ARTIGO ORIGINAL
ORIGINAL ARTICLE
Family world view in a context of chronic diseases: concept 1
analysis
Visão de mundo familiar no contexto de doenças cronicas: uma analise de conceito
Vista mundial de la familia en un contexto de las enfermedades crónicas: análisis del concepto
Autores
Paloma Cesar de Sales1
Deborah Ann Chyun
1
1
College of Nursing - New York University.
Resumo
Objetivo: Este artigo visa analisar o conceito de vista Mundial da Família no contexto de doenças crônicas. Isto
pode orientar o desenvolvimento de intervenções educativas centradas familiar eficaz. Metodos: O método
evolutivo de Rodger foi escolhido para conduzir a nossa análise. Resultados: Um total de 11 artigos compuseram o
estudo. Antecedentes e atributos poderia ser achados agrupados em três categorias principais: “nível de família”,
“características sociodemográficas” e “cultura”. Consequências foram considerados como “positivo” ou “negativo”.
Conclusão: A visao de mundo da Família é relevante para orientar enfermeiros para maior desenvolvimento de
intervenções educativas no contexto das doenças crônicas.
Palavras-chave: analise de conceito, doença cronica, enfermagem, visao de mundo familiar.
Abstract
Objective: This paper aim to analyze the concept of Family World view in the context of chronic diseases.
Background: Given the importance of family´s role in the management of chronic diseases it is relevant to
understand how their beliefs are built and perceived regarding management of chronic disease in the family
core Methods: Rodger´s evolutionary method was chosen to conduct our analysis. Results: A total of 11 articles
composed the study. Antecedents and attributes findings could be clustered in three main categories: “family
level”, “sociodemographics” and “culture”. Consequences were considered as “positive’ or “negative”. Conclusion:
Family World view is relevant to guide nurses to development of further educational interventions in the context
of chronic diseases.
Keywords: chronic disease, concept analysis, family world view, nursing.
Resumen
Objetivo: En este trabajo se pretende analizar el concepto de vista Mundial de la Familia en el contexto de las
enfermedades crónicas. Esto puede guiar el desarrollo de intervenciones educativas eficaces centrados en la
familia. Métodos: O método evolutivo de Rodger fue elegido para Realizar el análisis. Resultados: El total de
11 artículos componen el estudio. Antecedentes y atributos hallazgos podrían agruparse en tres categorías
principales: “nivel de familia”, “sociodemográficas” y “cultura”. Consecuencias Se consideraron los “positivo” o
“negativo”. Conclusión: Vista Mundial de la Familia es relevante para las enfermeras para guiar el desarrollo de
nuevas intervenciones educativas principales en el contexto de las enfermedades crónicas.
Palabras-clave: visión del mundo de la familia, las enfermedades crónicas, análisis de conceptos, de enfermería.
Data de submissão: 15/08/2014.
Data de aprovação: 12/11/2014.
Correspondência para:
Paloma Cesar de Sales.
College of Nursing - New York University.
14744 Jasmine Avenue, Flushing, New
York, NY, USA. CEP: 11355.
E-mail: [email protected]
DOI: 10.5935/2446-5682.20150002
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Sales PC, Chyun DA
Rev. Enf. 2015 Jan-Jun; 1(1):13- 18
INTRODUCTION
Given the increasing global burden of chronic diseases and
the impact caused especially in under-developed countries, it
is fundamental to nursing to consider a Family World view in
the care process. It is been well established in the literature
the importance of family role in the care individuals with
chronic diseases (Evans, Whitehead, Diderichsen, Bhuiya, &
Wirth, 2001;Glanz, Rimer & Lewis, 2002; Caldwell & Caldwell,
1991; Rosland & Heisler, 2009; Botelho, Lue & Fiscella, 1996).
Therefore, it is imperative to understand how family view are
perceived and constructed in the context of chronic diseases.
Explore the concept of Family World view also can contribute
to guide directive nursing interventions towards family’s health
promotion.
