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- 1. Journal of Advanced Nursing, 1997, 25, 554–561
Ethnography: studying the fate of health
promotion in coronary families
Rosemary M. Preston MSc RGN RM DipN DipEd RNT RCNT
Senior Lecturer, Faculty of Health Care and Social Studies, Luton University, Luton,
England
Accepted 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 challenging
I NTRODUCTI ON
question by drawing on data from an ethnographic study
Health promotion is conceptualized by Tones (1986) carried out in the South Buckinghamshire Hospital Trust
as any deliberate intervention which seeks to promote area, England (Preston 1993). The study set out to examine
health and prevent disease and disability. It incorporates how, and to what extent, the health information
health education and gives prominence to the influence of advice given by the community cardiac support nurse was
legal, fiscal, economic, and environmental measures on translated into their everyday domestic setting. Choosing
commnunity 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 this
its 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 health
care, like heart disease prevention and its management as
CONSIDERING AN ETHNOGRAPHIC
a chronic illness for life, nurses are in the frontline of
PERSPECTIVE
attending to the health promotion needs of their client and
associated family groups. Whether this is in the acute The emergence of a health promotion orientation in health
hospital sector or in the community setting. However, an care and the conceptual system that underpins it, is an
interesting question is raised by Dines (1994 p. 219), who area which is intimately connected to aspects of human
asks, ‘What changes in health behaviour might nurses culture and society that have long been a central concern
logically expect from their health education work?’ of anthropologists. In its original usage, the ethnography
554 © 1997 Blackwell Science Ltd
- 2. Ethnography
technique in the then emerging discipline of anthropology supervised practice and a rigorous scholarly background
in the 19th century, the village or tribe, was its most against which the trainee ethnographer, on return from the
common 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 that
1973). 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) highlights
becoming 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 general
or 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 the
homes where access to their health beliefs system, behav-
practitioners attention if threats to these key aspects have not been
iours 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 with
suggested by Wilms & Best (1990 p. 392). the development of yet another ‘methodological fad’,
Kleinman (1992 p. 134) argues for the novice ethnographer
In 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. Hanson
be 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 of
disease 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 the
heart 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 inherent
approach 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 several
and 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 difficult
theory 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 approval
focus on prescribed lifestyle changes without considering
the 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 ‘Ethics
searchers 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 argued
accusing them of holding a rather simplistic notion of how that, for the ethnography to be successful and deemed
health 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. Being
edge is high, misunderstandings concerning how, and to with the coronary families almost everday in their own
what 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 the
proper 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 data
However, Kleinman (1992) draws our attention to concerns gathering that cannot be gained in isolated visits or in one
about 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 the
cultural health care settings. The classical ethnographer researcher who conducted this study, and which required
being 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. R.M. Preston
the question of role conflict that nurses may encounter Using a grounded-theory approach (Glaser & Strauss
when conducting ethnography in this context, and 1967) to data analysis, enabled coding of themes in the
Hughes (1992 p. 444) critically appraises this dilemma by first round of interviews which could then be pursued in
explaining, the second and subsequent rounds. Through the use of an
ethnographic design, this data describes and interprets the
The ethnographer uses the senses of hearing, vision, smell and
individuals understanding of having heart disease in their
taste 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 had
icians, nurses and social workers centre their enquiring gaze on
received.
