Participatory Approaches in Family Health Promotion as an Opportunity for Health Behavior Change—A Rapid Review

Background: With their influence on health behavior of children, families are important addressees in health promotion and prevention of chronic diseases. However, they are often difficult to reach, partly due to the open approach of health promotion services. Therefore, they should be addressed directly and be involved in shaping their living environment. The aim is to examine which approaches are used in participatory family health promotion and what practical experiences are made. Methods: A systematic literature search in PubMed, Web of Science, LIVIVO and a supplementary hand search were conducted. Ten of 718 screened publications were analyzed qualitatively. Results: Most included publications applied the community-led participatory approach CBPR. In seven publications, family actors could make decisions at any or all project phases. One finding is that positive effects on desired behavior change and improved health of target groups were observed. Frequently described success factors are the type of interaction, and a common goal. Conclusion: The forms of family participation in health promotion vary widely, with the lack of participatory practices being a major challenge. Family participation is a useful approach in shaping health promotion and should be further developed. This overview provides support for planning future participatory projects with families.


Introduction
Families play a crucial role in health promotion and prevention of chronic diseases [1]. Families are long-term communities in which individual health behaviors are developed and consolidated [2]. This influence of the family on the health behavior of individual family members runs through all phases of life [3]. Chronic diseases, such as cardiovascular diseases or diabetes mellitus, are among the most common and economically significant health problems in industrialized countries [4]. Risk factors that influence the development of chronic diseases are already evident in childhood and adolescence. Health promotion and primarily prevention is a sensible starting point for combating chronic illnesses because they can prevent, reduce, or delay damage to health [5]. Therefore, the role of the family is particularly evident in the early stages of life, such as pregnancy, childhood, and adolescence [6], represents one of the primary socialization spaces of children and adolescents and can thus decisively shape health behavior through role model behavior, rules, and support [7,8].
Although families occupy a crucial position in health promotion, access to them is difficult in practice. The family does not represent a spatially fixed and defined setting, such as the institutions of school, kindergarten, or a workplace [6]. Moreover, in most Western countries, families have a right to autonomy and privacy that must be respected

Materials and Methods
The search strategy, selection process and data analysis were based on the preliminary guidelines of the Cochrane Rapid Reviews Methods Group [20] and are presented below. Publications were considered that were written in English or German, referred to industrialized nations and were published in the period 2010-2020. Included publications were on the topic of participatory health promotion or primary prevention, in which preliminary stages or stages of participation with families were applied along the lines of Wright et al. (2008). In addition, the family should be considered as a system and family health promotion should take place in primary socialization (pregnancy, birth, early childhood) or in secondary socialization (external care through day care, primary school, secondary school). Studies were excluded that had no participatory components, presented participation as mere participation in an offer, or took place outside the named socialization phases, such as in family care for the elderly or in the care of relatives. Apart from the existence of a full text, no specifications were made regarding the type of manuscript.

Selection Procedure and Data Analysis
Study identification and data extraction were carried out independently by two research assistants. Figure 1 shows the identification process of the included studies. After an initial screening of title, abstract and full text, ten of the 718 publications found in the databases and by hand search were included in the data analysis. From these publications, the relevant data were extracted and tabulated. Relevant data included the differentiation of participatory approaches and reported experiences on effects and facilitating factors in the participatory process. Publications were considered that were written in English or German, referred to industrialized nations and were published in the period 2010-2020. Included publications were on the topic of participatory health promotion or primary prevention, in which preliminary stages or stages of participation with families were applied along the lines of Wright et al. (2008). In addition, the family should be considered as a system and family health promotion should take place in primary socialization (pregnancy, birth, early childhood) or in secondary socialization (external care through day care, primary school, secondary school). Studies were excluded that had no participatory components, presented participation as mere participation in an offer, or took place outside the named socialization phases, such as in family care for the elderly or in the care of relatives. Apart from the existence of a full text, no specifications were made regarding the type of manuscript.

Selection Procedure and Data Analysis
Study identification and data extraction were carried out independently by two research assistants. Figure 1 shows the identification process of the included studies. After an initial screening of title, abstract and full text, ten of the 718 publications found in the databases and by hand search were included in the data analysis. From these publications, the relevant data were extracted and tabulated. Relevant data included the differentiation of participatory approaches and reported experiences on effects and facilitating factors in the participatory process.

