HE .4LTH CONCEPTION. FAMILY HEALTH WORK AND HEALTH PROMOTING LIFESTYLE PRACTICES IN LATIN AMERICAN MENNONITE FAMILIES

by

Elizabeth BumlI

School of Nursing

Subrnitted in partial fùlfilment of the requiremenrs for the degree of

Masters of Science in Nursing

Faculty of Graduate Studies The University of Western Ontario

London, Ontario September 1998

O Elizabeth Bumll 1998

National Libmy u* I ofCanada Bibiiithèque nationale du Canada Acquisitions and Acquisitions et BibbgraphÈ Services setvices bibliographiques s weilhgbn Street 395. rue Wdlington OüawaON K 1 A W OtiawaûN K 1 A W canada canada

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ABSTRACT

The purpose of this study was to examine the health conceptions. family health

work. and health-promoting lifestyle practices of Latin American Mennonite families

Latin American Mennonite families have a unique history and culture that is poorly

understood. Little is know about how these families understand and promote their health

The Developmental Health Mode1 @HM) provided the framework for examining

the variables in this study. In the model. it is proposed that health is a characteristic of the

family. which is teamed within the social context of the family (Kravitz & Frey. 1989)

Health work is the process by which families develop heaith (Ford-Gilboe & Spence

Laschinger. 1995). The degree to which families engage in heaith work is iduenced by

their health potential (Ford-Gilboe & Spence Laschinger, 1995). Health potential consists

of the family's strengths. motivations. and resources. Health-promoting lifestyle

behaviours are one outcome of health work. In this study. heaith conception was seen as a

motivational factor afFeaing family health promotion (health work) that results in healthy

outcomes (health-promoting lifestyle practices).

A convenience sample of 36 mothers of Latin Amencan Mennonite families living

in Southwestern Ontario participated in structured interviews during which the Health

Options Scale (HOS), a measure of family participation in health work (Ford-Gilboe,

1 994a). the Healt h-Promoting Lifestyle Profile II (Pender, 1 996). a measure of healthy

lifestyle practices. and a demographc questionnaire were administered. One open-ended

question was used to elicit mother's personal meanings of health. A subsarnple of 6

mothers panicipated in a second. semi-structured interview during which more in-depth

descriptions of their meanings of health and health promotion practices were sought.

Latin American Mennonite mothers in this study were found to hold

multidimensionai conceptions of health consisting of spintuai. mental. and physical health

components. Consistent with theoretical expectations. hedth work was moderateiy

correlated with health-prornoting lifestyle practices. No significant relationships were

found between health conception and either heaith work or health-promoting lifestyle

practices. Lengh of time resident in Canada, length of time of current marital status. and

family income were the only demographic variables related to any of the main study

variables.

This study contributes to the evolving knowledge base of culture and farnily health

promotion and provides support for the vaiidity of the Developmental Heaith Model.

within a religion-based culture. The results of this study contribute to understanding the

health beliefs and praaices of Latin Arnerican Mennonites in Southwestern Ontario Study

findings provide direction for future theory refinement and testing and for the development

and implementation of interventions which may enhance health-promoting lifestyle

practices of Latin American Mennonite families.

There are many people whose assistance had made the cornpletion of this project

possible. 1 would Iike to express my thanks to each one of them:

Dr. Marilyn Ford-Gilboe. for her vision in funher definine the Developmental

Health mode1 and her dedication to promoting health in families. Her challenge to achieve

excellence and her expertise made completing this project intellectually stirnulating and

personally sa t i shg;

Dr. Helene Berman, for her guidance, wisdom and support;

The Latin Amencan Mennonite mothers, who willing participated in this study:

The Mennonite Central Cornmittee Help Centre (Aylmer) for their support and

patience with this study;

Sigma Theta Tau International Honour Society of Kursing. Iota Omicron Chapter

for the research gram that supported this projea.

DEDICATION

To rny parents. Ken and Alice Burrill. for their suppon and faith in my ability to

succeed. Thank-you for the encouragement and your patience with this project.

TABLE OF CONTENTS

CERTIFICATE OF EXAMZNATION . . . . . ASSTRACT . . . . . . . . . . . . . . . . ACKNOWLEDGEhtENTS . . . . . . . . . . . . . . . . DEDICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LIST OF APPENDICES . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER I . INTRODUCTION .

VI

vii

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Si-dficance to Nursing 4

. CHAPTER 11 LITERATURE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Developmental Health Mode1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Key Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Research using the Developmental Health Mode1 . . . 9

Health Conception . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Descriptive Studies of Health Conceptions . . . . . . . . . . . . . . . 16 Development of Health Conceptions . . . . . . . . . . . . . . . . . . . 18

Health Promotion Behaviours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Factors Affecting Health Promotion Behaviours . . . . . . . . . 2 1

Family Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Culture and Heaith Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Hedth Beliefs and Practices of the Old Order Amish . . . . . . . . . . . . 32 Mennonite Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

CHAPTER III . METHOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Setting and Sarnple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Criteria for Sample Selection 40

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rationale for Sample Selection 41 . . . . . . . . . . . . . . . . . . . . . . . . . . Demographic Characteristics of the Sample 41

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study lnstmrnents .. . . . 46 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Options Scale 46

. . . . . . . . . . . . . . . . . . . . . . . . . . Health-Promotin_e Lifestyle Profile II 50 Demographic Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Inteiview Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Data Collection Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Data Analysis Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

vii

Table of Contents (Cont'd) Page

CHAPTER IV . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Descriptivestatistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Results Related to Research Questions . . . . . . . . . . . . . . . . . . . . . . 59

Research Question One . . . . . . . . . . . . . . . . . . . . . . . . . 59 Research Question Two 64 Research Question Three 67

. . . . . . . . . . . . . . . . . . . Research Question Four 71 Research Question Five . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Research Question Six . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

CHAPTER V . DISCUSSION AND CONCLUSION . . . . . . . . . . . . . . .

Discussion of Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . Heaith Conception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HealthWork Health-Prornoting Lifestyle Practices . . . . . . . . . . . . . . . . . . . . . Relationship between Health Conception and Health Work . . . . . . . . . Relationship between Health Work and Health-Prornoting Lifestyle Practices . . . . . . . . . . . . . . . . . . Relationships between Demographic Variables and Health Work and Health-Promoting Lifestyle Practices

Limitations of the Study . . . . . . . . . . . . . . . . . . . . . . Implications for Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . Directions for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

LIST OF TABLES

Table Description Page

. . . . . . . . . . . . . . . . . . . 1 Demographic Profile of Mothers . . 3 3

2 Partner Occupation and Income Profile for Sample Farnilies . . . . . . 44

. . . . . . 3 Characteristics of Sarnple Families . . . . . . . . . . . . . . . 15

4 Ranges . Means . and Standard Deviations of Scores of the HOS and HPLP II 58 . . . . . . . . . . . . . . . . . . . . . . . 5 Mothers' Health Conceptions 62

. . . 6 Highest Ranked HPLP II Items . . . . . . . . . . . . . 69

7 Ten Lowest Ranking HPLP II Items . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

8 Pearson r Correlations between Health Work and Health-Promoting Lifestyle Practices . . . . . . . . . . . . . . . . . .

LIST OF APPENDKES

Appendix Page

-4PPENDIX -4 Study lnstmments 1 O0

MPENDIX B Intexview Schedule 1 07

APPENDIX C Letter of Information and Consent 110

APPENDIX D Ethics Approval Form . . 113

The concept of health has been identified as a core phenomenon within the

discipline of nursing On a professional level. many different conceptions of health are

evident in the theoretical. research and practice literature (Colantonio. 1988: Laffrey.

1 986a). Heaith is defined differently by lay persons as well, based upon factors such as

eender, age, and culture. Differences in definitions of heaith between clients and health C

care providers can jeopardize clients' progress toward health. Culturally sensitive nursing

care incorporates the culrural care values and beliefs of clients including their views of

health and emphasizes family values as part of this process (Lantz, 1989; Leininger. I W O ) .

