Family as a health promotion setting: A scoping review of conceptual models of the health-promoting family

Background The family is a key setting for health promotion. Contemporary health promoting family models can establish scaffolds for shaping health behaviors and can be useful tools for education and health promotion. Objectives The objective of this scoping review is to provide details as to how conceptual and theoretical models of the health promoting potential of the family are being used in health promotion contexts. Design Guided by PRISMA ScR guidelines, we used a three-step search strategy to find relevant papers. This included key-word searching electronic databases (Medline, PSycINFO, Embase, and CINAHL), searching the reference lists of included studies, and intentionally searching for grey literature (in textbooks, dissertations, thesis manuscripts and reports.) Results After applying inclusion and exclusion criteria, the overall search generated 113 included manuscripts/chapters with 118 unique models. Through our analysis of these models, three main themes were apparent: 1) ecological factors are central components to most models or conceptual frameworks; 2) models were attentive to cultural and other diversities, allowing room for a wide range of differences across family types, and for different and ever-expanding social norms and roles; and 3) the role of the child as a passive recipient of their health journey rather than as an active agent in promoting their own family health was highlighted as an important gap in many of the identified models. Conclusions This review contributes a synthesis of contemporary literature in this area and supports the priority of ecological frameworks and diversity of family contexts. It encourages researchers, practitioners and family stakeholders to recognize the value of the child as an active agent in shaping the health promoting potential of their family context.

limited. We also noted how limited any attempts in the literature have been to clearly define what might constitute a "health promoting family." To date, such a definition does not appear to exist. There are numerous likely reasons for these gaps, including that family, parenting and child development are intimate and culturally bound activities which vary significantly across homes and settings and for which authority remains largely in the personal versus the public, state or organizational sphere. Further, families are complex and diverse. Any attempt to delineate what might characterize a family as a health promoting context must be broad and flexible enough to recognize the complexities of real people's lives. Indeed, some research has moved from setting up a false normal of what a family should look like, to a focus on what families do, and how they operate as a unit [11][12][13][14].
Prompted by our examination of Christensen's model, we conducted a scoping review with the objective of identifying, analyzing and interpreting conceptual and theoretical frameworks or models that focus on the health promoting potential of the family context. A scoping review was appropriate in that it enabled us to conduct a broad, interdisciplinary survey of previous research with the purpose of identifying key characteristics related to the concept of the health promoting family [15]. Our hope was that we would be able to use the findings from this review to inform research on family health by building on current and high-quality evidence. Further, we anticipated that this synthesis of knowledge would be valuable to practitioners who are involved in health promotion and whose work involves supporting families in their own contexts. Finally, through this review, we hoped to identify strengths and gaps in the ways that health promoting families are modelled in the academic literature and inform future initiatives at such modelling.

Overview
The approach to this scoping review was adapted from the PRISMA [16] guidelines for scoping reviews. Guidance in formulating our search strategy was sought from a Senior Health Sciences Librarian at the Bracken Library at Queen's University, Kingston, Ontario.
A three-step search strategy was used to find relevant papers in order to contribute to answering the question: How is the health promoting potential of the family portrayed in conceptual and theoretical models in academic and grey literature? In step one, studies were identified by key-word searching electronic databases: Medline (1996-2021); PsycINFO ; Embase ; and CINAHL . For example, we used the following search strategy in Ovid MEDLINE(R) without revisions (<1996 to Present-June, week 2, 2015) and (June week 2, 2015 -Present-September, 2020) was: ( Step two involved a hand search of the archives of the Journal of Marriage and Family, a search of the reference lists of included studies, and a thorough backward and forward search using Google Scholar and Web of Science for Christensen's key article [10], each of which enabled us to identify additional studies. In step three, we conducted an intentional search for grey literature that may not have been found in the scientific databases that we searched in steps one and two. This step generated an additional set of models from textbooks, dissertations, thesis manuscripts, literature reviews, academic journals and reports. English language documents that included an illustrated model related to the concept of the health-promoting family were included. Sources were excluded if they did not mention families that included adult(s) and child(ren) or if the outcomes or exposures of interest were not related to individual or family health. No additional restrictions were set on study date, study design, types of families, types of exposures or outcomes. After duplicates were removed, titles were reviewed by a research assistant to exclude articles that obviously did not meet inclusion criteria. All abstracts and then full text articles were reviewed by VM and either CD (studies up until 2017) or KP (studies from 2017 to 2020). A data charting spreadsheet was jointly developed by VM, CM and KP to determine which models to include. Three researchers (VM,CM, and later KP) independently charted the data, discussed results and updated the spreadsheet through an iterative process as inclusion and exclusion decisions were made. This project spanned multiple years. The first stage involved a search for models between the earliest date possible for each database up to June (week 2, 2015) that took place between June and August 2015. The second stage involved a search for models between June (week 2, 2015) and September, 2020. A research assistant (JB) was involved with every aspect of this scoping review until 2017. A postdoctoral fellow (KP) then provided extensive input in all aspects of this literature scan throughout 2020. To synthesize our results, we initially grouped the models by the disciplines from which they emerged and the family characteristics that were identified. As we engaged in an iterative and inductive process of analysis and critical discussion between researchers, we identified further ways of synthesizing the models. This included synthesizing the ecological and environmental factors that were identified as important; the health promoting features of the family; and the role of the child as an active or passive agent in promoting family health.

