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  1. 1. Journal of Advanced Nursing, 1997, 25, 554–561Ethnography: studying the fate of healthpromotion in coronary familiesRosemary M. Preston MSc RGN RM DipN DipEd RNT RCNTSenior Lecturer, Faculty of Health Care and Social Studies, Luton University, Luton,EnglandAccepted for publication 20 March 1996 PRESTON R.M. ( 1997) Journal of Advanced Nursing 25, 554–561 Ethnography: studying the fate of health promotion in coronary families The concept of the ‘mindful body’, ‘coronary candidacy’ and ‘prevention paradox’ are three of many interesting themes explored in this paper which examines how, and to what extent, health information is received and translated into the daily domestic setting by coronary family groups. Taking an ethnographic approach to collecting data highlights both the advantages and disadvantages of this methodology in practice. Certainly, the emergence of a health promotion orientation in health care is an area which is intimately connected to aspects of human culture and society that have long been a central concern of anthropologists. This mini-ethnography provides an anthropological understanding of the knowledge, beliefs and behaviours associated with heart disease and its prevention. The concept of the ‘mindful body’ is provided as a critical interpretive approach to analysing the potential outcome of prescribed lifestyle changes, as given to coronary sufferers and their families during the period following coronary artery bypass surgery. Data drawn from this study confirms the evidence of lay epidemiology which works within the cultural field of fate, luck and destiny, and which has interesting implications as to how nurses might plan for their health promotion strategies in the future. The intent of this paper is to address this challengingI NTRODUCTI ON question by drawing on data from an ethnographic studyHealth promotion is conceptualized by Tones (1986) carried out in the South Buckinghamshire Hospital Trustas any deliberate intervention which seeks to promote area, England (Preston 1993). The study set out to examinehealth and prevent disease and disability. It incorporates how, and to what extent, the health informationhealth education and gives prominence to the influence of advice given by the community cardiac support nurse waslegal, fiscal, economic, and environmental measures on translated into their everyday domestic setting. Choosingcommnunity health. In contemporary Britain, health pro- an ethnographic design proved to be an interesting experi-motion is increasingly seen as an emerging frontier within ence for the researcher. A critical examination of thisits health care system and, as suggested by King (1994 approach to research is offered in this paper for those con-p. 209), offers an intriguing challenge to the nursing pro- sidering ethnography as a design in the future.fession in particular. Certainly in specific areas of healthcare, like heart disease prevention and its management as CONSIDERING AN ETHNOGRAPHICa chronic illness for life, nurses are in the frontline of PERSPECTIVEattending to the health promotion needs of their client andassociated family groups. Whether this is in the acute The emergence of a health promotion orientation in healthhospital sector or in the community setting. However, an care and the conceptual system that underpins it, is aninteresting question is raised by Dines (1994 p. 219), who area which is intimately connected to aspects of humanasks, ‘What changes in health behaviour might nurses culture and society that have long been a central concernlogically expect from their health education work?’ of anthropologists. In its original usage, the ethnography554 © 1997 Blackwell Science Ltd
  2. 2. Ethnographytechnique in the then emerging discipline of anthropology supervised practice and a rigorous scholarly backgroundin the 19th century, the village or tribe, was its most against which the trainee ethnographer, on return from thecommon level of application for studying people who field, can be debriefed and systematically assisted to con-shared many similar and cultural characteristics (Geetz struct the ethnography as an academic monograph so that1973). In contemporary health care matters, Kleinman reliability and validity of its method in practice can be(1992) reports ethnography as a method of enquiry, fast critically appraised. Mackenzie (1994 p. 780) highlightsbecoming a fashionable choice where specific health the importance of this need by stating:care settings are considered to be the analogy of the village There is no justification for ethnographers to ignore the generalor tribe. In this study, five family groups who had a coron- rules of research reporting which include reliability and validity,ary sufferer in their midst were investigated in their own and that no research in practice-based professions is worth thehomes where