Health Climate. These shared cognitions and values, in turn, have consequences for the health of the individual. They can influence and change cognitive, motivational and behavioral factors with regard to health and may foster a healthy or unhealthy lifestyle. This lifestyle can affect biological aspects such as BMI or individual attitudes and interests and eventually causes circular closure of the model. It should be noted, however, that attitudes and behavior of many individuals can eventually contribute to the reproduction or changes of socio-cultural norms or changes of the built environment at the macro-level. However, these effects are not straightforward and subject to other environmental influences such as community policies and economic dynamics, which is why the association is depicted by a dashed arrow. In sum, the model comprises our main findings and describes a circular process that enables a better understanding of the Family Health Climate and its effect on individual health.
In the following, the main categories of the model – family interactions and Family Health Climate – and their relation to the other elements of the model are described and discussed based on the analyzed interviews.
Influences on health-related interactions among family members
Health-related interactions among family members are affected by individual and environmental factors. First, we discuss biological and psycho-social factors (individual), followed by factors of the socio-cultural and physical environment (environment).
The interviews revealed that biological factors affect both individual’s own health behaviors and the health behaviors of other family members. With regard to biological factors, the age of the children is a salient example. When children are young, family life is often associated with a lack of time for parents’ physical activities, especially for mothers.
Well, for a really long time I did nothing [with regard to sports]. I was absolutely busy with the children, and the family, and this and that. I had no more energy. It was much harder to leave the house. If you can’t leave the children alone, it is hard to organize things and to say ‘Now I go for sports’. It’s very hard to integrate it. (Mother 4)
Another challenge are age and gender differences of the children in a family that make it difficult to do sports together:
Well, this is the challenge. Since [name of 1st child] is 7 years old, [name of 2nd child] is 13, and [name of 3rd child] is 11 – boys and girls. It’s sometimes hard to find something you can do together. (Father 2)
Existing food intolerances of family members likely result in a more conscious handling of family nutrition. This handling is reflected in adapted family meals that affect the eating behavior of the other family members:
I have a special position in the family. When we prepare meals with milk, we often take lactose-free milk. The family is very considerate of me. And this is very good for me. I feel much healthier than one and half year ago. (Father 7)
In the interviews it became clear that biological factors such as age, gender and food intolerances are significantly affecting health-related interactions among family members.
Psycho-social factors such as individual preferences, attitudes, beliefs or values regarding foods and physical activities affect individuals’ health behaviors and influence daily family life. One example for such an influence is a vegetarian or vegan lifestyle:
I was vegetarian for six and a half years and now I am – since a few months – vegan and that is something essential for our diet [of the family].(Child 3)
A vegan diet affects joint actions in the family such as grocery shopping, meal planning, and family meals and might also affect the eating behavior of other family members.
In general, planning of family meals was reported to be difficult. It depends on different food preferences, tolerances or taste and some parents complained about the difficulties caused by various wishes:
So, the whole planning, what we eat and that already begins at noon. What do we eat today? I already know who has which needs and try to consider all of them to some extent, which is sometimes not that easy. (Mother 4)
Most of the families reported that individual food preferences were associated with difficulties and sometimes led to conflicts. While in these cases food preferences of individual family members influence food-related family interactions, there are also consequences of these interactions that are considered to be challenging, e.g. for the mother:
Well, sometimes when making the meal plan I found it exhausting and I thought, ‘No, what am I doing here? What an effort!’. So, it’s like a conflict with myself, where I’m thinking: ’Shit, what have I done wrong?’. (Mother 2)
Obviously, different needs with regard to meals can, in turn, affect individual’s psycho-social factors such as perceptions of stress. In the cited case, stress is a consequence of individual preferences within the family that are not part of shared cognitions about family meals. This is a noteworthy example because it shows that family interactions can also have negative consequences for the individual.
A similar pattern was apparent with regard to physical activity. Different activity preferences and motivational levels make joint physical activities a challenge. For example, parents want to go hiking or walking whereas their children prefer other activities:
Sure, this brings the mood down. When I say ‚Come on, let’s go hiking at the weekend!‘ then one or two [children] say ‚no way‘. (Mother 2)
We are simply individuals, and it is really a challenge to find a common thread, also with regard to physical activity. (Mother 2)
The interviews revealed that individual preferences and values have a significant impact on health-related family interactions. Distinct preferences often lead to difficulties and conflicts in the family. In sum, psycho-social and biological factors influence health-related interactions in several ways.