Study selection
After applying the inclusion and exclusion criteria, the overall search from all three steps generated 113 included manuscripts/chapters with 118 unique models relevant to the "health promoting family". The flow diagram depicted in Fig 2 outlines the steps that we used to arrive at the included studies and unique models in our search results. Table 1 provides a summary of the 118 distinct models that our review yielded. It includes: (1) the name of the model (including variations on the model that are included in the same source); (2) a short description of each model; (3) a description of the child's role in shaping  This model details supportive factors at school that empower mothers' in Saudi Arabia roles in their child's oral health at home. Extension between school and home, sustainability of oral health programs, obligation of children and parents for engaging in oral health activities, and authority between mothers and teachers influence on children's daily oral health behaviors can support mother's agency related to their children's oral health.

Summary table of identified models
Passive Aldossari, 2016 [17].   Figure 2. Potential mediating role of father in relationships linking health determinants to child health; Figure 3. Research evidence of direct effects of father's involvement on child development; Figure 4. Research evidence of direct effects of father's absence on child development; Figure 6. Reciprocally causal links among health determinants and outcomes of father's involvement.
This model demonstrates the role that fathers play in shaping child health outcomes. Figure 2 illustrates the potential mediating role of fathers between determinants of health, the family environment and child health outcomes. Figure 3 provides a schematic organization of positive effects gained from the involvement of fathers on four dimensions of child health outcomes (cognitive, academic, psychological/ emotional and social). Figure 4 offers a model of direct effects of a father's absence on child development and health outcomes (including adaptive functioning, academic, psychological/emotional and social). Figure 6 shows the relationship between direct and indirect impacts of father engagement in parenting and determinants of health. This framework details a number of family processes that contribute to aspects of family well-being, including family coping processes, interactive processes, integrity processes, developmental processes, and health maintenance. It also acknowledges the reciprocal impact that family members have on each other. It is used to show that a collaborative family nursing process must include assessment of multiple aspects of family life. 21 Figure 1. Model of the health-promoting family. This model of the health-promoting family illustrates how external influences on the family (community and societal), and well as processes internal to the family (family ecocultural pathway, genetics/ family health history, health practices) shape child health status. The child is viewed as a healthpromoting actor, and the degree to which children act in ways so as to promote (or demote) their own health is considered to be an important aspect of family life. This two-part model uses the circle to represent wholeness and happiness in the concept of well-being. It suggests that five basics of well-being (family support, extra familial support, completion of family obligation, sense of dignity and self-reliance) are essential to comprehensive well-being of self and family.
Passive Dai, 1995 [38].  demonstrates how congruity/incongruity between the mother's actual role and the mother's acceptance of ideologies around traditional gender roles can relate to adolescent depression. Figure 2 uses the same variables as Figure 1, but depicts the unstandardized parameter estimates and standard errors for all significant paths. Insignificant paths were not deleted from the statistical model but are not depicted in the diagram for simplicity of presentation. This model represents how the intervention actions in a nutrition program and the effects of the community health workers engagement influence community effects and household/child outcomes, including maternal and child nutrition behavior, household food security, improved maternal and child nutrition.  33 Figure. Theoretical model adopted in the study. This model outlines the influence that gender, SES, home environment and subjective aspects related to parental perceptions about oral health and children's own perceptions about self-oral health has on dental caries in school children. This model is used to quantitatively assess relationships between child functioning (measured by externalizing and internalizing behavior and social problems) and various family constructs. It demonstrates that parental support, affection, and family conflict all predicted children's later functioning.
(Continued )  Figure 1 provides a conceptual model that suggests that aspects of mothers' parenting and specific stresses within the family shape relationships between youths' siblings. In turn, these relationships influence adolescents' drug use, high-risk sexual behaviors and associated outcomes (i.e. pregnancy and sexually transmitted disease). Figure 2 demonstrates that certain qualities of the sibling relationship (i.e. high older sister power, low warmth/closeness) served as mediators between the risk behaviors of younger siblings. Model estimates for girls only are shown in Figure 3. This model shows linkages between stress (objective and perceived), family resources, and coping strategies and how these influence family adaptations to living in a war zone. Family resources supported family adaptation, and coping strategies partially supported adaptation.
44 Figure 1. Child, family, and community influences on oral health outcomes of children.
This model takes a holistic approach to examine how individual, family, and community influence oral health outcomes in children. It presents a number of detailed community, family, and child level influences child oral health, and recognizes the role of time and environment on oral health outcomes. On the family level, both physical (physical safety, family composition, etc.) and relational (family functioning, social support, etc.) factors are acknowledged to influence child oral health. The child is recognized as a potential health-promoting actor.
(Continued )  This framework illustrates healthy family processes that result in family congruence (harmony, compatibility). In accomplishing family tasks and striving towards the targets of stability, growth, control, and spirituality, congruence is the goal. Family tasks (ranging from physical care, emotional support, reproduction, culture maintenance, family commitment, acceptance, enhancement of social skills, etc.) occur within the earthly influences of space, time, energy, and matter.