access to their health beliefs system, behav- practitioners attention if threats to these key aspects have not beeniours and lifestyles that are normally obscured and dis- addressed as rigorously as possible.torted by standard biomedical and epidemiological studies(see Maclean 1988, Beattie 1991, Bunton et al. 1991, If this type of research method is to be used appropri-Kelly et al. 1991), could be explored more effectively. As ately by the medical and nursing professions, and not withsuggested by Wilms & Best (1990 p. 392). the development of yet another ‘methodological fad’, Kleinman (1992 p. 134) argues for the novice ethnographerIn contrast to the construct-driven studies of behavioural medi- to be aware of the many difficulties of conducting a self-cine and behavioural science, this approach permits research to anthropological study of this nature in practice. Hansonbe data-driven, particularly with regard to bodily and health (1994) has also critically appraised this problem and sug-related experience and to the natural history of illness, health and gests that the ethnographer requires an appreciation ofdisease experience. insider bias when being an observer in their own cultural Unfortunately though, some important research into setting. There is also a need to consider the effect of theheart disease and health behaviour practices as identified researcher on the informants being studied, and the taking,by Oliver (1992), have tended to take a reductionist recording, and analysis of field notes, with its inherentapproach which focus on a limited number of practices problem of the interpreters bias at source. However, carry-like smoking and eating fatty foods. Bunton et al. (1991) ing out ethnography in your own culture has severaland Caplan & Holland (1990) have both argued that this advantages which addresses the issue of access and famili-has given rise to a criticism of bias in health promotion arity of the cultural setting which are inherently difficulttheory as a field of practice and enquiry. From an anthro- for the ethnographer to achieve when entering a ‘foreign’pological perspective, it would appear that such criticisms culture.are not unfounded, and in many ways can be seen to rep-resent a disillusion with the medical model approach that Ethics commitee approvalfocus on prescribed lifestyle changes without consideringthe mindful components that influence its fate. One of the hardest aspects posed for the ethnographer in Bunton et al. (1991) and other health behaviour re- this study was gaining approval from the local ‘Ethicssearchers such as Hunt & Macleod (1987) have been critical Committee’ who were initially concerned with the intrus-in their observations of methods used in health promotion, ive nature of the research methodology. It had to be arguedaccusing them of holding a rather simplistic notion of how that, for the ethnography to be successful and deemedhealth knowledge is transmitted to the lay public. Tate & credible, there was a need to develop an on-going relation-Cade (1990) confirm this underlying issue in health pro- ship with the informants for the flow of their lived experi-motion strategy by discovering whilst lay health knowl- ences to assist the contextual framework of analysis. Beingedge is high, misunderstandings concerning how, and to with the coronary families almost everday in their ownwhat extent, health knowledge is being translated into homes, and being involved in their daily activities, includ-everyday behaviour does occur. ing social occasions over an eight-week period, enabled a In this context, therefore, Maclean (1988), supports a description of the particular social context from which theproper appreciation of researching health behaviour data emerged, and an interpretation within it, of places,matters through the use of an ethnographic approach. people and other meaningful things; a form of dataHowever, Kleinman (1992) draws our attention to concerns gathering that cannot be gained in isolated visits or in oneabout how health care professionals in particular are to be interview setting.trained to practice competent ethnography in their own However, this posed a daunting prospect for thecultural health care settings. The classical ethnographer researcher who conducted this study, and which requiredbeing viewed as someone who has to experience a trans- time, patience, and a good sense of humour, with a con-formation of being thrown into a new cultural setting, to scious effort not to approach these informants as a nurse,become emersed in its ethos. This approach requires but as an anthropologist. Baillie (1995 p. 11) acknowledges© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561 555