Various socio-cultural aspects affect health-related interactions among family members. It should be noted that many of the socio-cultural factors had an immediate influence on individual family members and did not directly affect family interaction. Nevertheless, the resulting actions were uttered by the interviewees with regard to the family context. As such, these socio-cultural influences exert an indirect influence on family interactions.
In the interviews, parents described today’s social lifestyle as fast moving, hectic and full of time pressure, causing a general lack of time. As a result, various families reported that a lack of time hinders conducive health-related interactions among family members, e.g. talking about healthy eating or discussing the next family meal. The lack of family communication about health-related issues affects shared values such as healthy eating or eating together as a family. They are less stable, which can result in less frequent family meals or unhealthy eating routines. In turn, this has a negative impact on individuals’ health behavior.
I think the critical issue is time. We live in an extremely fast-moving time, in an extremely hectic time . . . And if you are not able to structure your daily life and if you live from hand to mouth, it doesn’t work out, not at all. Then, you normally subsist on junkfood, well, such things like MCDonalds, kebab, Chinese snack or just, I would just say, thawing some frozen food and eat it. Because there is a lack of time. (Father 6)
Furthermore, social actors showed to be relevant. In many instances, peers were an important factor of the socio-cultural environment affecting individual’s health behavior and subsequently family life. In the interviews, various children reported that their health behavior is affected by their friends, e.g. with regard to picking up a sport:
Basketball then came through my classmates, well, a friend of my class also played. I always found that interesting, too. And then I went along once, then I had fun and so I stuck to it. (Child 4).
With regard to eating behavior, one father uttered his surprise on how his son changed his attitude towards a healthy meal (i.e. salad) during a sports training camp with friends:
The boys went to the handball training camp a few times now (…). And there the kids also eat together. You can’t believe what happens there. Our son came home in the evening and said: ‘I ate salad’. (Father 6)
As a consequence of the peer influence as described in this case, family meals can include more healthy options that are accepted by the children.
While peer influence was often reported to be positive, it can also be negative, e.g. when it comes to comparisons and ‘competitions’ of being skinny and eating excessively healthy:
Yes, especially in my age it can be realized quite clearly. There are a few people that develop an eating disorder, for sure. In my age it’s a big issue. (Child 4)
Here, a daughter reports how social norms among female adolescents can have a negative influence on health behavior. This negative influence, in turn, affects family interactions, as the mother of the child remarked:
We three girls [mother and two daughters] talk extremely often. I’m often about to say it’s enough. Sometimes you should just eat something without wondering how much fat is in it or anything else. You can just eat it. But for us it is a big issue I’d say – for me and the girls. (Mother 4)
In this case, the mother considers the constant talk about food to be problematic and it seems as if she fears negative consequences.
In sum, the interviews revealed that socio-cultural factors trigger various health-related family interactions. However, it appeared that influences are often moderated by individual family members.
Physical environmental factors
The interviewed families mentioned various relevant aspects of the physical environment. In contrast to socio-cultural factors, these aspects were mainly reported as factors that directly affect health-related interactions on the family level. In the following two citations it becomes clear that living in a hilly village or in a bike-friendly city can make a difference on the activity level of the whole family:
Well, sometimes we briefly talk about if we go somewhere by bike or by car. But I think – that’s my impression – that developed great. I think this is related to the fact that going by car in the city became unbearable. Our family uses the bike for nearly all ways by now, that’s very nice (...). I like it, we just get a bit of physical activity into everyday life. (Father 7)
To go by bike is here in [name of the village] a bit difficult. To go downhill is easy, but to go uphill is a bit problematic here. (Mother 5)
Next to physical factors due to the built and natural environment, the interviewees reported that daily weather conditions and the climate depending on the seasons affects individual health-related behavior and health-related actions on the family level like shared physical activity:
It also depends on the season. (…). In the summertime we go together to the public outdoor swimming pool, or we go biking or running outdoors. (Mother 7)
In the interviews, various situations were identified that underline the importance of the physical environment. The physical environment showed to affect family members’ behavior and to prompt family interactions immediately. Different to the socio-cultural environment, health-related behavior was mainly affected with regard to physical activity.
Emergence and Consequences of the Family Health Climate
The Family Health Climate (FHC) is formed through mutual interactions in the family and is reflected in shared cognitions or values within a family. These shared cognitions and values might affect individuals’ behavior. Therefore, the FHC is supposed to foster or hamper individual’s health related behaviors.