Passive
Friedemann, 1995 [56]. This model hypothesizes that child well-being and adjustment (to sibling illness) will be a function of relationships between the ecological, family, and sibling adaptation process. Family variables such as extended family, family functioning, family coping, sibling coping and efficacy impact the outcome (adaptation and well-being) on the ecological level and also mediate the association between illness and adaptation.  This conceptual model suggests that parent well-being is influenced by child and parent related stress. Both parent (education, marital status, assets) and child (age, sex, disability) individual characteristics influence family climate and relationships within the family, in addition to child skills. All of these consequently affect parent well-being. This model quantitatively summarizes the interactions between parent, family and child factors that influence child weight status and related behaviors. Parent health behaviors and knowledge impact their parenting style and feeding practices in addition to family environment (food and physical activity). Child screen time, exercise, BMI, and fruit and vegetable intake are influenced by parent behavior and family environment.   This model highlights facilitators of physical activity for adolescents. In order for adolescents to engage in physical activity, it must be fun and enjoyable. Enjoyment is impacted by variation, physical skills and friends. Enjoyment from physical activity that is supported by family and friends and a supportive school environment helps to foster a sense of autonomy and competence which facilitates engagement in physical activities. This multi-level model outlines five domains that influence child oral health outcomes. It includes community level, family-level and child-level influences, which are bound by time and environment, and shape children's oral health. This model illustrates how a number of environmental, family (especially maternal) and child factors influence early childhood caries. Maternal characteristics are influenced by economic and family stress and environment/ social disadvantage; consequently, these maternal factors influence child dental behaviors and outcomes. Parenting is also affected by maternal and family stress, which has important implications for child dental behaviors.  This is a conceptual model of the environmental, family, and child factors thought to influence child participation in recreation and leisure activities. It examines the interaction between environmental, family, and child factors that influence a disabled child's participation in activities (daily, recreational, physical, etc.  This models offers a framework that summarizes the relationship between programme factors that enhance family health promotion initiatives that improve healthy behaviors and family health in relation to seasonal influenza. Predisposing, reinforcing and enabling factors help determine delivery of nurse-led visiting programs that influence family health promotion initiatives in child health and in turn improve family health and health behavior maintenance.  75 Figure 1. The theoretical frame that will be modeled by using SEM.
This framework shows the relationship between child, parent, and family characteristics and how these determine parenting behaviors and children's psychological adjustment. Individual/ family characteristics have potential direct effects on child psychological adjustment.  This model demonstrates the positive relation between perceived family support by Spanish and immigrant adolescents to their psychological adjustment, which in turn is positively related to school adjustment. This relates negatively to problem behaviors. Adolescents' psychological adjustment can describe the relationship between family support and school adjustment with family support indirectly impacting school adjustment.
(Continued ) 77 Figure 1. Theoretical model linking co-parenting and parent and child anxiety.