  3. 3. R.M. Prestonthe question of role conflict that nurses may encounter Using a grounded-theory approach (Glaser & Strausswhen conducting ethnography in this context, and 1967) to data analysis, enabled coding of themes in theHughes (1992 p. 444) critically appraises this dilemma by first round of interviews which could then be pursued inexplaining, the second and subsequent rounds. Through the use of an ethnographic design, this data describes and interprets theThe ethnographer uses the senses of hearing, vision, smell and individuals understanding of having heart disease in theirtaste as much as cognition to characterize important physical and family and explores the mindful components that influ-social features of a given field of human behaviour. Where phys- enced the fate of the prescribed lifestyle changes they hadicians, nurses and social workers centre their enquiring gaze on received.the individual and his or her pathology, the ethnographerdescribes and interprets the suffering of individuals as part of thelived flow of interpersonal experiences and within the context of Mindful body conceptthe local moral worlds that encircle them. The ongoing contextual analysis utilized the heuristic con- Ethnographic studies are always difficult to conduct and cept of the ‘mindful body’ (Scheper-Hughes & Lock 1987report on, and Mackenzie (1994 p. 775) correctly confirms p. 7) as a framework for understanding the relationshipthe obscure nature of ethnography in research reporting. between the physical, social and political body, and ofThis can cause difficulty for those practitioners who wish heart disease causation and prevention in coronary familyto assess the potential of ethnographic research for their groups. The three bodies represent three separate and over-own practice, thereby restricting its value to the field of lapping units of analysis which considers phenomenologynursing practice. However, as a methodology it provides (lived-self, physical body), structuralism and symbolismflexibility of method, allowing data to be collected from (the social body), and post-structuralism (the body politic).different perspectives and by different methods. Drawing on data using this framework for analysis enabled the fate of health promotion in these family groups to be examined at both the macro and micro-level of analysis.STUDY Douglas (1966) has argued convincingly that the body isThis paper draws on data collected in extensive taped- a complex structure which provides an opportunity to seefield interviews in the informants own homes, including in the body a symbol of society and the powers and dangersparticipant and non-participant observation of family life credited to social structure reproduced on the humanas and when it happened. Each family had a coronary body. Scheper-Hughes & Lock (1987) have extended thesesufferer in their midst and involved a total of 12 adults in arguments and challenge western assumptions about thefive family homes. mind and body which may be detrimental to how health care is planned for, and received, by its individual mem- bers in society. By proposing this framework, the body canStudying families as cultural groups be examined from three separate but integrated perspec-As proposed by Helman (1991 p. 376), each family can be tives that may help to increase our knowledge and under-regarded as unique small-scale society, with its own standing of the cultural aspects of health behaviourinternal organization and view of the world. A crucial matters.aspect of each family culture involves those beliefs, behav-iours, habits, and lifestyles that are either protective of THE PHYSICAL BODYhealth or pathogenic. The three primary informants wereselected at random from records held by the community The ways in which the body self is both received andcardiac support nurse who was responsible for facilitating experienced in health and sickness is highly variable andthe families awareness (see kinship chart), of heart disease an analysis of how the coronary sufferer and his familyprevention and management in the weeks surrounding experienced the notion of heart disease in their midstpreparation and recovery from coronary artery bypass sur- offers intriguing insight into the perceived conceptions ofgery. This approach to health promotion management the nature of their universe. This has implications for theinvolved a structured programme which followed the concept of health promotion itself because how health‘Active Heart’ type campaigns as indentified by Saunders messages are received and experienced will determine its(1989 p. 62). This campaign was a local initiative in the fate. Observations drawn from the data in this context,South Buckinghamshire Hospital Trust area and followed highlight the informants dilemma in trying to achieve aa pattern of local news media coverage, information balance between their perceived health needs and enjoy-leaflets, individual/group counselling in their own homes, ment of their lived daily experience. As Scheper-Hughesand a heart club for the coronary sufferer, where stress & Lock (1987) argue, an approach to health care which isreducing workshops and participatory group exercise representative of the cartesian legacy reflects a mechanisticfacilitated positive health awareness. conception of how the individual body-self lives and556 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561