The concept of Family World view has been usually explored
by social sciences such as psychology and anthropology and
other disciplines related to human development. In nursing
science, the term of Family World view has notbeen clearly
definedand it is often a surrogate to similar or related key
constructs such as family coherence, family paradigm, family
perception, family coping and others (Kluckhohn & Leighton,
1962;Greenstein & Shannon, 2013). Family World view as an
abstract construct is originally derived from anthropology and
philosophy. The concept World view describes how personal
beliefs could lead and orient people´s interpretation of reality.
The concepts of family vary in the literature. Currently a broad
definition of family is commonly used in research. Many family
scholars consider family as complex core and can encompass
multiple dimensions in terms of meaning (Reiss & Oliveri, 1980;Bray
& Harvey, 1986;Antonovsky & Sourani, 1988). Literature shows that
family is more than a social label or status. The concept of family
is strongly related to emotional and social connections between a
group of people (McCarthy, Doolittle & Sclater, 2012;Nam, 2012).
These constructs combined, provide the concept of family World
view and it is relevant to be explored in nursing science. The concept
of Family World view can be considered new in the literature,
however, it has been described as families´ beliefs and values facing
an adverse event (Ransom, Fisher & Terry, 1992). Therefore, the
purpose of this paper is to analyze the concept of Family World
view regarding antecedents, attributes and consequences using
Rodger´s evolutionary method and contextually dependent in the
family’s management of chronic diseases.
METHODS
Rodger´s revolutionary method of concept analysis was
chosen to conduct this paper in order to examine variances
in concepts of the meaning of a particular phenomenon
(Rogers, 2000). A librarian was consulted for the literature
search. The literature search was performed in PsycInfo,
Cinahl, Cochrane Library, Medline and Pubmed databases.
Articles were selected based on the following inclusion
criteria: Full text, English language, essay, thesis, peerreviewed, quantitative and qualitative research papers
approaching family beliefs about factors related to chronic
diseases. The articles chosen were published between
2000 to the present year. Primary literature search found
only 56 articles and after review only 11 articles were
considered relevant to compose the sample as shown at
Table 1.
Initially our study was focused to analyze family World
view in the context of hypertension (HTN). However, due
shortage of literature related to this particular phenomenon,
it was decided to extrapolate our sample, encompassing all
chronic diseases.
BACKGROUND
In nursing, the study of family is relevant, not only as
a construct of interest in nursing science, but also as an
epistemological concept related to populations´ health in their
practice. During the 1980s, many changes occurred in the
health scenario worldwide. In 1986, health promotion principles
werepromulgated in the 1st International Conference on Health
Promotion and influenced the changed from the biomedical
health paradigm (World Health Organization, 2014). In this
sense, the focus of health care was expanded to include not
only the individual with the disease, but also the health of the
family and community as a whole. Thus, during the 1980s, many
theories focused on families started to emerge in order to better
understand family as a complex core in relation to health-illness
process. Antonovsky (1987) purposed a satulogenic theory sense
of coherence in order to claim that people´s world view has a
positive interaction in health (cited in Antonovsky & Sourani,
1988). Reiss (1981) also investigated the family´s construct
of reality, which is demonstrated when a family member’s
assumptions about the world, once shared with others members
can influence and organize the manner of how the family faces
and understands the world. All these theories have been linked
with several health and disease indicators in the literature (cited
in Reiss & Oliveri, 1980).