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This model outlines potential mechanisms of parent and child anxiety with co-parenting and parenting. It demonstrates that parental anxiety may directly interfere with positive coparenting; it may be related to general relationship problems and also result in elevated concerns about child activities and exposure. With its specific focus on anxiety, the model provides a useful description of the role of co-parenting in child emotional security and anxiety.    This is a conceptual model for reducing health-risk behaviors in children. It shows that there are risk factors for child health behavior on the family, individual, and environmental level. Both nonmodifiable (i.e., demographic traits) and modifiable (i.e., child traits, parenting behaviors) family and child factors determine health risk behaviors of children. The relationship between risk factors and health outcomes is hypothesizes to be mediated by parent-child communication processes, which can serve to either promote or discourage child health risk behavior participation.  Figure 2. Results for the model with satisfaction with migration; Figure. 3 Results for the model with desired migration.
This model explores the role of family dynamics on the relationship between migration, economic pressure, and child functioning/ life satisfaction. The influence of migration and pressure on parental and social support, family conflict, and parenting behaviors is examined, and the impact of these variables on child psychological functioning, educational achievement, and satisfaction with life is quantitated.
99 Figure 1. Theoretical stress process model with family cohesion and family reframing coping as mediators of the influence of family drinking problems and multiple family risks on child mental health with hypothesized direction of relationship arrows; Figure 2. SEM. 101 Fig. 2. Path analysis model of the moderating effect of future orientation (family) on the association between bereavement and externalizing problems. Fig. 3 and 4. Path analysis model of the moderating effect of parent-child relationship (Fig. 3) and parental monitoring (Fig. 4) on the association between bereavement and externalizing problems.
This model seeks to explain the moderating effects of future orientation at the individual and family level, parent-child relationship, and parental monitoring on the association between bereavement and externalizing problems. The model represents an ecological/transactional framework and illustrates the impact that protective factors for bereavement have on problem behaviors in adolescence.  This model demonstrates the many social and environmental aspects that contribute or influence family health. It includes external factors such as social policy, physical environment, employment, and the ways that social supports influence family characteristics and internal home processes. Family patterns of interaction directly impact family health promotion and consequently, family health. There is a dynamic interplay between external socio-contextual factors and the inter-home and family environment.
(Continued )  This model demonstrates how parental attributes and their perceptions of child physical activity attributes influence physical activity practices in both parent and child and also influence screen media practices. Physical activity practices and screen media practices are influenced by parental permissiveness/neglect, structure, and autonomy support/ responsiveness for their child to engage in these practices and this determines child physical activity and screen media behaviors.

Active/ Passive
Vaughn et al., 2019 [122].  health experiences and trajectories, which is described in more detail in Table 6; and (4) a reference for each model. Please note that many of the authors displayed their models in different ways in order to highlight different analyses. As long as the overarching model in any given paper was the same, it was counted only one time even though it may be have been reflected by several distinct figures.

Description of studies by discipline
Of the 118 unique models identified, 11 broad disciplines were represented in terms of the area of study. This broad range of disciplines, described in Table 2, illustrates the breadth of interest in understanding the multi-dimensional factors that shape family health in a wide range of contexts.

Family characteristics and behaviors identified in models
The family characteristics and behaviors that were identified in the models collectively are described in Table 3.

Environmental and/or ecological factors described in models
The environmental and/or ecological factors that were described in the models varied. Some focused more on social and physical health determinants and others emphasized intrapersonal and interpersonal health determinants. In all models, multiple levels of influences were described as having an impact on family health, health behaviors and health outcomes. Table 4 displays these ecological factors. To see how these environmental and ecological factors map onto each individual model, please see S2 Table (S2 Table Ecological factors and models). Table 5 presents core characteristics of health promoting families as observed through our next analysis. While the models prioritized positive characteristics, many of the models also offered what we have described as characteristics of "health threatening families." These health threatening characteristics were sometimes directly yet conversely related to the health promoting characteristics. Illustratively, family stability and positive mother and father relationship were identified as health promoting characteristics while interparental conflict and having an unsupportive family were health threatening characteristics. While each family is Table 2. Description of studies by discipline.