the individual and his or her pathology, the ethnographer
describes and interprets the suffering of individuals as part of the
lived flow of interpersonal experiences and within the context of Mindful body concept
the 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 1987
report on, and Mackenzie (1994 p. 775) correctly confirms p. 7) as a framework for understanding the relationship
the obscure nature of ethnography in research reporting. between the physical, social and political body, and of
This can cause difficulty for those practitioners who wish heart disease causation and prevention in coronary family
to 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 phenomenology
nursing practice. However, as a methodology it provides (lived-self, physical body), structuralism and symbolism
flexibility 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 is
This paper draws on data collected in extensive taped- a complex structure which provides an opportunity to see
field interviews in the informants own homes, including in the body a symbol of society and the powers and dangers
participant and non-participant observation of family life credited to social structure reproduced on the human
as and when it happened. Each family had a coronary body. Scheper-Hughes & Lock (1987) have extended these
sufferer in their midst and involved a total of 12 adults in arguments and challenge western assumptions about the
five 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 can
Studying 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 behaviour
internal 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 BODY
health or pathogenic. The three primary informants were
selected at random from records held by the community The ways in which the body self is both received and
cardiac support nurse who was responsible for facilitating experienced in health and sickness is highly variable and
the families awareness (see kinship chart), of heart disease an analysis of how the coronary sufferer and his family
prevention and management in the weeks surrounding experienced the notion of heart disease in their midst
preparation and recovery from coronary artery bypass sur- offers intriguing insight into the perceived conceptions of
gery. This approach to health promotion management the nature of their universe. This has implications for the
involved 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 a
a 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-Hughes
and a heart club for the coronary sufferer, where stress & Lock (1987) argue, an approach to health care which is
reducing workshops and participatory group exercise representative of the cartesian legacy reflects a mechanistic
facilitated positive health awareness. conception of how the individual body-self lives and
556 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561
- 4. Ethnography
Figure 1 Chart showing
FAMILY A
kinship links of the three
families 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, you
components of their beliefs as a separate and insignificant
know... make sure they get plenty of exercise... [pause]... but, I’m
problem, 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 being
had his operation he’s been fanatical with his diet and going to raised on the farm has meant I’ve always enjoyed my food, and
the health club. He’s always joking with us that it gives him a being a dairy farm you can guess what my diet consisted. Even
new 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 reduce
our 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 to
fit 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. R.M. Preston
that’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 frequently
But, that’s quite hard to do... [pause]... never enough time in the demonstrated by their understanding of their universe
day.... 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 result
views and was also supported through observing how the of being stressed, I suppose I would have to say yes. You only
families interacted at mealtimes and other social gather- have to look around you to see how life is speeding up to realize
ings. Often feelings of guilt were conveyed in their conver- that stress is a constant factor in our lives. Take my daughter for
sations 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 at
on have another, it won’t do any harm’. Observations of school... but, um, the pressures on her are quite frightening. I
family interactions like these support a tendency for health worry she’ll become a victim and...
messages to incur an artificial level of imposed anxiety
which leads to a separation of their lived-self from the flow Sufferer (family A): I’ve managed to give up smoking but my wife
of their daily routine and from the social context in which hasn’t. We’ve come to an agreement she doesn’t light up when
they would normally function. How food was cooked was I’m in the same room but she’s often anxious about one thing or
another 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 contradictions
effect, ‘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 about
observer noting the food was still cooked in a high amount his body in its relationship to the environment, including
of 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 how
diary: 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 the
A) had been most illuminating about how she had made a con- lived-body-self experience, as it confirms to the individual
scious 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 notion
in 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 thought
and 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 own
to 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 door
opened and I was surpised to see fish steaks covered in a bubbly Sister (family C): Being a postman I thought would be the fittest
batter, 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 you
and 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 to
despite my initial surprise I eagerly tucked into this satisfying get by [shrugs her shoulders].
meal. Somehow though, this observation contradicted with what
I had heard all morning... interesting!
Conflict
Such imagery is a seemingly collective activity which is
Messages chosen
facilitated by mass media and official bodies, as well as
Such observations imply that whilst health knowledge is friends, family and work colleagues. The informants in
high, the coronary families choose which health messages this study often referred to their own observations in this
they can comfortably identify with and disregard the rest. context and often cited celebrities (Michael Heseltine
This 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 a
558 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561
- 6. Ethnography
conflict 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 incorporating
contradictions presented by the coronary families’ under- potentially troublesome information and results in a
standing 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 for
of a ‘prevention paradox’ occuring. Rose (1985 p. 37) conducting assessment of health promotion strategy
explains that this, as a preventative measure which brings within a broader cultural framework, if desired outcomes
much 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) and
reminds us, must be considered unknown, there are no Leininger (1990), respectively, one should begin to address
guarantees that altering ones lifestyle will prevent heart both the emic (insider) and etic (outsider) viewpoints of
disease. 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 the
potential of any health promotion strategy if lay health prevailing orthodoxy of contemporary health promotion
beliefs are not identified and explored individually in practice. This is important for nurses to acknowledge
this context. when considering their own role as health promotion
strategists.