RESULTS
Many of the publications investigate and explore an
individual’s world view in the midst of chronic disease, but
not necessarily their family’s. Most of the articles considered
relevant to compose our sample were qualitative studies
(Barreto, Silva, Waidman, & Marcon, 2013; Wollenhaupt,
Rodgers & Sawin, 2012;.Flynn et al., 2013; Samuel-Hodge,
Cene, Corsino, Thomas, & Svetkey,2012).Systematic reviews
(Bhana & Bachoo, 2011; Ton et al., 2011; Rosland, Heisler, &
Piette, 2012) and integrative review of the literature (Golics
et al., 2013). However, a cross-sectional study (Castillo,
Izquierdo, Vazquez, & Godo, 2013) and a longitudinal mixedmethod study (Hines 2011) were found and also included in
our sample. It is important to highlight that only two studies
were derived from nursing science as shown in Table 2. These
findings demonstrate the lack of quantitative research related
to this topic and the need of more studies in nursing.
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Visao de mundo para doenças cronicas
Sales PC, Chyun DA
Rev. Enf. 2015 Jan-Jun; 1(1):13- 18
Table 1. Article selected to analyze the concept of Family World View.
Reference
Year of Publication/Journal
Method
Discipline
Surrogate/Related
Terms
1
Bhana, A., Bachoo,
S.
(2011). South African Journal of
Psychology, 41(2):131-139.
Systematic Review
Psychology
Family Resilience
2
Fisher, L. et al.
(2000). Diabetes Care, 3(23): 267272.
Cross sectional
Interdisciplinary
Family World View*
3
Ton G.N.T. et. al.
(2011). Circulation.1(124):958-964
DOI: 10.1161/CIRCULATIONAHA.110.940593
Systematic Review
Interdisciplinary
Relatives Perception
4
Barreto, M. C., et al.
(2013). Rev. Eletr. Enf.15(1):162-71.
DOI: 10.5216/ree.v15i1.19085
Qualitative Research
Nursing
Family Perception
5
Wollenhaupt, J.,
Rodgers, B., Sawin,
K. J.
(2012). Journal of Family Nursing
18(1) 65–90
Qualitative secondary analysis
Nursing
Family Philosophy
6
Hines, A.
(2011). University of North Carolina
at Greensboro. Phd. Thesis.1(1):215.
Mixed Method longitudinal study
Interdisciplinary
Parental Perception
7
Castillo, A. Del., et al.
(2013). Health; 4(5):47-58
http://dx.doi.org/10.4236/
health.2013.54A007
Cross-sectional
Psychology
Relative Beliefs
8
Flynn, S, J., et al.
(2013). Patient Preference and Adherence1(7):
741–749
Qualitative Research
Medicine
Family Perspectives
9
Samuel-Hodge, C.
D. et al.
(2012). J Gen Intern Med28(3):428–
35 DOI:
10.1007/s11606-012-2230-2
Qualitative Research
Medicine
Family Perspectives
10
Rosland, A. M., Heisler, M., Piette, J. D.
(2012). J Behav Med 35:221–239
DOI 10.1007/s10865-011-9354-4
Systematic Review
Medicine
Family Coherence
11
Golics, C. J., et al.
(2013). Journal of the Royal Society
of Medicine; 106(10) 399–407
DOI: 10.1177/0141076812472616
Integrative Review
Medicine
Family emotion
Nº
* The article n. 3 was the only article in our sample to use the term of Family World View as a domain.
DISCUSSION
Table 2. Summary of findings.
Antecedents
Attributes
Consequences
Socio demographics
Socio demographics
Negative
Family members age
Lack of education
Lack of
communication
Family Income
Mistrust
Ethnicity/Race
Gender
Educational Level
Uses of concept
In order to maintain scientific rigor on this concept analysis,
it is necessary to explore all usual aspects of the concept
in terms of meaning. Family World view as a description of
family’s beliefs and expected behavior facing an adverse
event is frequently explored in the literature. However, most
of the studies use this term for similar terms. It was possible
to identify a shortage of literature related to this concept,
especially addressing factors related to chronic disease.
Surrogate and related terms are often used to explore how
a family’s beliefs influences their disposition and ability to
manage chronic diseases. The use of term “Family World view”
has been constantly interchanged with terms such as Family
Coherence, Family Perception, Family Resilience, and others
as seen in Table 1.