Results
The ten publications included different types of publications (four empirical studies, three research reports, three practice reports) and came from different countries (USA (7), DE (2), FI (1)). The health promotion interventions and the addressees of the projects were also different. Table 1 gives an overview of the publications included. Legend: S = empirical study, R = research report, P = practice report.
The participatory approaches and methods of the projects and their relation to the research questions are discussed below. Subsequently, the practical experiences in the use and application of the contributions are presented under the identified topics of the observed effects and the described success factors for family participation. For a uniform clustering, the described inhibiting factors were reformulated into facilitating factors.

Participatory Approaches and Methods Used
To enable an overview and comparability, the participatory approaches and methods described in the included publications were differentiated according to six criteria con-cerning the research question, and are presented below. Table 2 shows an overview of the information collected.   Legend: I = Analysis; II = Development; III = Implementation; IV = Evaluation. X-Form of participation is described for this project phase. (X)-Form of participation is indicated in the publication and/or described in connection with the respective project phases. --Form of participation is not described for this project phase. + Aspect is mentioned in the article.

Participatory Approach
The seven US publications used the CBPR approach, which aims at creating structures for the participation of the addressees in the research process and shared decision-making power among the actors involved [31]. Ferré et al. (2010) also reported a move towards a community-led participatory research (CPPR) approach. The three European publications referred to participatory action research (PAR) [28], or a participatory approach in general, without defining the term precisely [27,29].

Theory-Based
A total of seven publications referred to a theory or model. They either referred to participation, such as the citizen health care model [21,23,25,27], or to the form of intervention used [24,30] only explicitly named families and parents, but also referred to the community in which they live. Some mentioned the community without further differentiation of the actors involved [23,26,30].

Form of Participation
Three of the ten publications included only descriptions of preliminary stages of participation, such as informing, listening, or involving the addressees [22,28,29]. Johnson-Shelton et al. (2015) and Schäfer and Bär (2019) exclusively indicated forms of actual participation. Five publications described preliminary stages and actual participation [21,23,24,26,30].

Participatory Methods
Participatory methods used can be divided into four categories. Seven times each, in different combinations, it was described that regular meetings (with the community, within the research team) were held [21][22][23][24][25][26][27], interviews and focus group discussions took place [21,22,24,26,27,29,30], and advisory board, action group or research group with the addressees were formed [21,[23][24][25][26][27]30]. Six publications described that events, such as kick-off events, conferences or workshops, were held [21,23,[26][27][28]30]. Table 3 provides an overview of the described experiences with the participatory approaches and measures of family health promotion in the publications considered. Reported effects and described facilitating factors were defined as criteria for the described experiences.

Reported Effects/Impact of the Participatory Approach
Various observations and experiences regarding the impact of the participatory approach were reported. Most publications mention the formation and strengthening of partnerships [21][22][23][24][25][26]28,30]. It was often emphasized that the participatory approach chosen should include addressee-specific perspectives and aspects [24][25][26][27]30]. Four publications described that participation had an influence on the acceptance/satisfaction with the intervention [21,[28][29][30], that innovative actions were developed [25,26,29,30], and that participants acquired competences and/or knowledge [24,[26][27][28]. Four of the ten publications described that participants were satisfied with the process [28] or felt equally involved [30], with three publications mentioning both [21,24,27]. Other aspects were the motivation for (further) participation [24,26,30], an observed positive influence on the desired behavior change and an improvement in health [22,30].  - Aspect is presented in connection with the described measures or highlighted as beneficial. • Aspect is stated and/or described in connection with the overall project/previous measures or as part of the process. -Aspect is not described. * The facilitating factors refer to the described aspect of the process "joint data evaluation". ** Aspect to be further examined.

Success Factors for Family Participation
Most success factors are found in process design. The most frequently described factor is respectful interaction and communication on an equal level [21][22][23][24]26,27,30]. Half of the publications describe the relevance of a common goal or the exchange of respective goals [24][25][26][27]30]. The identification and use of existing resources is also highlighted as helpful [21,[23][24][25][26]. Promotional for family participation is the open participation and involvement opportunity, especially the flexibility in the scope of participation [21,23,28]. Sormunen et al. (2013) emphasized compatibility with the family; for example, childcare should be offered, or activities planned for the whole family. Three other publications describe that it is beneficial to involve the families' environment [24][25][26] and two how helpful it is to address the addressees broadly and at a low threshold [29,30]; for example, by advertising via social media, emails, and phone calls and by addressing the addressees in their native language.
Some publications refer to general framework conditions such as financial and human resources [23,24,27,29], which are particularly relevant for enabling a successful participation design. More time needed for participatory processes is emphasized several times [23,24,27]. More than half of the publications refer to process facilitation, describe the importance of structure and coordination [23,25,26,30] and flexibility in the process [23][24][25]27]. Two publications also describe staff training as beneficial [29,30].
Regarding specific aspects of participation, the commitment of the participants and their desire for change are mentioned several times as beneficial [23][24][25]27,28]. Garcia et al. (2012) and Johnson-Shelton et al. (2015) emphasized the importance of balancing research and action in the process (to meet families' desire for change). The fact that empowering the addressees had a positive impact on the process is described three times [25,27,28]. Sormunen et al. (2013) emphasized that successful participation requires that the addressees have the opportunity to influence the process and that an existing culture of participation in the environment (in the institution or community) can have a positive impact on participation. They further express that open access, sharing and use of data is beneficial for partnership and participation [23][24][25].