However, existing studies of health conception have been conducted predominantly in the

majonty culture and with individuais (Colantonio. 1988; Laffrey, l986b; Reynolds-Tunon.

1997). Relatively little is known about the meaning of health within minonty cultural

groups and famiIies.

How health is defined by individuals. families or communities affects activity

directed toward maintaining or improving health (Domelly. 1990: Loveland-Cherry, 1989;

Weeks tk O'Connor, 1985). An emerging trend toward focusing on the farnily as a unit of

care is evident in practice (Wright & Leahey, 1990). Yet. studies of family health

behaviour have been neglected in nursing research (Hoehn Anderson & Short-Tomlinson.

1992; Wright & Leahey. 1990). A relationship between health conception (HC) and

lifestyle practices of individuals has been found in previous studies(Lafbey & Crabtree,

1 988; Pender, 1 987). However. researchers have not examined the relationship between

2

health conception and lifestyle practices within farnilies (Whall & Loveland-Cherry. 1994).

Families are the basic social context in which health behaviours are learned and perfomed.

Family health promotion is a process undenaken by the farnily to sustain or enhance the

social. emotional, and physical health of the famiiy system and its members. If nurses are

to facilitate farnily hedth promotion behaviour. the relationslip between health conception

and health promotion behaviours must be examined in farnilies from different cultural

backgrounds.

The Developmental Health Model (DHM), a theoretical nursing mode]. provided a

frarnework for examining the relationship between family health conception and health

promotion behaviour. Within the DKM, health is a characteristic of the farnily. leamed or

developed over time within the context of farnily life and observed in the coping (problem-

soiving) and developmentai (goal anainment) behaviours of families as they deal with

expected and unexpected life events (Kravitz & Frey, 1989). Health work. the process

through which farnilies develop the probiem-solving and god anainmenrs skills necessa-

for healthy living, reflects health promotion at the family level (Ford-Gilboe. 1997a;

Gottlieb & Rowat. 1987; Kravitz & Frey, 1989). Although health work is proposed as a

universal process, cultural variations are anticipated but have not been described. In order

to engage in health work the family mua have health potential-strengths. motivation and

resources (Gottlieb & Rowat. 1987). Family vaiues . health befiefs and health conceptions. which are culturally determined. are all potentially important motivational

factors affecting health promotion behaviour (Ford-Gilboe. 1994% 1 997a). The purposes

of this study were to: 1) describe the health conceptions and health promotion behaviours

(health work and health-promoting lifestyle practices) of families from a minority culture

(Latin Amencan Mennonite). 7) to compare these descriptions to existing

conceptualizations. and 3) to examine the relationships among health conception. health

work and health promoting lifestyle practices of these families.

Latin Amencan Mennonites are a large population. particularly in Southwestern

Ontario. with unique culture. history. and lifestyle. The Mennonite culture dates back to

Germanic Europe in the 1500's (Janzen. 1988). and is based upon strict adherence to

religious beliefs. isolation fiom the dominant culture, the use of a low German dialect. and

migration. Religion for the Mennonites was and is a way of life rather than one

component of a hfestyle. Because of their religious beliefs, Mennonites have ofien been

persecuted. marginalized and poorly understood (Janzen, 1988). As a result of

persecution they became a migratory people. The current population of Latin Amencan

Mennonite families in Southwestern Ontario emerged fkom Russia in the 1870's. and

emigrated to Manitoba. Canada and to Central America pnor to emigrating to Ontario.

Latin Arnencan Mennonites continue to expenence prejudice as they attempt to adjust and

struggle to hold ont0 their faith and lifestyle in the face of poveny, poor living conditions.

illiteracy. isolation and helplessness (Friesen. 1992; Fretz, 1977; Janzen. 1 988). The low

German dialect used almost exclusively by Mennonites. Hutterites, and Amsh only

recently becarne a written language and many ail1 do not read or write it (Fretz, 1977;

Friesen. 1992). The use of an obsolete and spoken language has fùrther enhanced the

isolation of this population.

The Mennonite culture holds the belief that family and community are of key

importance in the socialization of their children (Frerr 1977). Little is known about the

health beliefs and practices of this group and the extent to which these beliefs and

practices are similar to or different fiom the dominant culture.

-4 few studies (Armer. Tripp-Reimer & Stewan. 1996; Fuchs. et al.. 1990;

Levenson. et al.. 1989: Miller & Schwartz. 1992; Wenger. 1995) have examined the health

beliefs and practices of .eiilsh and Old Order Mennonites. Although Amish and Mennonite

people share some common cultural beliefs. Latin Arnerican Mennonites have a unique

history. Therefore. the extent to which knowledge about health beliefs and practices of

.&sh and Old Order Mennonites applies to Latin Amencan Mennonites is not known In

order to enhance collaborative relationships with this population it is necessary to have a

more complete understanding of the impact of culture on health conception. family health

work and health promoting lifestyle practices.

Sianificance to Nursinq

Nursing is bounded by its relationships ro clients. farnilies and communities. Many

of our communities are based upon minority cultures. If we believe that it is essential to

understand and respect the cultural care values and beliefs of al1 people. it is necessary to

examine conceptions of health within rninonty cultures. Without an understanding of the

heaith conceptions of families within minority cultures. there can be oniy lirnited success in

developing collaborative health promotion and health maintenance programs. Nursing. in

an attempt to be proactive, collaborative. and family-centred mua engage in research

aimed at understanding the complexity of culture and its impact on definitions of heaith.

and how families/individuals make decisions repding their lifestyle practices. This study

contnbuted to testing and possible refinement of the DKM-one of the few models

addressine farnily health promotion-by enhancine its cultural reference.

Understanding the impact of health conception on health work is essential for

effective nursing practice. The potential for misunderstandings and codict about heaith

5

beliefs and practices leads to ineffective collaborative relationships and perpetuates the

marginalization that many minonty cultures already experience. In order to enter into

effective health promotion with people of al1 cultures it is imperative that nursing

understand the impact of health conception on health work. If the family is the source of

socialization. the family must also become the focus of health conception and health

promotion research.

Health promotion is a fundamental component for nursing (Laffrey. 1985b) If

health promotion is to be effective for individuals. families and communities. programs

must be attuned to their beliefs, definitions of health, resources, and culture. Without an

understanding of the cornrnunity's health conception and health practices. health

professionals will make erroneous assumptions and provide programs that are ineffective

There are at least three risks to allowing nurses to practice heaith promotion for a cultural

cornmunity without an understanding of that culture: services are undemined. nurses are

at risk of failure and may leave. and an atmosphere of avoidance behaviour may develop

(Bernai, 1993). As a profession. nursing cannot afEord to take these risks and. therefore.

musr have a greater understanding of the cultural beliefs and practices of the communities

with which they are working.

CHAPTER ll

LITERATURE REVIEW

A review of the literature from the disciplines of nursing, medicine. psychology and

sociology focused on: a) the Developmental Heaith Model. b) health conception. c) health

promoting behaviours. d) family health promotio~ e) culture and health promotion. and. f )

Mennonites. Within each section there will be a description of relevant theoretical and

research literature.

Developmental Health Model

The objective of the Developmental Health Model is to assist clinicians and

researchers to develop basic knowledge about the nature of healthy living as seen throueh

the eyes of clients. their families. and significant others. and the role of nurses in

facilitatine y this process (Kravitz & Frey, 1989). The mode1 was originally developed by

Allen and associates at McGill University over 20 years ago as the cumculum model for

the school of nursing (Kravitz & Frey. 1989). The DHM has been tested in a vanety of

hospital and community settings. inciuding demonstration settings called health workshops

(Allen. 1985 : K r a v i ~ 198 1 ). Mien purposely refused to operationalize concepts without

data in order to ensure that the model be grounded in current understandings generated

through research and to allow for deveiopment and change over time. Most recently,

research has been undenaken with the intent of defining and refining key concepts of the

mode1 as part of a move to begin forrnally testing hypotheses denved from the model

(Ford-GiIboe. 1994b). Given that this model has been developed and teaed with a

relatively homogeneous group of faMlies (ie rniddle class. Anglo-Canadians) the

7

applicability of the model ro more diverse groups, including families of different cultures is

not known (Lindeman, 1985).

