Sharon A. Denham

Relationships between Family Rituals, Family Routines, and Health

Rituals and routines are widely discussed in the literature, but clear distinctions between them are seldom made. Rituals are most often described in terms of celebrations, traditions, religious observances, and symbolic events. Routines have been operationalized as behaviors closely linked with daily or regular activities pertinent to health. Family households are the primary places where families construct, deconstruct, and reconstruct rituals and routines. Support exists that links rituals and routines and health and illness. Both concepts involve multiple family members, are unique to family households, and seem to have a potential role in understandings about health potentials, illness risks, and chronic disease. Although some researchers have studied relationships between rituals or routines and health, nurses have completed few focused studies. The purpose of this literature review is to focus on therapeutic benefits of rituals and routines, stimulate conversation about their utility in nursing practice, and identify areas for research.

Family routines: a structural perspective for viewing family health.

Although rituals are considered in the anthropological and sociological literature, less attention is given to associated biophysical and health perspectives. Three ethnographic studies were conducted to identify the ways family health was defined and practiced. Findings indicated that routines were an important aspect of family health. Families described routines linked to family health and discussed how they evolved, ways they were modified over time, and how families recreated them when stress and change were encountered. Findings indicated that routines provide a structural perspective for assessments, interventions, and outcome evaluations related to health and useful to nursing practice. This article explains some of what is known about family routines, describes the authors findings, and suggests implications for nursing.

Providing health education to Appalachia populations.

Since the 1980s, theorists have posited that health education that reflects the cultural realities of communities that health educators targeted for behavioral interventions would be more successful than interventions that are not culturally sensitive. Between 1997 and 2002, 52 focus groups of youth, women, and men were conducted in the Appalachian portions of 10 states to discern cultural themes relevant to health education in Appalachia. Groups occurred within the context of 5 studies funded by institutes within the National Institutes of Health. Findings suggest that an emphasis on family shows immense promise as a culturally sensitive approach to health education. Interventions that use the central role of women in the health of their families may be useful. The study results also suggest that one-on-one approaches to health education may prove a promising technique, attacks on individuals and institutions are not useful strategies, and a preference for realism or “the facts” may be a good way to present information.

Cultural Perspectives Concerning Adolescent Use of Tobacco and Alcohol in the Appalachian Mountain Region

CONTEXT Appalachia has high rates of tobacco use and related health problems, and despite significant impediments to alcohol use, alcohol abuse is common. Adolescents are exposed to sophisticated tobacco and alcohol advertising. Prevention messages, therefore, should reflect research concerning culturally influenced attitudes toward tobacco and alcohol use. METHODS With 4 grants from the National Institutes of Health, 34 focus groups occurred between 1999 and 2003 in 17 rural Appalachian jurisdictions in 7 states. These jurisdictions ranged between 4 and 8 on the Rural-Urban Continuum Codes of the Economic Research Service of the US Department of Agriculture. Of the focus groups, 25 sought the perspectives of women in Appalachia, and 9, opinions of adolescents. FINDINGS The family represented the key context where residents of Appalachia learn about tobacco and alcohol use. Experimentation with tobacco and alcohol frequently commenced by early adolescence and initially occurred in the context of the family home. Reasons to abstain from tobacco and alcohol included a variety of reasons related to family circumstances. Adults generally displayed a greater degree of tolerance for adolescent alcohol use than tobacco use. Tobacco growing represents an economic mainstay in many communities, a fact that contributes to the acceptance of its use, and many coal miners use smokeless tobacco since they cannot light up in the mines. The production and distribution of homemade alcohol was not a significant issue in alcohol use in the mountains even though it appeared not to have entirely disappeared. CONCLUSIONS Though cultural factors support tobacco and alcohol use in Appalachia, risk awareness is common. Messages tailored to cultural themes may decrease prevalence.

Family routines: a construct for considering family health.

Nursing has tended to focus on health needs of individuals rather than the life-style implications of health for families and the natural support systems they provide. Health care reform is demanding that new methods be formulated for ensuring health promotion, disease prevention, and health maintenance within our society in a cost-effective and cost-efficient way. The article considers family routines as a construct for entering into dialog with families about their health. Family routines are observable relationship patterns occurring among family members on a consistent basis that describe, explain, and predict the uniqueness of families as the members interact and respond to their environment. Family routines provide an authentic demonstration of identifiable family health practices that can serve as areas for developing, implementing, and evaluating health interventions

The Storied Nature of Health Legacies in the Familial Experience of Type 2 Diabetes

In this study, we position families as pivotal anchors for coping with biophysical and psychosocial needs of members with Type 2 diabetes in two vital ways. First, we present narrative theory as a conceptual framework for moving beyond an individualistic understanding of health and healing. Second, we illustrate the efficacy of this position through an interpretive study of meaning-making about intergenerational diabetes among families living in rural Appalachian areas—contexts historically characterized by disproportionately high rates for numerous diseases including diabetes. Stories elicited from participants during interviews characterized their diabetes health legacies as dense and devastating. Our analysis illustrates how legacies evolve and shift across generations and shape how family members understand and manage diabetes, including the role of family members as intergenerational lynchpins and intergenerational buffers.