Discussion of Methods
The geographical imbalance of the search hits could indicate possible limitations in the search terms used, e.g., that the keywords used only relate to research practice in the USA. Clar and Wright (2020) emphasize that participatory approaches are not considered research by many practitioners who use these approaches. As a result, some experiences with using participatory approaches may not be found in academic journals and standard databases. Given the current data situation, future methodological approaches may benefit from following the recommendation for limited use of grey literature and supplementary internet research in the preliminary guide to the rapid review method [20].
The publications analyzed describe their participatory components in varying depth and degrees, which, according to [33] or [34], is a characteristic of the entire field of participatory research in health promotion. Gathering information is difficult because aspects of participation are not described in detail. As a result, individual project experiences are lost, and potentially relevant contributions may be excluded due to a lack of information. How participation was organized in the projects included here could not be adequately clarified. However, the tabular presentation enabled a helpful systematization and comparability and proved useful for a first overview. With a clearer understanding of participation in the general research culture, further rapid reviews may provide more in-depth insights in the future. In addition, telephone contact with authors could provide a more concrete representation of the reality of future projects [34].

Prevalence of Family Participatory Approaches
Overall, the number of included publications exemplifies that the participation of families in the process of health promotion projects is not yet widespread and has not been sufficiently investigated scientifically. In the large number of excluded publications, participation was often equated with pure participation and not with a decision-making competence of the addressees in the design of a health-promoting offer. For scientific research on participation in family health promotion, the development of a uniform understanding of participation is necessary, as is repeatedly demanded in the participatory research culture [34]. A common definition and differentiation would make the research comparable and enable more targeted information to be collected on the use of participatory family health promotion.
The accumulation of hits in the Anglo-American area is partly due to a longer history of development of participatory research in North America [35]. In the USA, the approach of CBPR is widespread, while European publications use different and partly undefined participatory approaches. Two further research aspects would be worthwhile for the European area. First, the identification of factors that lead to the low application of elsewhere common participatory approaches such as CBPR, currently is hardly used in European participatory health promotion. Second, an in-depth academic exchange on the benefits and effects of participatory approaches in family health promotion should be started/encouraged. Both would be conceivable within the framework of Delphi studies. This could support the already existing efforts in the development of uniform participatory approaches in Europe. For example, a group of the German-speaking network PartNet is in the process of translating and testing the CBPR model [36]. This development is likely to be influenced by the trend towards "participation" in research and health promotion, although it is still undetermined whether the research culture in general will change or whether participatory research will continue to prevail as a specific approach [37].

Family Participation to Prevent Chronic Diseases
Some publications describe actions to reduce risk factors for chronic diseases. Similar to the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020, different determinants were addressed. Three publications describe projects dealing with nutrition and obesity [21,25,30], in the intervention of one publication the goal is to reduce passive smoking as a risk factor for the development of chronic diseases in childhood [29]. CBPR is emphasized in two publications as an approach that allows for the development of culturally sensitive interventions for disease prevention (also of chronic diseases) [23,30]. Participation enables the development of interventions individually for each community, i.e., through understanding the community's risk factors appropriate solutions can be found together.