Kev con ce^^

The unit of concem for the Developmental Health Model is the family or any

other social - eroup "in which learning buds, fin& shape. and takes direction" (Kravirz & Frey, 1989. p. 3 1 5). Farnily. although a centra1 concept of the model. is broadly defined to

allow clients to define their families as they wish. The family is seen as the context for

developine health. however. individuals are not excluded fiorn the model but are seen

through the "family filter" (Gottlieb & Rowat. 1987). The individual is acknowledged to

both be affected by the family and to affect the family A systems approach allows for the

individual and/or family to be seen as an open system in constant interaction with each

other and with the environment (Allen 1983).

Health is a multidimensional conaruct that is learned within the context of family

life and develops over tirne. Health is a characteristic of family and consists of two

interrelated processes- coping and development (Ford-Gilboe, 1994b: Gottlieb &

Rowat. 1987: Kravitz & Frey. 1989). Situations of everyday living provide opportunities

for the development of health (Ford-Giiboe, 1994b). Health is reflected by family health

behaviour--the family's coping skills and growth seeking behaviours at any point in time

(Ford-Gilboe. 1994b). Coping is a function of problem-solving, while development relates

ro setting and achieving health goals (Wamer, 198 1). Development includes three sets of

famiiy activities. a) recognizing and managing resources. b) taking aim and c) identifying

and working toward goals (Warner, 1981). Heaith behaviour, according to Allen (1983),

is a measurable and modifiable characteristic that is shaped within the environment.

8

Within the context of a learning environrnent. Allen ( 1986) describes life events

and health -related situations. These events/situations are expenences through which the

famiiy leams health behaviour and are the common health events experienced by families

(Ford-Gilboe. 1994b). Leaming is the result of the constant interaction between the family

and the environrnent (Gottlieb & Rowat. 1987). Nursing's role is to create new

environrnents or manipulate the existing environrnent to assist families to leam healthy

ways of living (Gottlieb & Rowat. 1987).

"The process through which families develop health is called health work" (Ford-

Gilboe & Spence Laschinger. 1995. p. 2). Inherent in this process is the active

involvement of families in learning a repenoire of problem-solving (coping) and goal

attainment (development) skills (Ford-Gilboe & Spence Laschinger. 1995; Laforèt-Fliesser

& Ford-Gilboe. 1996). Ford-Gilboe and Spence Laschinger ( 1995) conceptualize health

work on a continuum that ranges fiom lower to higher degrees. Lower degrees of health

work are characterized by a lack of conscious thought about health, choosing established

health routines over new ideas. and a tendenq to base health choices on expert opinion or

default. In contrast. higher degrees of health work are associated with reflective and active

involvement in health matters. looking for alternative choices for promoting and

maintaining health, and making health decisions usine a problem-solving approach (Ford-

Gilboe & Spence Laschinger, 1995). Thus, as families engage in higher levels of heaith

work. their interest in and responsibility for heaith matters increases. The degree to which

families engage in health work is idluenced by their health potential (Ford-Gilboe &

Spence Laschinger, 1995; Laforêt-Fliesser b: Ford-Gilboe, 1996).

9

Health potential consists of the family's strengths, resources and motivation

(Allen 1983.1986; Ford-Gilboe, 1995; Gottlieb & Rowat. 1987). The Developmental

Health Model proposes that families are motivated to assume responsibility for health and

that within the family system there are strengths. resources and the energy to do so

(Gottlieb & Rowat, 1987). Strengths are the characteristics of stability and flexibility

within the family svstern and its rnernbers (Aileh 1983; Ford-Gilboe. 1997a) Motivation

is characterized by the farnily's interest in health. value of health. beliefs related to health.

and their desire to change health behaviours (Ailen. 1983; Ford-Gilboe. 1997a) Family

resources refer to sources of assistance with health matters such as access to health

information. econornic stability, suppon ffom extended famiiy, and suppo~t from the

cornmunity (Allen, 1 983 ; Ford-Gilboe, 1997a).

Nursing's role. within the DHM , is to assist families and individuals to leam to

cope with situations effectively. Allen (1983) calls this "situation-responsive nursing"

The DHM emphasizes the need for nurses to leam more about the characteristics of

coping and developrnent in order to more effectively collaborate with the client (Allen.

1983). The nurse assists families to recognize and develop their health potential and to

take responsibility for health, while engaging the family in an active leaming process

(Feeley & Gerez-Lirette, 1 992).

Research using; the Develo~mental Health Model

Researchers. using the Developmental Health Model. have focused on exploring

the concept of health as a social learning process and the role of nursing as a facilitator

and collaborator wit h families in achieving health goals (Gottlieb, 1 98 1 ; Kravitz, 1 98 1 ;

Wamer, 198 1 ). Much of the research has been conducted by faculty and students at

10

McGill University. where the mode1 was developed as a means of assisting in the desien of

praaice expenences for nursing students. Health workshops were created in an attempt

to answer questions about the impact of nursing on families' level of cornpetence in health

behaviour (Kravitz. 198 1 ). In a quasi-expenmentai study. Gottlieb ( 198 1 ) documented

nursing interventions used with 600 families. fiom a wide range of developmental stases.

in order to more fully describe styles of nursing practice with families Nurses. who used a

Situation-Responsive approach provided greater opportunities for clients to engase in

leaming situations that enhanced their coping.

Pless et al. ( 1994) studied the effect of Situation-Responsive Nursing on the

adjustment of 332 children (age 4 to 16 vears) with a variety chronic physical disorders.

The study was a clinical trial, in which children attending ambulatory care ciinics were

assigned to an intervention (received enhanced nursing care over a one year penod) or a

control group (received the usual care available). The nursing intervention, aimed at

optimizing family and parent functioning. was characterized by developing relationshps

with assigned families and assessing for needs. providing emotional support. providing

information regarding coping, assisting with problem-solving. and assining farnilies to

acquire new resources. A baseline cornpanson of the intervention and control group

showed the two groups to be sirnilar with respect to ail measured child and family

characreristics. and there were no significant differences between the two groups on any of

the dependent variables. Using Analysis of Covariance (ANCOVA). Pless et ai. ( 1994)

found that when compared to the control group. children in the intervention group

expressed si_pificantly greater functioning, role performance, and self-worth. The authors

reponed group means and identified significant differences but failed to specify the

1 1

ma-gitude of the F statistic for each hypotheses tested. The post-intemention mean score

on the PARSIII. a mesure of child functioning and role performance. was 88.3 for the

intervention eroup and 86.3 for the control group ( p 4 0 1 ). Self-worth was measured usin3

the Harter scale, which has versions for children less than and greater than seven years of

age. The Harter subscaie. Global Self-worth. which represents the overall value that the

chiid places on him/herself as a person increased by 3% for the intervention Sroup but

increased by > 1 70h for the control group. for older children (8- 16 years). This suggested

that older children in the intervention group had higher global self-wonh than their

counterpans in the control group (Pless et al., 1994).

Farnilies in this study were predominantly french-speaking. mamed couples with

children in which mothers had higher than high school education. Families who refused to

participate in the nudy were more likely to be English-speaking and the authors advise

caution in generalizing the findings to other populations (Pless et al.. 1994).

