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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
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
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
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
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
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
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
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
References                                                              Science and Medicine 32(3), 311–320.
                                                                      King P.M. (1994) Health promotion: the emerging frontier in
Anderson J.M. (1987) The cultural context of caring. Canadian           nursing. Journal of Advanced Nursing 20, 209–218.
  Critical Care Nursing Journal 4(4), 7–13.                           Kleinman A. (1992) Local worlds of suffering: an interpersonal
Baillie L. (1995) Ethnography and nursing research: a critical          focus for ethnographers. Qualitative Health Research 2(2),
  appraisal. Nurse Researcher 3(2), 5–21.                               127–134.
Beattie A. (1991) Knowledge and control in health promotion: a        Leininger M.M. (1990) Importance and uses of ethnomethods, eth-
  test case for social policy and social theory. In The Sociology       nography and ethnonursing research. In Recent Advances in
  of the Health Service (Gabe J. ed), Routledge, London.                Nursing: Research Methodology (Cahoon M.C. ed), Churchill
Bunton R., Murphy S. & Bennett P. (1991) Theories of behavioural        Livingstone, Edinburgh.
  change and their use in health promotion: some neglected areas.     Mackenzie A.E. (1994) Evaluating ethnography: considerations for
  Health Education Research 6(2), 153–162.                              analysis. Journal of Advanced Nursing 19, 774–781.
Caplan R. & Holland R. (1990) Rethinking health education theory.     Maclean U. (1988) Ethnographic approaches to health. In Health
  Health Education Journal 49(1), 10–16.                                Behaviour Research and Health Promotion (Anderson J.M. ed.),
Davison C., Smith G.D. & Frankel S. (1991) Lay epidemiology and         Oxford University Press, Oxford, pp. 41–45.
  the prevention paradox: the implications of coronary candidacy      Oliver M.F. (1992) Doubts about preventing coronary heart
  for health education. Sociology of Health and Illness 13(1),          disease. British Medical Journal 304, 393–394.
  1–19.                                                               Preston R.M. (1993) Mindful Bodies and Diseased Hearts: the
Dines A. (1994) What changes in health behaviour might nurses           Fate of Health Promotion in Coronary Families. MSc thesis,
  logically expect from their health education work? Journal of         Department of Social Science, Brunel University, Uxbridge.
  Advanced Nursing 20, 219–226.                                       Rose G. (1985) Sick individuals and sick populations.
Douglas M. (1970) Natural Symbols. Vintage, New York.                   International Journal of Epidemiology 14, 32–38.
Douglas M. (1966) Purity and Danger. Praeger, New York.               Saunders R. (1989) Look after your heart: heartbeat award scheme.
Geetz C. (1973) The Interpretation of Cultures. Basic Books,            Health Trends 2(21), 62.
  New York.                                                           Scheper-Hughes N. & Lock M. (1987) The mindful body: a pro-
Glaser B.G. & Strauss A.L. (1967) The Discovery of Grounded             legomenon to future work in medical anthropology. Medical
  Theory. Weidenfeld and Nicholson, London.                             Anthropology Quarterly 1(1), 6–41.
Hanson E.J. (1994) Issues concerning the familiarity of researchers   Tate J. & Cade J. (1990) Public knowledge of dietary fat and coron-
  with the research setting. Journal of Advanced Nursing 20,            ary heart disease. Health Education Journal 49(1), 32–35.
  940–942.                                                            Tones B.K. (1986) Health education and the ideology of health
Hart J.T. (1990) Coronary heart disease: preventable but not            promotion: a review of alternative approaches. Health
  prevented? British Journal of General Practice 40, 441–443.           Education Research 1(1), 3–12.
Helman C. (1991) The family culture: a useful concept of family       Wilms D.G. & Best J.A. (1990) A systematic approach for using
  practice. Family Medicine 23(5), 376–381.                             qualitative methods in primary prevention research. Medical
Helman C. (1990) Culture Health and Illness 2nd edn. Wright,            Anthropology Quarterly 4(4), 391–409.
  Oxford.




© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 554–561                                                              561

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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
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