Possible Applications for Participation in Family Health Promotion
Families consist of different family members who are to be reached in participatory health promotion [3]. The results in the included publication emphasize that the attitude towards the participation of children and adolescents needs development, as in most of the publications they are not considered in the participatory process. This passive role does not give them the opportunity to help shape the offers intended to influence their own health attitudes and behaviors. Michaelson et al. (2021) show that many conceptual and theoretical models of the family in health promotion do not recognize children as active agents. Concerns regarding how children and young people may negatively affect the quality of research and an underestimation of children's competencies contribute to the exclusion of children and young people in health promotion models [14,38,39].
The results show that for large groups the levels "informing" and "listening" were used, and for defined small groups members were given decision-making competencies and powers. This illustrates that different levels of participation can be present during a project and that these are oriented towards the circumstances and existing possibilities of the project. Preliminary stages of participation and actual participation thus have their place in the project process. However, when working with the addressees, regular checks should be made on how decision-making powers and responsibilities can be transferred to them and whether the opportunities for participation are being fully maximized [13]. A variety of methods are reported in the publications, ranging from regular meetings to events. Some of the descriptions indicate how participation was ensured, but not how the methods were implemented. There is a need for research and presentation regarding the application of the individual methods and clear criteria for participation.
A suitable project phase for the participation of family actors seems to be the development phase. In all publications, participation took place in this phase. Participation here and in the preceding joint analysis phase is necessary for the course of the project, as this can lead to tailored actions that positively influence effectiveness and sustainability [14]. It can be assumed that successful participation in the early project phases lays the foundation for participation in the subsequent phases. It is critical to note that family actors are less often involved in the final evaluation phase of the project. It is often unclear how, and to what extent, they will be informed about the results produced or involved in further steps. The question here is whether this is only of interest to the researchers, as the additional perspectives mean that the best possible research methods and the long-term benefits of the research are recognized by the addressees [31], or whether the family actors are interested, or gain added value by participating in the evaluation. Incentives may motivate addressees' participation, and is practiced in countries with a long tradition of participatory health research.

Effects of the Participatory Approach
The results show that there are many positive effects on different levels through family participation. The fact that family participation strengthens and forms new partnerships coincides with the general impact of participatory projects on relationships [40]. It expands resources and paves the way for later collaborations. The emphasis on this aspect, in almost all publications analyzed, illustrates the attractiveness of this aspect for the institutions involved. The effects described are closely related to the type and extent of participation. For example, groups of authors report a feeling of equal participation if the addressees were closely involved in the process as part of a formed action or research group [21,24,27,30]. Others emphasize the acceptance of actions after information and or involvement of larger groups (community or similar) [21,28,29].
The preliminary stage of participation can already have positive effects, and since the research and health promotion culture in Europe is still not very participatory, applying this stage would form a foundation for participation and health promotion. Higher acceptance of actions and a decrease of health inequalities, precise recommendations for action are needed. It is unclear how the complexity in the development of effects [41] can be assessed.

Similar Success Factors as for Participatory Processes in General
A successful process requires the inclusion of families in health promotion projects, fundamental aspects such as respectful interaction, communication as equals, and agreement on a goal. These factors, and the need for additional resources (financial, personnel, time), do not differ from health promotion projects [42] but gain even more relevance under the aspect of participation. The result that communication and interaction as equals are mentioned particularly frequently illustrates that power imbalances and inequalities in the setting should be critically reflected upon [43]. These represent a central limitation to participation in projects [44].
The engagement of the participants through their desire for change illustrates the relevance and opportunity that are commonly defined goals. A balance of research and action needs to be considered in the planning and implementation of projects. This desire for action presumably correlates to the challenge of joint research and the evaluation of actions and processes described above.

The Importance of Empowerment and Flexibility
Empowerment and participatory attitudes (participatory culture in the setting) are a core element of participatory health research, yet are only addressed in a few publications [40]. It is possible that this lack of reporting results from an incorrect perception that families are sufficiently empowered in their settings, or a lack of awareness for the need for empowerment. This is an important aspect to consider when planning and implementing participatory projects with families. Flexibility in the nature and extent of participation is even more important for families than for other target groups. As Sormunen et al. (2013) have described, participation opportunities must be compatible with the everyday life of the individual family.

Conclusions
In conclusion, the following aspects can be summarized with respect to the research questions:

1.
There are only a few publications on participatory family health promotion projects, and there is a great need for theoretical and methodological development, especially outside the Anglo-American area, i.e., Europe.

2.
Form and method of participation must be adapted to individual circumstances, and continuous consideration should be given to how the highest possible form of participation can be achieved.

3.
Participation in family health promotion leads to effects on different levels, including strengthening partnerships and a higher acceptance of actions, and can be used to develop interventions that reduce chronic diseases.

4.
As with other participation processes, particularly suitable framework conditions and attitudes contribute to success, whereby flexibility in the form of participation is of particular importance in family participation.
The participatory approach and its impact are complex, as is the behavioral change that results from participatory action. This is probably why this outcome is so rarely explored in publications. This review shows that the participatory approach nevertheless has many effects that will, over time, trigger behavior changes in the family and the respective environment or community. The approach is, therefore, very promising because behavior can be influenced in the entire living environment.

Conflicts of Interest:
The authors declare no conflict of interest.