Few studies have focused on testing theoretical relationships between the

concepts in the Developmental Health Modei. Ford-Gilboe ( l994b) used a predictive

comparative survey design to determine the extent to which measures of farnily strengths.

motivation and resources predicted farnily health work in single-parent and two-parent

families. The Health Options Scale. created by the researcher. was used to determine the

extent of family involvement in health work. The mother and one child ( 1 0- 14 years) from

68 single parent and 70 two-parent families completed questionnaires measuring levels of

family pride. family cohesion. mother's non-traditional sex role orientation, intemal locus

of control. self-efficacy. family income, network support, community support, and health

work. A sub-sample of 7 single-parent and 9 two-parent families participated in family

12

interviews designed tu obtain more in-depth qualitative data regarding family health work.

heaith promotion activities, and fmily strengths (Ford-Gilboe. 1994b). Ford-Gilboe

( 1994b) found that farnily pride. farnily cohesion mothef s non-traditional sex role

orientation. self-efficacy, network suppon, and cornrnunity support were each positively

related to health work. Although single-parent families had significantly fewer resources

l( 1 36) = -5.1 6. p< 00 1. including significantly lower incomes l( 13 3) = -6.82. p< 0 0 1.

than two-parent families family strengths and motivation were similar across the family

types. The qualitative analysis showed that. regardless of family type, a higher level of

heaith work in families was characterized by the use of problem-solving in collaboration

with health professionals and openness to change. A lower degree of health work was

characterized by defemng to expens to solve health-related problems, variable compliance

with medical regimens, and choosing alternatives that resulted in the least change for the

family. Findings unique to the single-parent farnilies included: a) more multidimensional

definitions of healtb b) an emphasis on role function as a dimension of health. c)

identification of heaith seMces as a significant resource for health promotion. and d) in

lower health work farnilies. greater compliance with expert advice than simiiar two-parent

families (Ford-Gilboe. 1994b). Although this study provides beginning suppon for the

relationship between health work and heaith potential, the sample was predominantly

Caucasian (90%) and the majority identified with the dominant culture (65%).

Using a descriptive correlational design, Monteith (1 997) examined the

reiationships among mothers' resilience (a dimension of health potential), family health

work and mothers' health-promoting lifestyle practices in 67 families with pre-school

ctiildren. Monteith (1 997) found a weak but significant relationship between mothers'

13

resiIience and family hedth work (-2 1, p

13

prekiously studied. As well. Ford-Gilboe ( 1994b) identified that funher suppon for the

reliability and validity of the Health Options Scale is needed with different populations of

families.

Health Conce~tion

Health conception can be defined as the sum of an individual's ideas and beliefs

concemine health. Schlengr ( 1976) described seven perspectives on health. These

perspectives ranged from the medical view of health with an emphasis on diagnosis and

cure of disease to the philosophic view of health, with an emphasis on realization of

potential. Schlenger (1 976) proposed that the common thread to ail of these definitions of

health was the fact that heaith can be represented by a singîe continuum. Schlenger

( 1976) argues that health is not a unidimensional concept but is multidimensional.

consisting of two fundamental systems-- equilibrium (negative health) and actualization

(positive health). This two dimensional structure makes it possible for individuals to

realize potentials despite chronic or terminal disease processes (Schlenger. 1976).

Ln an attempt to clariQ the idea of heaith. Smith ( 198 1 ) conducted a philosophic

inquiry into the definition of health by searching for and analysing the fiindamental ideas

in the available literature. Four models of health found both implicitly and expiicitly in the

literature were identified: a) eudaimonistic, b) adaptive, c) role-performance, and ci)

clinical.

The eudaimonistic model consists of several views of hurnan nature that were

based upon the idea of health as general well being and self-realization (Smith 198 1 ),

Health is viewed as "exuberant well-being" and assumes a holistic view of the person. The

adaptive model of health is based on a belief that health is a characteristic of the person

15

who engages in effective interaction with the physical and social environment. Health.

within this mode!. is seen as adaptive behaviour for the purpose of effectively coping with

a changing environment. The role-performance mode1 is a "minimal conception" of health

based upon the ability of the person to do his or her job. The clinical model of health is

consistent with the modem medical model, within which the focus is on the elimination of

morbid physical or mental conditions. Health can also be perceived as the absence of

disease (Smith, 198 1 ). Smith ( 198 1) views these models as arranged in a hierarchy fiom

the least developed (clinical model) to the most sophisticated (eudaimonistic).

individuals hold one of these models as their conception of health. with each model

building progressively on and replacing the previous model. The models of health. used

by nurses and clients. defined the parameters within which health promotion. illness

prevention and health restoration activities were camed out. Nurses. according to Smith

( 198 1 ), have the responsibility to understand the consumers' conception of health and to

tailor health related activities to be consistent with the client's health conception. Smith

( 198 1 ) also proposed that health researchers have a responsibility to explicitly identify the

health conception used within their research. in order to enhance understanding of

research findings and ease applicability of the findings to a particular heaith environment.

Pender (1 990) proposes 5 categones for classiQing human expressions of health:

a) affect. b) attitudes. c) activity. d) aspirations. and e) accornplishrnents. Each of the five

categories is fùrther subdivided. The five dimensions are seen by Pender ( 1 990) as

evolving over time and as fluctuating daily. The five categones are culture-free but each of

the fifieen sub-categories may be influenced by culture. Pender (1990) argues that health

conception is a prirnary motivational mechanism influencing health promotion behaviour.

16

Laffrey ( 1986a) developed the Health Conception Scale (LHCS), as a rneasure of

Smith's four models of health conception. In contrast to Smith's ( 1 98 1 ) contention that

individuals hold one of these modeis as their definition of health. and that the four models

cm be represented on a progressive scale, findings h m a number of studies that have

used the LHCS have supponed the idea that health conception is multidimensional

(Laffrey, 1986a). Individuals showed similar scores across dimensions or predominance in

one or more dimensions. Subsequent testing of the LHCS has led to the reduction of the

3 rnodels to two models--clinical and wellness. The two modeis accounted for 5 1% of the

variance in definition of health with al1 but one item loaded on one of the two factors with

a ioading 4 1. when tested with a sample of blue collar factory workers (Laffrey. 1995).

Laffrey ( 1986a) recomrnended funher testing of the LHCS using dif3erent populations of

"healthy" and chronicaily ill individuals as well as individuals fiom different ethnie eroups.

ies of Health Conce~t'ons Descri~tive Stud I

Fugate-Woods et a1 (1988) posed the question "What does it mean to be healthv"

to 528 women, as pan of a larger study which deait with the prevalence of premenstmal

symptoms. The random sample of women ranging in age from 18 - 45 years was

ethnically, educationally and financiaily diverse. Content anaiysis was used to categorize

women's responses. The most comrnon conception of health was clinicai (56.5%) followed

by positive affect (49.2%) and fitness (43 -8%). The least fiequently reported conceptions

of heaith included positive self-concept (0.9%) and cognitive funaion ( 10.1%). Age did

not appear to influence the health images reported. However. older women tended to

report imases that fit the role performance mode1 (F. 17, p

17

eudairnonistic mode1 of health. Ethnicity did not appear to play a role in determining

health conception. The researchers concluded that women's images of health appear to be

consistent with contemporary nursing definitions of health (Fugate-Woods. et al. 1988).

However. fùrther work is needed to explore the role of culture. maturation and education

on health conception.

Colantonio ( 1988) studied la? concepts of health. using the following three health

definitions: a) absence of illness. b) tiinctional capacity, and c) a general feeling of well-

being. A structured personal i n t e ~ e w was completed with a sarnple of 100.

predominantly Caucasian. adults stratified by age and sex. Participants complered a

demographic questionnaire and were asked to respond to open-ended questions such as

"What does the expression being healthy mean to you?" (Colantonio. 1988). Content

analysis of participants' responses revealed that being fit was the most fiequent definition

of health (36.1 %). followed by feeling good ( 16.1 %), and not being il1 ( 1 XOh).There

were no significant differences in health conception of older and younger participants nor

between males and females using a chi-square analysis (Colantonio. 1988). Like Laffrey

( 1986). Colantonio ( 1988) found that individuais held several views of heaith within their

health conception rather than a single and progressive view as Smith (198 1) suggested.

However. Colantonio ( 1988) also used a relatively homogeneous sarnple from the

predominant culture.