Interestingly, the study developed by Wollenhaupt,
Rodgers and Sawin (2012) used the term “Family Philosophy”
as a domain to assess family management of a chronic health
condition from the perspective of adolescents. Authors
considered “Family Philosophy” as a domain that encompass
Social Vulnerability
Family Level
Shared Views/Values/
Expectation
Family Level
Behavior
Positive
Emotional Connections
Attitudes
Enhance compliance/
Adherence
Family communication
Family Environment
Enhance Support/
Improved Coping
Strengtheningof family
engagement in care
Family Role
Culture
Social Context/
Collectivity
Culture
Awareness to healthy
behavior changes
Religiousness/Ritual/
Myths
Lived-experience with
the disease
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shared goals, values and priorities between parent and
adolescent that could lead them to construct a family
philosophy. Based on our findings it is important to point out
that due to epistemological complexity to define the concept of
“family” it is usual to find studies segregating family members
from the individual with chronic disease. It also usual to find
research focused on only immediate families or only extended
families. These characteristics can be observed in the studies
developed by Fisher et al. (2000), Hines, (2011); Castillo et al.
(2013), Flynn et al. (2013), Samuel-Hodge et al. (2012), and
Golics et al. (2013). The study conducted by Flynn et al. (2013)
was the only one thatused the term “Family World view” as
a domain to investigate families’ management of diabetes. In
order to explore families’ beliefs in relation to chronic disease
and their influence on management and support to individuals
with a chronic condition, research has often needed to focus
on individuals that composed the family core separately.
could be clustered in the same categories as antecedents,
however, different themes were evidenced. Regarding sociodemographic characteristics, illiteracy and family income
appeared as the main variables considered as attributes to
Family World view. Particularly in nursing in primary care,
educate families to an appropriate manage chronic diseases is
a priority in terms of assistance. Conversely, lack of education
appeared as a barrier in the health educational process.
Low educational level strongly influenced families mistrust
of health care providers’ educational intervention (Bhana &
Bachoo, 2011; Ton et. al., 2013;Hines, 2011; Castillo et al.,
2013;Flynn et al., 2013, Samuel-Hodge et al., 2012; Golics et
al., 2013). The study developed by Castillo et al., (2013) showed
that regarding HTN management stronger families’ beliefs
to perform an appropriate management of HTN increased
with higher educational level (p=0.012).Flynn et al. (2013)
also revealed in their qualitative study that family members
considered their own knowledge about HTN limited and they
felt that they could better support their hypertensive family
member if more education about the disease was provided.
Despite all educational efforts that nurses have done in
order to promote families autonomy towards appropriate
management of chronic diseases, barriers were still found.
Our findings suggest that, especially in primary care, it is
fundamental to develop educational interventions that
consider the educational level of the family being assisted. In
this way, positive outcomes in terms of management of chronic
diseases such as adherence to the plan of care, compliance to
drug therapy and others can be expected. Family income also
constitutes socio-demographic attribute to family beliefs when
associated to treatment costs of chronic diseases. A Systematic
Review developed by Bhana and Bachoo (2011) assessing
determinants of resilience among families in low- and middleincome contexts revealed that family cohesion facing an illness
process is significant in low-income countries. Depending on
the cost impact to treat chronic diseases, families can have a
negligent or complacent attitude in deal with chronic disease.
Regarding attributes in a family level, shared beliefs
between family members, family attitudes, behaviors and
family environment were found as significant themes related
to families’ beliefs about management of chronic diseases.