Part I: The Definition and Practice of Family Health:

Although the literature reflects wide use of the term family health, the concept is ambiguous and lacks conceptual clarity. An ethnographic study about family health was conducted to identify how family health was actually defined and practiced within family households. Multiple members of rural Appalachian families and community informants participated in taped and later transcribed interviews. Family health was identified as a dynamic and complex construct consisting of multiple member interactions within and across the boundaries of households nested within social contexts. Family members used communication, cooperation, and caregiving to develop and sustain individual and family health routines. Family health was influenced by the participants’ embedded cultural context and characterized by highly interactive functional, contextual, and structural perspectives.

High self-reported prevalence of diabetes mellitus, heart disease, and stroke in 11 counties of rural Appalachian Ohio.

UNLABELLED CONTEXT/PURPOSE: There is an epidemic of obesity and diabetes in the United States, especially in economically at-risk populations such as rural Appalachia. This survey determined the self-reported prevalence of obesity, diabetes mellitus, and associated macrovascular complications in 11 rural counties of Appalachian Ohio. The impacts of lifestyle, cardiovascular risk factors, income, and access to medical care were also determined. METHODS A telephone survey identical to the 2004 Behavioral Risk Factor Surveillance System (BRFSS) survey was conducted. Surveys were collected from 3,927 randomly selected residents 18 years of age and older in 11 counties of Appalachian Ohio and compared to published aggregate Ohio and national 2004 BRFSS data. FINDINGS The self-reported prevalence of diabetes (11.3%) was markedly higher in Appalachian Ohio counties surveyed compared to aggregate Ohio (7.8%) or national (7.2%) 2004 BRFSS data (P < .044). The prevalence of heart disease (7.6%) and stroke (4.1%) in these counties was slightly higher than aggregate Ohio or national 2004 BRFSS data. In persons with diabetes, the prevalence of heart disease was 2-fold higher (20.0%) and stroke 3-fold higher (11.4%) than among nondiabetics (P < .042) in the region and higher than aggregate Ohio and National 2004 BRFSS data. Lower-income levels and decreased access to medications and glucose monitoring supplies correlated with the increased risk for cardiovascular complications in this rural population (P < .042). CONCLUSION The self-reported prevalence of diabetes mellitus and its associated macrovascular complications are much higher in rural Appalachian Ohio compared to aggregate Ohio and National 2004 BRFSS data.

Experiences of Children and Adolescents With Type 1 Diabetes in School: Survey of Children, Parents, and Schools

More than 160,000 children and adolescents with type 1 diabetes are enrolled in public and private schools in the United States.1,2 School children with type 1 diabetes must be afforded the proper time and tools for diabetes self-care to be safe, learn effectively, and be able to participate in all school activities.3,4 In addition, knowledgeable school personnel are needed to assist them when they do need help. Thanks to the efforts of the American Diabetes Association (ADA), the Juvenile Diabetes Research Foundation (JDRF), the National Diabetes Education Program (NDEP), and the Children with Diabetes Web site, much progress has been made in the past 20 years to ensure that children in schools are safe and protected. Each of these organizations has provided valuable educational and advocacy resources for parents and educational materials for school systems. The daily self-management of children and adolescents with type 1 diabetes is complex and dynamic. It requires frequent self-monitoring of blood glucose (SMBG), insulin injections, and individual meal plans.5-7 However, changes in daily schedules (e.g., recess, physical education class, school outings, and participation in sports) or an acute illness complicate childrens blood glucose management while at school. In addition, children are continually growing during each academic year, requiring frequent changes to their individualized treatment plans. Decisions concerning adjustments in insulin doses occur often while children are in school and frequently must be made by a school nurse, parent, or guardian following protocols in the comprehensive diabetes care plan prescribed by the childrens physicians.8,9 School nurses are the principal contact person between parents and guardians and health care providers with regard to updating childrens individualized diabetes care plans for management of acute problems during the school day. Unfortunately, some school systems do not have …

Part 2: Family Health During and After Death of a Family Member

An ethnographic study of families who used hospice services was conducted to identify how families defined and practiced family health during a time of family transition. Eight families (N = 29) who recently experienced the death of a family member participated in three interviews. Key findings were: (a) family health is a complex construct with dynamic intergenerational linked patterns, (b) mothers continue to have roles related to family health when children are adults, (c) household context influences family health, and (d) health routines changed during caregiving and loss. Hospice care was a valued family health support during caregiving and following death. Family members deconstructed, reconstructed, and established some new health routines during the terminal phase and bereavement. Future family research should consider transgenerational influences, mothers’ roles related to the health of adult children, contextual influences most predictive of family health, and interventions most supportive of families during change and transition.