In a qualitative. descriptive study, Williams-Utz. Hammer. Whitrnire and Grass

( 1990) studied the perceptions of body image and health status of 20 individuals with

Mitral Valve Prolapse (MPV), using Smith's (198 1 ) four models of health conception as

an orienting framework. Participants were screened for time of diagnosis of MPV and

18

symptoms associated with the condition. The mean age of participants was 40 years and

the group was predorninantly fernale and Caucasian. A semi-stmctured interview was

conducted and content analysis was used to categorize participants' responses. The

researchers found that the majonty of individu& incorporated three out of four of the

models of health defined by Smith and that the most common definitions of health were

clinical, role-performance and adaptive (Williams-Utz et al.. 1990). Eudaimonistic views

of health were only verbalized by two subjects. The researchers concluded that most

panicipants incorporated several models of health into their individual health conception.

in opposition to Smith's assenion of an individual predominant mode1 (Williams-Utz. et

al.. 1990).

Development of Health Conceptions

The impact of maturation on the deveiopment of health conception has also been

studied (Natapoff, 1978. Bibace & Walsh. 1980, Logsdon, 199 1 ). Bibace and Walsh

( 1980) studied the development of concepts of illness in 72 children fkom three age goups

(4. 7 and 1 1 years old) The study population was equally disttibuted between the three

eroups with equal numbers of males and females in each group Children were chosen C

who had no known cognitive or emotionai deficits and who were of average or above

average intelligence. Children were in te~ewed individually using a "Concept of Illness

Protocol". developed by the researchers. Children as young a four understood to some

extent that illness has both intemal and extemal components. Although Bibace and Walsh

( 1980) specifically dealt with the concept of illness, children are just as likely to have

similar ideas about the concept of health.

19

Natapoff ( 1978) studied children's views of health usine a similar developmental

approach as Bibace and Walsh ( 1 980). However, Natapoff ( 1978) believed that children's

explanations of health although based upon developmental age were also influenced bu

culture. The study sample consisted of -64 first. fourth, and seventh grade children.

equally distributed by gender and socioeconomic status. The children were interviewed

individually using a researcher developed interview guide. which consisted of question

related to describing what it means to be healthy and/or unhealthy. Definitions of health

included feeling good, not being sick. and doing things they wanted to. Natapoff ( 1978)

noted that older children's responses were more complex and involved more than one

model of health as described by Smith ( 198 1 ).

Logsdon's ( 199 1 ) study of heaith conception and the modifjnng factors of age and

gender of 30 healthy children (age 4 and 5 years) was based upon Pender's model of health

promotion ( 1 989). The instrument used to collect data was a modificarion of the

Preschool Health Picture Interview (PHPI). Al1 children associated the word health with a

happy facial expression and 3n0/b of children descnbed activities such as going to school

and being able to play as indicators of heaith.

Bibace and Walsh ( 1980). Natapoff ( 1978), and Logsdon (199 1 ) using varied

methods and theoretical Frarneworks have demonstrated sirnilar finds regarding the

development of health conception in young children. However. none of the researchers

discussed the influence of family on the development of health conception and al1 used

relatively homogeneous sarnples that eliminated those children who may have been

exposed to chronic illness. Children identi@ health as a positive feeling state and as the

ability to participate in activities. These two statement parallei the eudaemonistic and the

20

tiinction-role models of health descnbed by Smith ( 198 1 ). There are no studies that

examine the impact of farnily on the developrnent of health conception or the influence of

culture on this process. Nursing theonsts agree that understanding the development of

health meanings across the lifespan. and in different cultures is essential to providing

culturaily consistent nursing care to cornmunities (Huch. 199 1 ).

Health Promotion Behaviours

The World Health Organization defines health promotion as the process of

"enabling people to increase control over and improve their health" (WHO. 1988). Health

promotion is an essential concept to nursing (Laffrey. I985b; D u e . 1988: Pender. 1990).

Laffrey ( 1985) proposes that the nature of health promotion should fit with an individual's

health conception. Therefore. health promotion c m focus on disease prevention (absence

of illness). the abiiity to c a q out role functions. effective interaction with one's social and

physical environment. or a sense of well being. However. health promotion is more

consistently understood as an attempt to improve the well-being of individuals or eroups

(Pender, Walker. Sechrist & Frank-Stromborg, 1988; Pender, 1990). The emphasis within

this definition of health promotion is on developing health lifestyie behaviours that

increase an individual's responsibility for health and self-reliance, rather rhan on the

process of developing these characteristics.

Pender's (1 990) health promotion mode1 has cornrnonly been used to examine

health promotion behaviours. Pender ( 1990) proposes that cognitive/perceptual factors

such as importance of health. perceived control of health. perceived self-efficacy,

definition of health. perceived health aatus, perceived heaith benefits, and bamers to

health-promoting behaviours influence health promotion behaviours. These factors are

2 1

modified by a range of demographic characteristics. biologic charactenstics. interpersonal

infiuences. situational factors. and behavioural factors (Pender, 1990).

Donnelly ( 1990) proposes that it is essential to differentiate between health -

promoting behaviours and hedth-protecting behaviours. The distinction between health

promotion and health protection is critical in the development of client goals, and

ultimately different patterns of health behaviours (Donnelly. 1990). Health protecting

behaviours focus on avoiding illness and preventing disease. Health promotion behaviours

focus on activities that develop client resources and enhance well-being. There are radical

differences in the goals set by individuais and f d l i e s who are focused on health

promotion activities in contrast to those families who are focused of protecting their

present state of health. D o ~ e i l y (1990) describes the family as being a primary influence

on definitions of health and the initiation of health behaviours.

Health promotion behaviours and health practices are terms that have been used

interchangeably in the Iiterature. However. the scope of these tems are quite distinct.

Health promotion behaviours are related to the broad problem-solving and decision-

making processes, that are critical in enhancing heaith (Du@. 1988; Ford-Gilboe, 1994a).

Health practices are restricted to specific activities that promote health or prevent disease

(Ford-Gilboe. 1994b).

Factors Affectinr! Heahh Promotion Behaviours

Research examining individual health promotion behaviours, conceptuaiized as

lifestyle practices. has focused on attempting to link variables such as health conception.

motivation. locus of control. health beliefs, self-efficacy. disease processes. and age with

both general lifestyle patterns and specific behaviours (Davis. et al., 1992; Lee. 1993;

22

Frank-Stromborg, Pender. Walker, b: Sechrist. 1990: Huck & Armer, 1996; Laffrey.

1985b. 1986b. 1990; Laffrey & Crabtree. 1988: Quadrel & Lau. 1989). In general, it has

been possible for researchers to link locus of control. beliefs a h u t health. and age with

health promotion behaviours (Pender, 1996). In a correlational study examining the extent

to which cognitive/perceptual and rnodi@ng variables. as identified by the Health

Promotion Model. explained the occurrence of health promoting behaviours in 385

ambulatory adult cancer patients. Frank-Stromborg et al ( 1990) found that 23.5% of the

variance in heaith-promoting lifestyle practices was explained by cognitive perceptual

factors and four modifjing variables. Patients who held a wellness-oriented definition of

health viewed themselves as heaithy. had an interna1 health locus of control. were more

educated. older, had higher incomes. and were not employed outside the home were more

likely to repon engaging in healthier Iifestyies. An overall F value for the regression mode1

was not reponed. However, holding a wellness-oriented definition of health was identified

as the strongest predictor (P=.22) of health-promoting lifestyle practices in this sample.

F(6.3 84)= 19.32. p

23

13% of the variance in health promotion behaviours However. values of statistical tests

used were not provided. This study emphasizes the need to include the social context of

the population when designing heaith promotion programs.