Systematic reviews assessing family behaviors, communication
patterns, knowledge and attitudes revealed that these
variables cause significant impact on chronic disease outcomes
(Ton et. al., 2011; Rosland,Heisler & Piette, 2012).Families’
religiousness, cultural rituals and myths appeared as cultural
attributes influencing families’ beliefs about chronic disease
management. However these constructs are also considered
by many scholars as the main barriers for health care providers
to reach families and patients’ adherence and compliance
to treatment and control of chronic disease. It is important
to point out that health educational interventions drawn
to address a population culture are more likely to be better
accepted and understood. Families’ religiousness is strongly
associated with coping, especially in relation to children with
Antecedents
Antecedents can be defined as themes or events that
precede the concept (Rodgers, 2000). Our findings through
interdisciplinary studies in the literature allowed us to
group them into three main categories -“socio-demographic
characteristics”, “family level” and “culture”. Regarding socio
demographics characteristics, age, race/ethnicity, gender
and educational level, these variables arise as antecedents
of “Family World view” on management of chronic diseases.
Regarding age as an antecedent, the study developed by
Wollenhaupt, Rodgers and Sawin (2012), explored the
management of chronic diseases from the perspective of
adolescents. The authors concluded that adolescents are
able to convey relevant perspectives in family management.
It demonstrates age as a precedent to build Family World
view on the management of chronic diseases. Studies
showed that depending on the emotional connections that
characterize a familiar relationship, hence, a person’s role in
the family, their beliefs and attitudes towards an adverse event
can vary (Golics et al., 2013). Family communications also
influence family beliefs, especially regarding aspects related
to chronic diseases. For example, if a person lives in a family
environment that does not favor communication it is less likely
that his/her family will reach a consensus about the disease’s
management(Rosland, Heisler and Piette, 2012; Fisher et al.
2000). Families’ social context and collectivity such as friends,
community members and others also appeared as variables
related to families’ culture. It is important to point out that
families’ support systems are important to the management of
chronic diseases and exert significant influence on their beliefs.
Attributes
According to Rodgers (2000) attributes can be defined
as commonalities extracted from the literature and related
to the concept. These attributes once synthesized can
provide meaning and definition to a particular phenomenon.
In this sense, common characteristics found in our study
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Conceptual Framework - Family Management Style
Framework (FMSF)
a chronic condition (Golics et al., 2013). Lived experiences with
the disease in the care processcan also contribute to influence
families’ beliefs about aspects related to chronic disease.
Families´ beliefs towards health lifestyle and whether or not
to support a new family member with chronic disease are
strongly related to their previous experiences with the disease
(Barreto et al., 2013).
Theoretically, the concept of family World view to manage
chronic diseases can be better understood through the lens
of family management style conceptual framework (FMSF).
A conceptual framework can be understood as a group
of concepts originated from the same paradigm or same
perspective (Ravitch & Riggan, 2012). FMSFwas developed by
Knafl et at. (1990) and incorporates families views in response
to a particular health condition. It derives from nursing family
research and consists of three main domains: “Definition
of the situation”, “Management behaviors”, and “Perceived
consequences”. Based on our findings and the relevance
to nursing science, FMSF can be considered appropriate to
underpin the concept of “Family World view”.
Consequences
Consequences are considered facts or events that appear as
result of the concept (Rodgers, 2000). Family members can perform a positive or negative role to support the management of
chronic disease, once the disease takes place in the family core.
Lack of communication not only between families and health
care providers, but also between family members was found as
negative consequence of families beliefs. Systematic reviews point
out that lack of communication negatively affects not only the
management of a chronic disease but also family relationships
(Golics et al., 2013).Based on these findings, creating an emphatic
relationship with all family members and promoting space for communication with an effective educational process is necessary. In
order to reach these goals, nurses and health care providers must
be sensitive to perceive families willingness to share their beliefs
about the chronic disease process in the family core. Through this,
negative outcomes such as families´ mistrust are expected to be
reduced. Hines (2011) defines mistrust as a cultural characteristic among minority groups that may contribute to a worsening
of chronic diseases such as asthma. Regarding minority groups,
social vulnerabilities also were found as a factor that negatively
influence families’ beliefs on management of chronic disease (Ton
et al., 2001). Financial and social needs can also influence the way
families will deal with the chronic disease. In under-developed
countries, such as Brazil, it is known that families with financial
problems related to the cost of treatment of a chronic disease
such as HTN, often drop out of drug treatment to adopt alternative
practices to control the disease as for example the use of chayote
tea (Oliveira & Oliveira, 2013).