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unique, broad characteristics were universally important. These include holding shared values, having healthy intra-family relationships and communication, and encouraging healthy behaviours. Note that there was no consensus between models on what these healthy  Table 5. Core characteristics of health promoting families.

Health promoting family characteristics
Health promoting familial values Shared meaning, history and culture; family rituals; family spirituality; commitment to family unity; ethical values; sense of meaning and purpose, religiosity.
Health promoting relationships Positive mother and father relationship (marriage quality); kin support; maternal care and support; mutual support throughout family; family stability and cohesion; positive parent-child communication; affection and attention; sense of family togetherness and congruence; family bonding; emotional bonding and support; family climate (warmth, respect, love, honesty, trust); family balance and harmony, family relationships with neighborhood, peers and school; relationship skills Health promoting attitudes Family flexibility (adaptability and compromise, acceptance of difference of personality and opinion); self-efficacy (family and child, child self-perceived competence); autonomy granting; encouragement of child personal development, sense of identity and sense of meaning; non-blaming attitudes; positivity; respect for privacy for family members; positive attitudes about food/diet and parental perceived child weight status and health related feeding goals; parental beliefs about child's participation in physical activity; illness acceptance; encourages hope; parental sense of control; congruity between ideologies and roles in mothers; maternal self-esteem; appreciation and affection; compassionate; sense of humour, behaviours would be, and models all had specific foci around behaviours (e.g., dietary behaviours and exercise). Even more consistent across models, regardless of the behavioural focus of the model, was access to basic determinants of health such as socio economic background (and related determinants such as access to nutritious food) and education and positive relationships and support within the family.

The child's role in the health promoting family
There were variations in the models as to how the role of the child was represented. Thirty-two of the models specifically ascribe a role to the child that positions them as active agents in shaping their own health experiences. Another twenty-nine models represent the child as an individual member of the family but with the child having a less prominent or active role in shaping their own health. We describe this as having an active/passive role. Nearly half of the models (58) depict the child as a passive recipient of the actions of others, and the ecological determinants that surround him or her, and as part of a wider system but not necessarily as an active agent in his and or her own right. Table 6 presents the various ways that the different models present the role of the child in the family. (The specific ways that the child's role is depicted in each model is also noted briefly in column 3 in Table 1).

Summary of main findings of the studies
Our search for models related to the health promoting family resulted in the consideration of studies from a very broad range of disciplines, methodological approaches, purposes and perspectives. Whether the study was looking at effects of parental depression [20], weight loss and obesity [66,77]; academic outcomes [107]; mental health outcomes [105]; dieting and nutrition [82]; the participation of children with disabilities [76], child resilience [19], influences on participation in physical activity [36,60,61,122], or parental perceptions regarding health behaviors for their children [63,111] the importance-but also the complexity-of the task of modeling the potential of the family in the promotion of health or well-being was acknowledged. Through our analysis, three main themes were apparent. First, and not unexpectedly, ecological or environmental factors are central components to most models or conceptual frameworks [17,19,27,40,43,44,52,74,96,100]. Yet, the factors that were presented and their relative importance varies among the models. Second, most models were attentive to cultural and other diversities. In doing so, it appeared that authors were being intentional about presenting models that were broad enough to make room for a wide range of differences across family types, and for different and ever-expanding social norms and roles pertaining to families and family life. Rather than focus on what a family looks like, many of the models focused on how the family operates together [23,58,66,75,87,125]. And finally, our review drew attention to the way that the role of the child is often presented in models of the health promoting family: less as an active agent and contributor to his or her own health within a family and more as a passive recipient of health that is shaped by a complex range of contexts.

Environmental factors are important but their conceptualization varies by context
A strong similarity among most of the papers and models we reviewed was the priority given to ecological frameworks or approaches when considering the health promoting nature of Table 6. Child's role in shaping health experiences.