Pill. Peters and Robling (1993) examined factors associated with health behaviours

of lower socioeconomic rnothers (N=360) usine the data available from a national survey

of health and lifestyle. The survey provided information about individual health practices

and demographic information such as socioeconomic aatus. work status, and marital

status. Pi11 et al ( 1993) found that 5 out of 17 demographic and attitudinal factors were

significantly associated with health practices. Being manied employed pan-time, living in

owner-occupied housing, perceiving higher social support and seeing one's own persona1

lifestyle choices as relevant to health were al1 independently associated with healthy

lifestyle practices (range of F ratio's =3.5-5 -6. p

24

promoting behaviours between urban and rural dwellers but suggested that ecological and

cultural factors contribute to specific regional behaviours.

Zirnrnerman and C o ~ o r ( 1989) studied the effects of significant orhers on long

term health behaviour changes of eiehty-four panicipants in a work site health promotion

program focused on reducing cardiovascular nsk factors. Using a pre- and post-health

promotion program questionnaire focused on demographics. health-related behaviours.

and overall plans to change health behaviours. the researchers found that. although healt h

promotion activities increased in general. less than 20% of respondents reponed that

family. fnends and CO-workers supponed the changes in behaviour (Zirnmermaii &

Cornor. 1989). However. researchers found family suppon to be most infiuential in

explaining successful long-term changes in an individual's health promotion behaviours

-(Zirnmerman & Cornor, 1989). The influence of the family system on individual health-

promoting practices needs to be explored.

In a randomized clinical triai, Shattuck, White and Kristai (1 992) found that

women's adoption of a low-fat diet positively afEected their husband's fat consumption.

The male spouses of women in the intervention group showed 4% lower consumption of

fat 12 months after the dietary intervention program was completed compared to spouses

of the control group participants (&32.9 vs. 36.9. p=.OO 1 ). Further. husbands' and

wives' fat consumption were moderately correlated ( ~ 3 4 . pC.0 1 ). Although the

researchers concluded that the findings were not generdizable due to the hioh motivation

of the women in the study. the findings do suppon the need for tùrther research examinino

the influence of individual family members on family health-promoting lifestyle practices.

25

Health promotion research has focused primarily on lifestyle practices rather than

on the decision-making and problem-solving processes that result in healthy lifestyle

practices. Researchers have s h o w that many variables such as geographic location. age.

gender. motivation. locus of control. and individual health conception affect the practice

o f healthy lifestyle behaviours. This body of research focuses on the individual with little

attention given to the famiiy. Further research is needed to begin to understand the roie of

the family in promoting the health of its members and how culture affects decicions

regarding family health promotion behaviours.

Farnilv Health Promotion

Very little research has focused on farnily health promotion activities (Loveland-

Cheny, 1986. 1989; Du@. 1988). As the basic unit of health care management. the

family assumes responsibility for 75% of the al1 health care provided (Du@. 1988).

However. nursing has failed to zeaiousiy snidy farnily health-promotion activities. Du@

( 1988) describes family health promotion as the activities undenaken by a family for the

purposes of maintaining and enhancing the ievel of physical. emotional. and social well-

being of its members. The focus of hedth professionals working with families has been

on medical care and disease treatment. Only recently has the focus tumed to health

promotion behaviours and the problem-solving processes of health promotion (Loveland-

Cheny. 1989: Ford-Gilboe. 1994a).

ln a descriptive. correlational study. Pratt (1 976) examined the relationships

among family structure. level of heaith and effectiveness of heaith behaviour in a sample of

5 10 nuclear families. An i n t e ~ e w consisting of fixed response questions was

administered to mothers. fathers. and children (age 9- 13). for the purpose of determining

26

level of health and illness. use of professional medical services. personal health practices.

and family structure concepts. Pratt ( 1976) hypothesized that persona1 health practices

reflected the level of cornpetence with which individual members cared for their health.

and that tküs ampetence was developed within the family stmcture. A significant

relationship was found between regular interaction among members and their health

practices ( ~ = . 2 6 . p=.O5). Male involvement in the family appeared to have more influence

on the overall health practices of the combined family than did mother-child interaction

( i . 2 6 . 18. respectively). Positive relationships were found between autonomy and

support of the child and the child's health practices (1.=.34.1=.24. pc.05). Parents' heaith

training efforts were weakiy correlated with health practices of both parents (F. 1 3 - -6)

and children (-2 1. p

27

between the two groups Mexican Amencan women descnbed empowering chiidren to be

responsible for their own cures. while Anglo American women encouraged a more

preventive approach to health responsibility Mexican Amencan mothers reponed usin3

fewer preventive health actions and more curative herbai remedies. However. values of

statistical tests were not provided. The researcher concluded that family differences in

approaches to taking and negotiating responsibiiity for the health were culturally

detemined. Funher study is needed to address economic and cultural differences that

influence matemal responsibiIity for health (Clark. 1995).

A few researchers have examined the differences in health practices of single- and

two-parent farnilies (Loveland-Cherry. 1986; Ford-Gilboe. 1994b) in an attempr to

determine whether family type influences health practices. Loveland-Cherry ( 1986)

conducted a descriptive correlational study using a convenience sample of female-headed

single-parent farnilies (n=2 1 ) and two-parent families (n=20). Pratt's ( 1976) instrument

was used to measure family variables and persona1 health practices. No significant

differences in personal health practices were found between femde-headed and two-parent

families as evidenced by children's. mother's and total farnily scores (Tilton overlap

statistic showed 82-83% overlap for family unit scores in the two types of families)

(Loveland-Cherry. 1986). Differences in means by family type were examined using t-

tests. However. values of statistical tests were not provided. In single-parent families.

mothets socialization practices were positively correlated with mothers' persona1 health

practices (F. 53. p=.02) and family health practices (r =.3 9. pZ.08). Loveland-Cherry

( 1986) found that it was pnrnarily mothef s scores which were related to personal health

practices. Due to the small and homogeneous sample, generakations to the larger

population must be made cautiously. In a study of 13 8 fernale-headed single-parent

families and two-parent families . Ford-Gilboe ( l997a) found that there were few significant differences between single-parent and two-parent families. The single-parent

and two-parent families were cornpared on Nne variables: family cohesion. family pide.

non-traditional sex role orientation. interna1 health locus of control. eeneral self-efficacv.

network suppon. comrnunity support. family income. and health work. Single-parent

families had significantly lower incomes. 1(133)= -6.82. p

29

greater understanding of the process of health promotion and the impact of culture on the

process.

Culture and Heaith Promotion

Many cultural groups within Our society have maintained their own cultural

patterns and working with these people. whose way of life is different fiorn the main

Stream is an area that needs continuous and systematic audy (Leininger. 1990). Culture

in its broadest meaning is a "way of life belonging to a designated group of people"

(Leininger. 1990. p. 54). Culture is universal. dynamic. learned within the family. and

determines the course of a person's life on an unconscious level (Leininger, 1990).

Culturally sensitive family nursing emphasizes family and human values, achievement of

one's maximum level of well-being. and therapeutic partnerships between the farnily and

the nurse for the purpose of addressing health promotion and health maintenance needs of

the family (Lantz, 1989). According to Lanu ( 1989) culture is the sum total of acquired

values. beliefs. practices. customs. traditions. language. knowledge, and patterns of

behaviour Culture includes values and beliefs about health and patterns of health

practices. In contrast. ethnicity is the "sense of community transrnitted over generations by

families". that is usually reinforced by the surrounding community (lantz, 1989. p. 49).

Farnily culture consists of a) definitions of family. b) roles of individual members. c) status

of members. d) communication patterns, and e) decision-making patterns (Lantz, 1989).

Health culture is defined as the traditional ways in which a unit copes with illness and

maintains well-being. Lantz ( 1989) proposes that individu& are more cornfortable with

their own health culture as it is a direct reflection of their own values and beliefs.

30

Niederhauser ( 1989) describes the components of culture as iife-views.

communication. family practices, health beliefs, education, and time and personal space

issues. These components underlying a culture create a value system which will affect

health care and compliance (Niederhauser, 1989). In providing culturally sensitive care the

emphasis is on a detailed and accurate baseline knowledge of cultural components in order

to provide a guide for health care strateges. Airhihenbuwa ( 1 994) identifies the need to

determine cultural practices related to knowledge production and acquisition, particulariy

for those cultures that have an oral tradition as the pnmary means of communication.