THE SOCIAL BODY
THE BODY POLITIC
The second level of analysis considers the representational
uses 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 concern
families. As Douglas (1970 p. 65) observes more than metaphors and collective representations of the
natural and collective order. It is also about power and
The body is a natural symbol supplying some of our richest
control of threats and regulation of individual and group
sources 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 individualistic
body 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. Certainly
ral and supernatural set of beliefs held by families in con- the ‘Active Heart’ campaign takes on the form of collective
temporary 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 not
context 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 Threat
identify a causal link for the heart disease afflicting their
family group. In this study, the informants believed that the issue of
lifestyle causality factors was imposed as a threat to them
Wife (family A): It seems anyone can be at risk, um, I mean look (meaning their heart) by those seen to be in power and
at us. Who’d have thought we’d have this problem.... No, I look control of their care, namely, the cardiac support nurse
at 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 naughty
scary you know, but [pause]... um, I don’t believe you can do with the booze and other things sometimes, but it don’t seem
much 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’t
your 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 I
who concluded that lay epidemiology readily accommo- don’t have to worry too much. What does he know? Having a
dates 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. R.M. Preston
two years my brother kept saying he didn’t feel right, what did
DISCUSSION
the 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 the
become blurred and the symbols of self-control intensified danger of death. As this study has shown, considering
through 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 insight
Active Heart Club can be seen as a developing community- into the fate of health promotion in coronary family
based 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 when
Sufferer B comments on his experiences when visiting engineering their strategies to the point where health
the club: knowledge can be translated successfully into the dom-
estic setting. This raises the interesting question of why
Sufferer (family B): We’re told to rest.... There are about eight of
family beliefs systems persist despite an input of new
us 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 that
taken up by anyone who has had some experience of that problem.
it has ruled the planning of health campaigns over the
There is a quiet feeling of reassurance, a sense of sharing and
years. From a cultural perspective though, it can be
belonging.
acknowledged that many people do endanger their lives
and are constantly exposed to health threats which they
Ritual of family get togethers deem beyond their immediate control. This is despite con-
temporary research highlighting health knowledge to be
Those individuals who did not attend the club preferred high in the general population (Tate & Cade 1990, Hart
instead 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 of
Sufferer (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 or
as such. If any of us are suffering, we all suffer.... It’s our way.
postponable — the idea that it could happen to anyone at
You saw us last time, sitting around the table for an evening meal
anytime was omnipresent. This has serious implications
together. We didn’t do that because we knew you were coming.
as to what changes in health behaviour nurses can logically
No, 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 the
help 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 the
ured framework of support when lifestyle changes are problem of lifestyle adopted practices, may be one way
prescribed. 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 ON
celebrates, 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 provides
they had a coronary sufferer in their midst, and during the a detailed account of peoples lives and the ways they make
transition phase that encompassed their adoption of new sense of their world as part of the flow of their lived-body
lifestyle 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 facilitate
chaos that this situation had afflicted them with. the development of meaningful knowledge and a theory
560 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561
- 8. Ethnography
base for nursing practice, where an understanding of the Hughes C.C. (1992) Ethnography: what’s in a word — process?
lay epidemiology that operates in the cultural fields of product? promise? Qualitative Health Research 2(4), 439–450.
luck, fate, and destiny can be acknowledged to be a fac- Hunt S.M. & McCleod M. (1987) Health and behaviour change:
some lay perspectives. Community Medicine 9(1), 68–76.
tor influencing the fate of health promotion in the daily
Kelly R.B., Zyzanski S.J. & Alemagno S.A. (1991) Prediction of
domestic setting.
motivation and behaviour change following health promotion:
role of health beliefs, social support and self-efficacy. Social
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