  4. 4. EthnographyFigure 1 Chart showing FAMILY Akinship links of the threefamilies studied. Father (deceased–heart attack/52 y) Mother (deceased–stroke/80 y) Brother (48 y) Brother (52 y) Patient (58 y) and wife (52 y) (x 4 MI bypass surgery) Son (22 y) Son (26 y) Daughter (30 y) Daughter (32 y) and wife (22 y) and husband (28 y) + 2 children + 3 children aged 2 y/8mths aged 10 y/8 y/2 y FAMILY B Father (deceased–heart attack/84 y) Mother (deceased–heart attack/82 y) Sister (56 y) and husband (61 y) +2 children aged 40 y and 38 y Patient (65 y) and wife (58 y) (x 2 MI and bypass surgery) Daughter (32 y) and husband (47 y) + 3 children aged 12 y/8 y/2 y FAMILY C Father (deceased–heart attack/42 y) Mother (deceased–heart attack/65 y) Twin sister (32 y) Brother (29 y) Sister (42 y) and Patient (32 y) and live-in partner (24 y) husband (41 y) (x 4 MI and + 4 children aged bypass surgery) 16 y/12 y/11 y/3 y Son (3 y)functions. Thereby, a focus on so many of the physical for you than having regular meals... but,... don’t tell my dad that...aspects of their previously preferred lifestyle when life- he’ll go nuts!style changes were prescribed, whilst ignoring the mindful Daughter (family B): I try to do what’s right for my children, youcomponents of their beliefs as a separate and insignificant know... make sure they get plenty of exercise... [pause]... but, I’mproblem, seemingly caused unnecessary anxieties. not sure that’ll be enough to protect them in the future. Me, well,Son (family A): I don’t like to give it much thought. Since dad um, I’ve only recently started to look after myself. You see beinghad his operation he’s been fanatical with his diet and going to raised on the farm has meant I’ve always enjoyed my food, andthe health club. He’s always joking with us that it gives him a being a dairy farm you can guess what my diet consisted. Evennew lease on life and we should try it, but,... [pause]... um, I never when I married I still cooked the same way my mother had....have time. My wife can’t see any problems with what we do and Since my husband had his last physical he’s been told to reduceour friends feel the same way. None of us are overweight, we keep his cholesterol and its meant I’ve had to make a lot of changes tofit and we enjoy our lifestyle. The kids are happy enough, they how and what I cook. We’ve thought about becoming vegetarians,are allowed to eat when and what they want. I believe that’s better it’s something my eldest daughter wants to do, but I’m not sure© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561 557
  5. 5. R.M. Prestonthat’s the answer. I’ve started to go swimming every week and I that balance which was often due to the many contradic-try not to use the car everyday, you know, walk to work instead. tions that life presented them with. This was frequentlyBut, that’s quite hard to do... [pause]... never enough time in the demonstrated by their understanding of their universeday.... being tense, fast, and full of chaos. Data of this nature recurred many times in other inter- Sister (family C): If you’re asking me if I believe this is the resultviews and was also supported through observing how the of being stressed, I suppose I would have to say yes. You onlyfamilies interacted at mealtimes and other social gather- have to look around you to see how life is speeding up to realizeings. Often feelings of guilt were conveyed in their conver- that stress is a constant factor in our lives. Take my daughter forsations like, ‘Don’t you know coffee is bad for you’, or, ‘Go example. I don’t want her to get pregnant whilst she is still aton have another, it won’t do any harm’. Observations of school... but, um, the pressures on her are quite frightening. Ifamily interactions like these support a tendency for health worry she’ll become a victim and...messages to incur an artificial level of imposed anxietywhich leads to a separation of their lived-self from the flow Sufferer (family A): I’ve managed to give up smoking but my wifeof their daily routine and from the social context in which hasn’t. We’ve come to an agreement she doesn’t light up whenthey would normally function. How food was cooked was I’m in the same room but she’s often anxious about one thing oranother area where this was highlighted and often when another and then forgets,... what can you say?explored with the informants, rationale was given to the Scheper-Hughes & Lock (1987) note these contradictionseffect, ‘Well we’ve always done it this way or, I was told and tensions as being an integral part of Western cos-to stop frying food so now I cook in the oven’ (despite the mology. How an individual