Description Examples # of Models
Active Child has an active role in health and health behaviors that is specifically represented in the model.

Active/ Passive
Child is mentioned in model but has a less prominent role in shaping health and health behaviors, which are instead regulated by adult caregivers.

28
• Child's psychological adjustment is a product of child characteristics, family, and parents [86,107].

Passive
Child is not prominently displayed in model and does not have an active role in his/her/their own health.

58
• Causal model of determinants that have an impact on child health [20,46,103].

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families. Overwhelmingly, authors argued that human behaviors and health outcomes cannot be understood without taking into consideration the contexts in which they occur [21,76,82,119]. This kind of thinking was integrated into most of the models, and the ways that each family interacts with various contextual aspects were described as influencing family functioning and health outcomes for all family members. Indeed, individuals within family systems not only influence each other, but are simultaneously influenced by interactions between family members and the environment [21]. Illustratively, the model by Fisher-Owens et al. (2007) depicts community, family and child level influences as important in shaping child oral health [55]. These authors elucidate their model by describing how the influences on oral health do not act in isolation but rather dynamically, via complex interactions. In 2017, Kalil [72] used Fisher-Owen's et al. (2007) model to further posit that these community, family and child level influences are bound by time and environment as complex interactions in which children live and experience their lives, and they have an impact on child oral health. In their 2014 model, De Coster and Zito demonstrate the importance of contextual factors by describing how emotional attachment of young people to their mothers is shaped by maternal distress, which in turn influences adolescent mental health outcomes [41]. The importance of environmental or ecological factors is well-established in the academic literature [1,2], and our observation about their importance in these models is hardly groundbreaking. What is interesting about our findings, however, is that while there were variables that were seen in models repeatedly (for example, SES, family organization, etc.), there was no real consensus about what the actual environmental factors that were important to the various models might be. In part, identifying environmental factors that are important is complicated by the importance of contextually and culturally appropriate measurement and interpretation; what is a valid measurement or factor in one context may be interpreted differently in another. For instance, the environmental, individual and family factors related to acculturation in adolescent Latino [84] and Spanish [87] immigrant mental health differ from the influences related to youth mental health and parental risk taking, alcohol dependency, or single parent households [108,123]. The issues that appear to shape the influence of parents over their child's mental health are different in different cultural contexts. While in all of these models [84,87,108,123] child/adolescent mental health is influenced by parental and family variables, in some models, parental variables are predisposed by culture and context. Illustratively, in some contexts, acculturation [84] and immigration [87] are important shaping factors on youth/adolescent mental health, in other contexts these are not relevant. From geographic and cultural contexts as far ranging as rural northwest China [86], Romania [107], Latino youth in the United States [84], South Africa [78], South Korea [102], Kenya [42], Spain [87], African American [57], and Uganda [69] complex and dynamic relationships between various aspects of the child and family environment were characterized in diverse ways. The conceptual frameworks that were developed were influenced by geographic and cultural contexts. One of the challenges of developing a conceptual framework for the health promoting family, and which indeed was recognized strongly in the studies in this review, is the importance of acknowledging that cultures, contexts, and families are unique. So too are at least some of the environmental factors that contribute to family well-being [24,85,91,96].
Despite these natural contextual variations, the environmental and/or ecological factors that were described in the models mapped readily onto already well established social, physical, and structural determinants of health. Overall, while not surprising, our review suggests that researchers continue to find and use determinant of health frameworks when developing conceptual models related to family health [31,46,103]. While each family is unique, as our analysis in Table 5 demonstrates, there are other broad characteristics that appear to characterize family health. These include shared values (it does not matter what the values are so much as that they are shared); positive relationships; attitudes that support positivity, flexibility, care and healthy behaviours; access to basic determinants of health such as sufficient income and other health resources and access to healthcare. Table 5 also includes an analysis of health threatening family characteristics and includes factors such as family and interparental conflict; negative health behaviours (improper diet, lack of sleep and physical activity; family substance problems) and lack of basic determinants of health such as insufficient income; food insecurity and lack of access to health care providers and healthcare relationships. This review was prompted by our observation that a universal definition of a health promoting family does not exist. This scoping review reinforces the complexity of providing such a definition. Yet, what it does contribute is a synthesis of some of the basic categories and characteristics of health promoting (and health threatening) features of families, even in their uniqueness.