Emergence of the Family Health Climate
Shared time as a family showed to be an important prerequisite for the emergence of the FHC. When the families were asked in which situations they share time together, it appeared that family meals are a very important element:
When we spend time together during the week, it’s almost only for eating. At least for breakfast and for dinner (…). Once a day we need to have a joint family meal. To see each other at least once a day. (Mother 6)
Here, sharing time is a family value realized through eating together as a daily routine. While this does not necessarily imply healthy eating, it shows that eating together as a family contributes to the emergence of the FHC.
Eating together also provides the opportunity to influence healthy eating of all family members:
Yes, sometimes it goes well with fruits and vegetables, when you prepare it right after shopping in way that you can easily grab it. (Mother 6)
Moreover, joint meals provide a platform for family conversations about health:
And yes, I think the topic health… such topics are most often discussed at dinner. When we sit together talking, it often pops up. (Child 4)
As such, the meals showed to be a critical factor for the emergence of shared values. This is reflected in the perception of family meals and the shared time as important. In all families, family meals are a fixed component in daily family life and were considered the easiest way for sitting together and talking to each other, but due to a lack of time family meals were only possible for dinner or for breakfast:
It’s a fixed ritual. We always take our breakfast together. (Father 4)
Another example how the FHC emerges in daily family life are existing rules and restrictions. Mostly the parents are the initiators of rules. The rules concern for example fruit and vegetable consumption, TV and smartphone use during meals as well as alcohol consumption. TV watching or smartphone use while eating was reported as a barrier for conversation and a disturbing factor for joint meals. Restrictions exist also for candies and sweetened beverages. Sometimes deals are made to support healthy eating as compensation for sweet consumption.
Well, fruit and vegetables once a day is a must. There are no unlimited sweets. We have sweets every day but always a small portion. Sometimes a bit more, but as an exception. But that are our rules, which we have. We try to eat varied. (Mother 6)
All families reported struggle and conflicts due to rules on eating, however, the families reported more healthy food consumption and less intake of candies and sweetened beverages consequently.
Interestingly, across all families, there was a lot more conversation about family meals than joint physical activities. However, joint physical activity is valued as well as expressed in wishes for more joint activity:
And there is a wish I have, that we take more time for some physical activity. For example, this year we made it only once to the public swimming pool. (Father 7).
In all interviewed families, shared physical activities could almost only be realized at weekends:
Yes, it’s like you said before [shared activities] are limited to holidays and weekends. And at the weekends, one plans with regard to the children and physical activities, and one tries to get things organized around it. (Father 6)
The interviews showed that family values are mainly reflected in eating together as a family. As such family meals are an important catalyst of the FHC. However, there were also situations with regard to physical activities that showed how shared cognitions and family values emerge.
Consequences of the Family Health Climate
The emergence of the FHC as a result of health-related family interactions has various consequences for individual family members. The following statement about the change of eating habits clearly illustrates this:
And then we adapted a bit, and (…) primarily the meat consumption has been dramatically reduced in our family. (Father 4)
Besides consequences for the diet, the FHC also has consequences for the level of physical activity:
Always. Exactly, always by bike (…). Taking the children somewhere and then pick them up. I make a lot of kilometers in a week. It’s surely 60 to 70 kilometers (…) The kids go to school by bike. They rarely get a bus tickets. (Mother 2)
Another interesting result was happiness as a consequence of the FHC that comprises joint activities as a family value:
Yes, it’s swimming. All of us being in the water, all of us on the waterslide, all of us being active. This is the sport that makes all of us happy, I’d say. (Mother 2)
The influential power of the FHC is reflected in the following citation. A mother described that being active was a norm in her family, and then she compared it to other families. Reflecting on the power of different family values, she considers it to be hard to free yourself form unhealthy family values. Further, she uttered the assumption that only a certain educational level might help to reflect and detach from unhealthy behavior patterns of the family:
We were active, we ran, we did various things without any limits, I don’t know it any other way. (…) I think that family background and educational background play an important role. The way you know it will be passed on to the children. (…) It is incredibly difficult to free yourself from an unhealthy family, away from these rituals, well, you can only make it if you achieve a certain educational level and then might be able to reflect on it and read about it, and then start to practice it by yourself. (Mother 7)
In sum, the interviews revealed that the FHC is reflected in shared cognitions and values with regard to health. It influences cognitive, motivational and behavioral factors of the family members, and affects the health behavior of individual family members. This comprises eating habits as well as physical activities and sports.