self entertains notions aboutobserver noting the food was still cooked in a high amount his body in its relationship to the environment, includingof fat). external and internal perceptions, memories, affects, cog- The following is an extract from the researchers own nitions, and actions, is an important contribution to howdiary: his lay health knowledge, beliefs and behaviours are con-We had had a good discussion virtually all morning. Wife (family structed. Body image is one important component of theA) had been most illuminating about how she had made a con- lived-body-self experience, as it confirms to the individualscious effort to change her style of cooking from frying to grilling the social and cultural meanings of what it is to be human,or cooking in the oven following a chat she had had with the and provides a framework for them to base their lay epi-cardiac support nurse. There were tales about what her cooking demiology that explains their sickness or health status.was like when they first got married with her husband chipping Davison et al. (1991 p. 7) draws our attention to the notionin every so often when he wasn’t being distracted by his energetic of ‘coronary candidacy’ as belonging to the area of lay epi-grandson. I found myself being coerced into staying for lunch. It demiology related to body image perception. In this study,had not been my intention, but I was cold and felt quite hungry informants held specific images of the person they thoughtand the smells coming from the kitchen had been too inviting. most likely to suffer from heart trouble.Although we had spent most of the morning in the conservatory Wife (family A): I’ve always known Dave to be a fit man. [laughs]because of the rain, wife A had flitted in and out of the kitchen Yes much fitter than me. I’ve always been too tubby for my ownto prepare the lunch and I was only too willing to set the table good and I know I smoke too much.for the four of us as she prepared to dish-up. The oven dooropened and I was surpised to see fish steaks covered in a bubbly Sister (family C): Being a postman I thought would be the fittestbatter, floating in boiling oil on one shelf and a tray of noisette job he could have. All that walking with the postal rounds well,...potatoes also floating in oil on the other shelf. Peas were drained um, who’d have thought he’d get so sick. Now me yes. As youand a knob of Flora margarine was dropped onto its pile and can see, I smoke too much and I eat too much. It’s what I do todespite my initial surprise I eagerly tucked into this satisfying get by [shrugs her shoulders].meal. Somehow though, this observation contradicted with whatI had heard all morning... interesting! Conflict Such imagery is a seemingly collective activity which isMessages chosen facilitated by mass media and official bodies, as well asSuch observations imply that whilst health knowledge is friends, family and work colleagues. The informants inhigh, the coronary families choose which health messages this study often referred to their own observations in thisthey can comfortably identify with and disregard the rest. context and often cited celebrities (Michael HeseltineThis has implications for health promotion strategies, (member of parliament) and James Hunt (racing driver))because it seems achieving a balance in any lifestyle is who had recently been afflicted, in their attempt to ration-very important to the individual self. However, the data alize the image they had of a typical heart attack victim.here highlights how individuals had difficulty in achieving However, it was clearly evident they encountered a558 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561
  6. 6. Ethnographyconflict in their understanding of heart disease causation within the cultural fields of luck, fate and destiny. A cogni-and often asked, ‘Why me?’ Certainly, the tensions and tive process which offers a rational way of incorporatingcontradictions presented by the coronary families’ under- potentially troublesome information and results in astanding of their cosmology and the constructed imagery potential barrier to the aims of health promotion strategy.of the ‘coronary candidate’ emphasizes the real dilemma This part of the analysis, therefore, highlights the need forof a ‘prevention paradox’ occuring. Rose (1985 p. 37) conducting assessment of health promotion strategyexplains that this, as a preventative measure which brings within a broader cultural framework, if desired outcomesmuch benefit to the population, offers little to each partici- for health disease prevention are to be achieved.pating individual. Assuming heart disease causation to be When considering a cultural perspective within a nurs-multifactorial, but which in many ways, as Oliver (1992) ing assessment, as advocated by both Anderson (1987) andreminds us, must be considered unknown, there are no Leininger (1990), respectively, one should