Understanding the role of storyteller and listener and the context of the story would be

vital for developing health promotion programmes for cultures with a strong oral tradition.

such as Latin Arnerican Mennonites.

McAUister ( 1992) used qualitative semi-nnictured i n t e ~ e w s to compare the

health beliefs of women of Asian ongin (N43)and white indigenous women (N= 14) living

in inner-London, England. The rwo groups were relatively similar in age and occupation.

-4sian women were more likely to rate their Iife as unhealthy when compared to white

indigenous women. Factors identified as contributing to poor health were stress. British

weather. health womes, separation from family, and other family circumstances. In

contrast. white indigenous women identified diet. alcohol consumption and health w0n-k~

as contributing to poor heaith (McAllister, 1992). Both groups identified farnily and

fiends as contributing to good health. However. Asian women also identified diet and

feelings of happiness as contnbuting to good health. Asian women were less likely to

identify causes of cornmon diseases . The researcher concluded that further study is

needed to examine the meaning of health promotion among culturally diverse groups in

3 1

order to determine if a western mode! of health promotion is appropriate for a defined

ethnic group or whether there are bamiers to health promotion such as language and

exposure to health knowledge (McAllister. 1992).

The health meanings and practices of older Greek-Canadian widows were studied

using an ethnographic interview design (Rosenbaum. 199 1 ). Using Leininger's Sunnse

Mode1 of Cultural Care Diversity and Universality. Rosenbaum ( 1 99 1 ) in te~ewed twelve

widowed key informants and 30 general informants using serni-stmctured and open-ended

questions. Life health-care histories of the key infamants and field journal recordings

compteted the data collection. Rosenbaum (199 1) detennined that health for older Greek-

Canadian widows meant a state of well-being. ability to function within their perceived

roles, and an avoidance of pain and illness. Meanings of health were pluralistic and multi-

dimensional. Health promotion beliefs related to nutrition, use of vitamins. exercise. and

the use of folk remedies were cornmon to al1 inforrnants. The extent to whch folk

remedies were used for prevention and treatment of illness varied arnong first and second

generarion widows and by geographic ongin (Rosenbaum. 199 1). The researcher C

concluded that fùrther study is needed with widows of other cultures for cornparison and

that studies of gender beliefs and expressions would provide a greater understanding of

the impact of health meanings on health promotion behaviours.

Hansen and Resic k ( 1990) conducted an et hnograp hic study examining the healt h

beliefs and practices of Appalachian mothers (N=j). Semi-structured inteMews

addressing health. life ways. perceived susceptibility to illness. seriousness of an illness.

benefits of taking action. barriers to action. and treatment alternatives were conducted.

Mothers did not perceive themselves as being highly susceptible to illness and did not feel

32

that they had control over susceptibility. Seriousness of an illness was judged by its effect

on the role function of the individual and the level of dependency that resulted. Seeking

medical care was the major activity undenaken for the prevention of illness and

knowled_ee of pnmary prevention was vague. Hansen and Resick ( 199 1 ) concluded that

the strone historical tradition of folk medicine among the Appalachian people had not been

passed to the younger generation and new ways of prornoting health and preventing illness

had not been learned. This study has important implications for deaiing with cultural

eroups that have been isolated but are now being exposed to western culture without the CI

resources needed to manage health issues.

Health Beliefs and Practices of the OId Order . b i s h

The Old Order Amish are culturally similar to Mennonites. Their beliefs and

practices reiated to religion, family and cornmunity originated fiom the same geographical

region and time as the Mennonite culture. and they have remained isolated corn the

dominant culture ( Fretz, 1 977: Wiggins. 1983 ). Wiggins ( 1983) describes health care

among the Arnish as being based on intense f a d y and kinship loyaity to either folk or

professional medicine. There are no religious prohibitions against the use of medical

doctors. prescription dmgs or hospitals. The Amish do not have their own doctors as they

do not believe in higher education (Wiggins. 1983). There is evidence that the .enish

believe that illness may be the resuit of sin, loss of soul, and spiritual invasion. According

to Wiggins ( 1983). the Amish define illness in terms of ability to perform role functions

rather than in terms of symptorns.

Fuchs. Levinson. Stoddard. Mullet and Jones (1990) conducted a survey amon3

the Amish in Ohio (N=400) to determine health risk factors, using the Behavioural Risk

33

Factor Survey. Results from the h s h were compared with data from non-Arnish state

residents. When compared to the non-Amish group the Amish were less likely to self-

repon hypertension (5.8% of Amish males and 1 1 O h of .4mish femaies compared to

2 1.799 and 28% of non-Amish males and fernales, respectively)- The overall prevalence of

obesity in Amish women (39.9%) was significantly higher than that of non-.4mish women

(30.8%) but comparable in the two groups of men. Funher. Amish people who were

obese were less likely to repon engaging in physical activity as a means of weight control

than non-Amish people. Amish women also reported higher rates of feeling depressed

(46.7%) than non-Amish women (35%).These women were also more likely to feel that

nervousness or anxiety interfered with their ability to hnction (30.6%) than the' lr non-

Amish counterparts (14.9%). Although chi square analysis was conducted. specific values

of these statistical tests were not reponed. The researchers cautioned that. due to Ievel of

diversity in the Arnish culture, study results are not generalizable to the entire culture.

However, the differences between the Amish and the non-Amish group were si-sgificant

enough that health promotion programmes designed for the Amish culture would need to

difler from that of the non-Amish culture in order to succeed (Fuchs, et al.. 1990).

Another area of concem arnong the Arnish, Mennonite and Hunerite cultures

relates to testing for genetic diseases. Miller and S h w m ( 1992) surveyed Amsh.

Mennonite and Hutterite Cynic Fibrosis (CF) families (parents of minors and adult

siblings) for their attitudes towards genetic testing. The questionnaire used was developed

to obtain personal, religious, financial and education data, as well as information related to

eeneral knowledge of CF. the emotional impact on the farniiy, and attitudes towards C

camer testing, prenatal diagnosis. and abortion. Of the 544 questionnaires sent, 3 16

34

(58%) were returned completed. Families with the highea level of education (Mennonites.

Rochestenans and intermarrieds) were most knowiedgeable about CF . However. 88% of

parents and 75% of siblines were unable to correctly respond to questions about

unaffected sibling camer nsk (Miller & Schwam. 1992) . Despite lack of knowledge

related to recurrence risk 53% of Mennonite and 6 1% of Hutterite parents stated that

they had changed their planned family size after having one child with C F The majority of

Mennonite and Rochestenans approved of prenatal testing and carrier testing while 864h

of Amish disapproved of prenatal testing and 40% disapproved of carrier testing The

question related to approval for camers manying carriers generated no response in the

majority of Amish and half of the Mennonite respondents, although the majority of

Hutterites disapproved and the majority of Rochesterians approved of mamage (Miller &

Schwartz, 1992). This study emphasizes the diversity of beliefs and practices among

populations of people with shared history. geographic ongins. and with similar basic

religious beliefs One cannot make assumptions regarding health promotion and illness

prevention for these populations based upon a general knowledge of their belief systems.