Positive consequences extracted from the studies in relation
to families´ beliefs in the context of chronic disease were found.
Families´ compliance and adherence to treatment of chronic
diseases, enhance families´support of the patient and improve
coping to deal with different aspects of care process such as
appropriate management or potential disease outcome. In
addition strengthening of family engagement in care and
awareness to healthy behavior changes were described as
a positive consequence of families´ beliefs in the context of
chronic disease (Bhana & Bachoo, 2011; Fisher et al., 2000;
Ton et. al., 2011; Wollenhaupt, Rodgers & Sawin, 2012; Hines,
2011; Castillo et al., 2013; Flynn et al., 2013; Samuel-Hodge et
al., 2012; Rosland, Heisler & Piette 2012; Golics et al., 2013).
It is important to point out that positive consequences of
families’ beliefs may significantly contribute to reduce the
actual worldwide scenario of chronic diseases. In this sense,
educational interventions based on families’ beliefs are not
only recommended but strongly encouraged.
Empirical indicators to family World view in the
context of chronic diseases
Given the phenomenological nature of the concept of
family World view in the context of chronic diseases, it was
not possible to find qualitative instruments psychometrically
consistent and adequate to assess this phenomenon in the
context of chronic disease. Nevertheless, family is considered
a complex organizational system and encompasses multiple
dimensions. Therefore our findings suggest that empirical
indicators must be developed to address all dimensions related
to family World view such as culture, socio-demographic
characteristics and other aspects related to the family level.
Limitations
Even though the concept analysis of “Family World
view” can be considered relevant, our study presents some
limitations. Family World view in the context of chronic diseases
can be considered a new construct. There is an overall shortage
of literature addressing this specific phenomenon and further
research is recommended. Only two studies in our sample are
derived from nursing science, which emphasizes the need to
develop more studies related to this concept in this discipline.
Furthermore, due the phenomenological nature of this concept
it is difficult to measure family World view. Empirical indicator
adequate reliable and validated addressing this concept in the
chronic disease context is necessary.
Implications for clinical practice
Aiming to prevent chronic diseases and promote health
among families, it is fundamental to nursing practice to
acknowledge families’ beliefs, especially in primary care. Given
families’ multiple potentialities to influence the management
factors related to chronic diseases, it is fundamental that
health care providers involve them as allies in the care process.
Furthermore, a grasp of families´ beliefs about chronic disease
can led the development of effective heath educational
interventions starting from families’ point of view. Thereby,
positive outcomes from families such as engagement to
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Visao de mundo para doenças cronicas
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Rev. Enf. 2015 Jan-Jun; 1(1):13- 18
management of the disease, resilience, awareness of the need
of behavior changes, etc. are more likely to result. Barriers
between the health care providers and families’ view in
relation to the care process of chronic diseases could also be
considerably reduced.
Greenstein, T. N. & Shannon, N. Davis (2013). Methods of Family Research, (3rd
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Khatib, R., Schwalm, J. D., Yusuf, S., Haynes, R. B., Mckee, M., Khan, M., &
Nieuwlaat, R. (2014) Patient and healthcare provider barriers to hypertension awareness, treatment and follow-up: A systematic review and meta-analysis of qualitative and quantitative studies. PLoS ONE 9(1): e84238
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journal.pone.0084238
CONCLUSION
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Our findings suggest that health care providers and families
must to create and develop a dialogic interaction in dealing with
chronic disease management. In this sense, understanding a
families’ World view in the context of chronic diseases is the first
step in nursing planning. Our findings also contribute to a better
understanding of nurses, health care providers and researchers
about the multiple dimensions surrounding this concept. Family
World view can be relevant not only for nursing but also for all
disciplines concerned about family health.
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