begin to addressguarantees that altering ones lifestyle will prevent heart both the emic (insider) and etic (outsider) viewpoints ofdisease. That is assuming you were a candidate in the first both the clients and nurses own beliefs system in this con-place. The informants perception of what they consider to text. The data suggests that the coronary families’ percep-be a ‘coronary candidate’ seriously undermines the success tion of heart disease causation is in direct contrast to thepotential of any health promotion strategy if lay health prevailing orthodoxy of contemporary health promotionbeliefs are not identified and explored individually in practice. This is important for nurses to acknowledgethis context. when considering their own role as health promotion strategists.THE SOCIAL BODY THE BODY POLITICThe second level of analysis considers the representationaluses of the body as a natural symbol with which to think As argued by Scheper-Hughes & Lock (1987), the relation-about the nature of health behaviour practices in coronary ship between the individual and social bodies concernfamilies. As Douglas (1970 p. 65) observes more than metaphors and collective representations of the natural and collective order. It is also about power andThe body is a natural symbol supplying some of our richest control of threats and regulation of individual and groupsources of metaphor. These may be used as a cognitive map to boundaries. For example, the overall shape of health pro-represent the natural, supernatural, social and even spatial motion policies and the way they have been oper-relations that are experienced in everyday language and functions. ationalized, swinging from the most fundamental pole of A symbolic anthropology takes the experiences of the social theory and political action, between individualisticbody as a representation of society itself. A failure to seek and collectivist modes of intervention, between paternal-out the individual’s true understanding of heart disease istic imposed and consultatory participatory forms of auth-causation as this study has attempted to do, ignores a natu- ority, demonstrate the nature of these barriers. Certainlyral and supernatural set of beliefs held by families in con- the ‘Active Heart’ campaign takes on the form of collectivetemporary Britain. In this respect, frequently quoted and consultative participatory approach to health pro-metaphors such as, ‘he can’t unwind’ were noted in the motion strategy which involves the whole community notcontext of everday language. Usage of the cultural fields just the coronary sufferers themselves.of luck, fate and destiny also figured prominently as super-natural metaphors which exemplified their inability to Threatidentify a causal link for the heart disease afflicting theirfamily group. In this study, the informants believed that the issue of lifestyle causality factors was imposed as a threat to themWife (family A): It seems anyone can be at risk, um, I mean look (meaning their heart) by those seen to be in power andat us. Who’d have thought we’d have this problem.... No, I look control of their care, namely, the cardiac support nurseat my family and I think we’ve been unlucky. I just hope and pray and the cardiac consultant.my kids will be alright. Sufferer (family A): I just can’t accept I’m sick and [pause] well,Daughter (family B): Having heart disease in the family is quite I’ve always been a keep-fit fanatic, even if I have been naughtyscary you know, but [pause]... um, I don’t believe you can do with the booze and other things sometimes, but it don’t seemmuch to prevent it happening. It’s the same with cancer. If it’s right. I’m told I have 10 years following this op but less if I don’tyour turn to get it then there’s not much you can do about it. change the way I live.... Some choice eh? This finding is very similar to Davison et al.’s (1991), Sister (family C): My doctor says my cholesterol is normal so Iwho concluded that lay epidemiology readily accommo- don’t have to worry too much. What does he know? Having adates offical messages concerning health behaviour risks heart attack at 30 is something you don’t expect to happen. For© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561 559