Diversity, and changing norms around social roles
Over the past many decades, dramatic societal shifts have occurred around norms of family life (including, for example, shifts in social and employment roles of men and women [28,41], and the role and status of women overall). These societal changes include a resistance to restrictive paradigms about what it is to be a family, and a growing recognition that families come in many shapes, sizes and configurations. This makes it difficult to determine what a healthy family might look like in a diversity of contexts, and perhaps more importantly, reveals not only the pointlessness but also the danger of prescribing a typical family life cycle too specifically. This is especially true as families inevitably have expected or unexpected transitions over the life span. The focus we see in this literature review away from what "constitutes" a family to how a family operates is certainly healthy and avoids claims of any false normal.
As thinking around health and families evolve in ways that decentre what may be considered "normal", it draws attention to how understandings of health have evolved. This, too, was reflected in our review. Illustratively, Ball, Moselle & Pedersen (2007), point to the way that as understandings of health have expanded, "scholars and policy makers focused on families are increasingly subscribing to understandings of health as reciprocally determined by a broad array of biological and non-biological factors" [23, p. 6]. Notably, Denham (2003) [43] encourages thinking that moves beyond Western, dualistic and biomedical foci on health, illness and disease to a consideration of more diverse ways to approach individual and family health.
Consideration of adult gender was important across the models. It was then surprising that it was not as big a consideration in relation to the children in the majority of the models. However, where gender was considered, it was important. Illustratively, in their model, Molborn & Lawrence [84] draw attention to the overall weakening of socioeconomic disparities in health lifestyles and a strengthening of gender disparities as children age. Niermann et al. [96] model gender differences in the association between family functioning and weight status. While a higher level of family functioning was associated with decreased likelihood of being overweight among girls, this was not the case for boys. In the 2018 model by Shapiro et al., [113] there was a significant association between child's gender and the Precaution, Adoption, Process Model (PAPM) stage of decision-making, with parents of boys more likely to report being in earlier PAPM stages. Here, parents of daughters (compared to sons), parents of older children, and parents with a health care provider recommendation had decreased odds of being in any earlier PAPM stage as compared to the last PAPM stage (i.e. decided to get vaccinated). None of the models made any room for gender diversity or non-binary gender. We would expect as models of the family continue to evolve, attention to non-binary gender among all family members will become much more prominent in future models.

The child as a health promoting actor is undervalued
In our analysis of these models, the lack of attention to the kind of robust vision that was cast by Christensen in 2004 [10] as to the value of the child as health-promoting actor in these models was striking. Admittedly, and as depicted in Table 6, 32 (out of a possible 118) of the models that were reviewed did present children as active participants in achieving their own health. For example, both Gold et al. (2008) [59] and Wade et al. (2015) [123] noted self-efficacy as important to their model and Hauser-Cram et al. (2001) [64] drew attention to the child's ability to attain mastery and also to regulate one's own behavior. We were interested to note that gender did not appear to be a consideration in terms of the child's active or passive role. Age, however, appears to be important. In the 32 "active participant", older children and adolescents were more likely to be described as having an active role than younger children. This is not surprising given that as children and youth age, they naturally begin to take a more independent role in their own health. Several studies drew attention to the child's role in avoiding risk behaviors such as risky tobacco and alcohol use [5,17,35,40,51,94,96,97,99]. While another 28 of the models presented children's roles in what we categorized as "active/ passive" roles, more often, however, these models (58 out of 118) presented children as passive recipients of health rather than as contributing agents to their own health journeys.
This lack of attention is short-sighted, because as Christensen [10] and others [129] [130] have argued, when children themselves are not included and encouraged as competent, capable agents, they are deprived of the opportunity to learn to make their own health related decisions, and to gradually learn to take responsibility for their own health behaviors and decisions. Including the child in this way is not intended to diminish the importance of the role of the parent(s) or environmental and contextual factors in shaping the health trajectories of children. Rather, it is in keeping with a growing body of research that illuminates the importance of children's contributions to the health promoting nature of their own families, and the empowerment that ensues when children are encouraged to contribute to the health promoting activities in the family [80,129,130]. In keeping with this scholarship, Woodhead and Faulkner [131] use research evidence to describe how the emergent competencies of children are not so much set along an artificial developmental timeline as they are grown into through active participation. When children are guided in their participation by supportive adults, their developmental capabilities evolve. In other words, when children are encouraged to become active agents in their own health journey, their participation itself appears to serve the dual purpose of also supporting their development [131].
One area to which this scoping review draws attention is in relation to illness acceptance, maintenance and self-management behavior in adolescents, and the ways that these kinds of active roles can be of particular importance [90,128]. For instance, in their model, Mammen et al. (2018) [90] describe how self-management behaviors are motivated by personally important outcomes in teens related to their own ideas about symptom perceptions, medication beliefs, symptom management, and personal goals and priorities. Additionally, Zheng et al. (2019) [128] describe how the active roles that adolescents play in terms of understanding of their illness, overcoming limitations, normalization and readiness for responsibility lead to positive consequences of higher self-esteem, stronger sense of identity, better disease control, and improved quality of life in adolescents. In turn, all of this supports illness acceptance.
We observed a slow but potentially encouraging shift that appears to have occurred over the past five years. Whereas we observed that in earlier models, children were prescribed a primarily passive role (for example, only about ¼ of the models identified before Christensen's model was published in 2004 recognized the child as having an active role), a shift towards recognizing children as active agents in promoting their own health in many of the later studies was notable. Illustratively, within the 44 models that we identified between 2016 and 2020, over 1/3 of them (16/44) depicted the child as having an active role in promoting family health. It may be that the initial vision Christensen [10] proposed in her original theoretical framework, which includes the child as a health promoting actor, and that was the impetus for this review, is becoming more widely accepted as important to the health promoting potential of family contexts.
The notion of the child as a key health promoting actor in families is in keeping with Article 12 of the Convention on the Rights of the Child (CRC), which outlines participation rights [132]. Children from countries who have ratified the CRC, in keeping with their age and evolving capacities, have the legal right to express their opinions, to have a say in matters affecting their own lives, and to participate fully in society. This enables not only public agency, but also agency in their own family context. Participation as active, health promoting agents in the life of their family is an opportunity by which young people can have their ideas valued and recognized and can influence decision-making in ways that affect their lives. These kinds of roles not only contribute to the life of the family overall, but also facilitate growth, resilience, meaning and agency in the life of the child [71,93]. This kind of active participation is also an internationally protected right [132]. Consequently, attending to children's voice, agency and participation should remain central to the ways that models of family health are shaped [133,134].

Strengths and limitations
To our knowledge this is the first scoping review to identify studies that model the health promoting family. The strengths of this review include the systematic methods used for identifying included models. It provides an overall summary table that demonstrates the diversity of interest in this topic, and the different ways that health promoting families have been modelled across disciplines over decades. A limitation of this review is that only papers written in English were considered and relevant material written in foreign languages were omitted. This inevitably introduced a layer of bias in the final sample of included models.

Conclusions
In this review, we identified 118 models that describe the health promoting potential of families. The complexity of contemporary family life was well-described, including appropriate attentiveness to rapidly changing social norms and roles. Ecological and environmental factors were given high importance in all models, yet consensus on what the specific factors are that would facilitate a health promoting family rightly remained elusive. The models identified in this literature review come from a diversity of disciplines and indicate a broad and general relevance of family health. This could imply that a broad range of stakeholders are open to considering family health promotion and intervention strategies in a variety of different disciplinary contexts. The role of the child as an active agent-rather than a passive recipientof their health journey was highlighted as an important gap in many of the identified models. Future research would do well to pay attention to the capacity of children within families to be active agents in shaping their own lives and the lives of their family members [134]. Not only is the active participation of children an internationally protected right, it is a powerful vehicle for supporting the emergent competencies of young people in terms of managing their own health experiences and trajectories.
The family is a key setting for health promotion. Contemporary health promoting family models can be used to establish scaffolds for shaping health behaviors and outcomes for families and can be useful tools for education and health promotion. This review contributes a synthesis of contemporary literature in this area and supports the priority of ecological frameworks and diversity of family contexts. It also encourages researchers, practitioners and family stakeholders to recognize the value of the child his or herself as an active agent in shaping the health promoting potential of their family context.  Table. Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) checklist. (DOCX)