  7. 7. R.M. Prestontwo years my brother kept saying he didn’t feel right, what did DISCUSSIONthe doctor do? Nothing! Now he’s been told to change his lifestyle.Talk about calling the kettle black. Teaching others about health and lifestyle practices needs to involve an appreciation of the lay person’s current When the sense of social order is threatened in this way, beliefs which are situated within the context of their dis-boundaries between the individual and body politic tinctive ways for dealing with sickness, disability and thebecome blurred and the symbols of self-control intensified danger of death. As this study has shown, consideringthrough an increased need for ritual and acts of purifi- heart disease and risk behaviour practice within the ana-cation (Scheper-Hughes & Lock 1987). For example, the lytical frame of the ‘mindful body’ offers intriguing insightActive Heart Club can be seen as a developing community- into the fate of health promotion in coronary familybased ritual which functions as a self-help group for coron- groups. Certainly, a confirmation of Davison et al.’s (1991)ary sufferers. This ritual appears to create social distance earlier findings of the operation of a lay epidemiology dem-and a sense of control and security for these informants. onstrates the difficulty all health promoters face whenSufferer B comments on his experiences when visiting engineering their strategies to the point where healththe club: knowledge can be translated successfully into the dom- estic setting. This raises the interesting question of whySufferer (family B): We’re told to rest.... There are about eight of family beliefs systems persist despite an input of newus here this evening and we all sit in a circle and have a chat health knowledge being present?about anything and everything. It was certainly nice to feel relaxed Certainly, the phrase risk behaviour has gained promi-after our strenuous aerobic workout. Questions are raised and nence in the dialogue of health promotion to the point thattaken up by anyone who has had some experience of that problem. it has ruled the planning of health campaigns over theThere is a quiet feeling of reassurance, a sense of sharing and years. From a cultural perspective though, it can bebelonging. acknowledged that many people do endanger their lives and are constantly exposed to health threats which theyRitual of family get togethers deem beyond their immediate control. This is despite con- temporary research highlighting health knowledge to beThose individuals who did not attend the club preferred high in the general population (Tate & Cade 1990, Hartinstead to utilize rituals of family get togethers to control 1990). By drawing on a mini-ethnographic perspective,their bodies in times of crisis. this study has examined family culture in the domes- tic setting with a view to identifying those patterns ofSufferer (family A): We’re all close as families go. As you know, behaviour which are protective of health, or pathogenic.all my kids except one are married and live locally. We tend to There is evidence here to suggest the operation of a ‘pre-live out of each others pockets. It seems right somehow. I’ve vention paradox’, based on the informants professed opi-always kept us close. You see we never have individual problems nion that heart disease was to some extent preventable oras such. If any of us are suffering, we all suffer.... It’s our way. postponable — the idea that it could happen to anyone atYou saw us last time, sitting around the table for an evening meal anytime was omnipresent. This has serious implicationstogether. We didn’t do that because we knew you were coming. as to what changes in health behaviour nurses can logicallyNo, its something we do regular. We sit around and talk like about expect from their health education work. For families, pat-anything and everything that’s bothering us. terns of risk behaviour may, as this study has shown, be How individuals and family groups utilize rituals to highly acceptable in the moral worlds that encircle thehelp control their bodies in crisis might offer the health coronary sufferers and their families. Developing assess-promotion strategist insight into planning a struct- ment strategies which include a cultural perspective to theured framework of support when lifestyle changes are problem of lifestyle adopted practices, may be one wayprescribed. As Helman (1990 p. 192) explains, forward for the nurse health promoter of the future.All rituals are an important part of the way that any social group CONCLUSI ONcelebrates, maintains or renews the world in which they live. By studying family culture, as this study has attempted to Certainly, during the most difficult period of discovering do, the value of conducting an ethnography that providesthey had a coronary sufferer in their midst, and during the a detailed account of peoples lives and the ways they maketransition phase that encompassed their adoption of new sense of their world as part of the flow of their lived-bodylifestyle practices, the rituals of the heart club and family experience has hopefully been highlighted. The appli-get-togethers provided these individuals with a strong cation of this approach, as Baillie (1995) so rightly ident-sense of cultural order imposed on, and superior to, the ifies, is not without its problems. However, it can facilitatechaos that this situation had afflicted them with. the development of meaningful knowledge and a theory560 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561
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