Armer. Tripp-Reimer and Stewart (1996) described the definition of health and

health promotion behaviours of Midwestem Amish farnilies (N=87). Respondents

completed a questionnaire cornprised of the Health-Promoting Lifestyle Profile (HPLP)

(Pender. 1990). Multidimensional Health Locus of Control Scale (Wailston, Wallston &

DeVelIis. 1978). Perceived Social Suppon Scale (Procidano & HeIler, 1 983) . and several open-ended questions. Participants represented three generations of old order Amish and

had an average of eight years of formal education and a mean age of 40. Respondents

were equally Split berneen male (48%)and female (52%). Across the generations, six

35

thernes regarding health definition emersed fkom the data. a) the imponance of being

healthy. b) the ability to work, c) a sense of freedom to enjoy life, d) family responsibility.

e) physical well being. and f) spintual well-being Self-reponed health maintenance

behaviours inciuded work-related physical activity and nuttition. In contrast to the

qualitative data. analysis of HPLP reveaied that nutrition was ranked highest and exercise

was ranked lowest HPLP scores were consistent across generations. The .enish tended

to see one's health as determined by chance and the actions of powerful others such as

doctors. nurses and farnily. The researchers concluded that strong family support svstems

may have implications for family influence on decision-making related to health screenings.

care-planning, and care-giving. Study findings suppon a rnulti-dimensional concept of

health and the use of diverse health-promoting activities in the Amish (Armer. Tripp-

Reimer Br Stewart. 1 996).

Funher study into the health beliefs. health promotion behaviours and Iifestyle

practices of these similar but unique cultures is warranted. There were no studies in the

literature related specificaily to the Latin Arnerican Mennonite population. Mennonite

beliefs are similar to those of the Arnish but the level of diversity within the Mennonite

culture and differences in migration expenences may influence the translation of these

beliefs into practice.

ennorute Culture

Mennonite culture developed out of Gemanic Europe in the 1500's as a result of

social. economic. political and religious reform. Mennonites are classified as anabaptists.

believing in voluntary church membership through adult baptism (Fretz, 1977). Due to a

pattern of relieious persecution. the Mennonites became migratory people looking for a

36

country that would allow them: a) self-contained colonies. b) control over education. c) a

land-holding system. d) their own low German language. e) an interna1 government

system. and f) exemption from military senrice (Janzen. 1988).

Although al1 Mennonites have a cornmon language. they are not al1 German in

onsin and identify themselves as being of Russian. Swiss or Dutch descent based upon

their movement across Europe durinp the 1700's and 1800's. The Mennonites who would

eventually ernigrate to Mexico and Southwestern Ontario are of Russian and Dutch

descent and moved to Kansas, U S A and Manitoba. Canada in the 1870's (Janzen. 1988).

Initially, the Mennonites were warmly welcorned in Manitoba but mon were pressured to

send their children to public. English speaking schoois (Janzen. 1988). Pressure in the

f o m of fines and prejudice resulted in migration (Janzen. 1988).

In 1 92 1. the first delegation of Old Colonist Mennonites began a mass migration to

Mexico (Smith, 1950). By 1926, nearly 6.000 Mennonites were located in two large

colonies in rural Mexico. The first two decades were hard for the Mennonites due to

poveny, less fertile soil, reduced rainfall and few ready markets for their crops (Janzen.

1988). However. by the 1940's the colonies were thriving. They had learned to work the

land. were getting modest yields from their crops, and their cheese was weil received by

Mexican markets. It is important to note that the Mennonites reproduced. as nearly as

possible, the kind of life they had lefi behind in Canada and. before that. in Russia (Smith.

19 50: Janzen, 1988). By 1946. the population of Old Colony Mennonites had grown to

over 13.000.

The population grew rapidly resulting in a shortage of land to sustain the

community (Janzen 1988). Education became an issue as individuais within the colony

37

sought to bnng new knowledge and ideas into the colony. As tensions within the colony

a e w over issues of education and technological improvement, excommunication of - individuais began. leading to marginalization (Janzea 1988; Regehr, 1996). Canada

becarne appealing and Mennonites begm to flow back into Canada through British

Colornbia and Southwestem Ontario (Regehr. 1996). Although Mennonites found work as

farm labourers in Southwestem Ontario. many found the work seasonal and either

retumed to Mexico for the winter. relied on social assistance or were forced to go into

other Iines of work (Janzen, 1988).

Social adjustment has been hard for Mennonites returning to Canada. Poverty and

religious ostracism have resulted in few resources. They are forced to live in scattered

isolation among people whose beliefs are dflerent from theirs rather than in the

homogeneous villages to which they are accustomed. They must learn a new langage and

many rely on government assistance (Janzen, 1988). Public, English education. which

once had been a reason for leaving Canada. is now attractive as families qualie for family

allowance when the children are enrolfed (Regehr, 1996).

Mennonite families continue to arrive from Mexico with the hope of a better future

but social adjustment problems continue. There is little known about Mennonites' health

and practices and there are no studies of the Latin Amencan Mennonites, who have a

unique history among the Mennonites. In order to assist with adjustment, health

maintenance and health promotion. we are obligated to develop an understanding of the

impact of culture. religion and social isolation on the meanings of health and health

practices of this group.

Summaq

Although there is suppon in the theoretical literature for the influence of health

conception. culture. and health work on healthy lifestyle practices. few studies have tested

these relationships. In no study has the relationship between health conception and healrh

work been examined. Although support for a relationship between health work and health

promoting lifestyle practices was found in a study of families of pre-school children

(Monteith. 1997). this relationship has not been examined in families who are culturally

diverse. Lirnited study of the Amish and Hutterite populations has revealed diversity which

makes generalization impmdent. There is a ciear gap in the literature related to

Mennonites. and specifically Latin Arnerican Mennonites. This study attempted to address

this gap by exploring the meaning of health within Latin Arnerican Mennonite families.

describing their heaith work and health-promoting lifestyle behaviours, and examining the

relationships among these variables.

Research Ouest ions

The following questions were addressed in this study:

1 . What does health mean to Latin Arnencan Mennonite families living in

Southwestern Ontario?

2 . How do Latin American Mennonite f ~ l i e s engage in health work?

3. What are the specific lifestyle practices used by Latin Arnerican Mennonite

families to maintain and promote health?

4. How are the health conceptions of Latin American Mennonites living in

Southwestern Ontario related to their engagement in heaith work?

39

5 . What is the relationship between health work and health promoting lifestyle

practices of Latin Arnerican Mennonite families?

6 . What are the relationships between selected demographic variables and level of

health work and health-promoting lifestyle practices in Latin Amencan Merinonite families

living in Southwestern Ontario?

CHAPTER III

METHOD

Desien

A descriptive. correlational survey design was used to examine the relationships

among health conception. health work and health-promoting lifestyle practices in Latin

American Mennonite families. In addition semi-stmctured qualitative inteniews were

conducted with a subsample of 6 mothers in order to more fully explore and describe the

study vanables.

Settine and Sam&

A convenience sample of 36 Latin Amencan Mennonite mothers was recruited

fiom a small comrnunity in Southern Ontario concaining a Mennonite Central Cornmittee

Help Centre. Sarnple size was determined by conduaing a power analysis. based on a

desired power of -80, a moderate effea size of .40. and level of significance of .O5

(Kraemer & Thieman, 1987). Effect size was based upon Ford-Gilboe's (1994b) finding

that health work was moderately correlated with health-promoting lifestyle practices (r=

. j 1 ) in a sample of families OIJ= 13 8) with pre-adolescent children. The relationship

between health conception and health work has not been previously exarnined.

Criteria for Sarnple Selection

Mothers recruited for this study fulfilled the following cnteria:

1. physical custody of at least one biological or adopted child

2. spoke English or low Gennan

3 . identified themselves as being Latin Arnencan Mennonite

4. consenred to participate in the study

Rationale for Sample Selection

Latin Amencan Mennonite farnilies are based upon a traditional male-headed

family model. Concern for health is most often part of the mother's role. as the nurturer.

within these farnilies. Latin American Mennonite mothers are. therefore. the best

infamants for reponing about family health. Multiple members of the farnilies were no<

used for reporting due to the wide variety of ages among the chiidren and limited English

language skills arnong fathers, making it difficuit to achieve consensus and to conduct the

interviews.

In order to obtain the greatest variety of responses to the questionnaires. it was

determined that length of time in Canada was an important variable. The greater the time

in Canada the more likely it is that the mothers are able to comprehend and speak English.

Rather than eliminate those mothers who had only been in Canada for a shon time. it was

determined that those mothers who spoke low German (the language of Mennonites)

would be in te~ewed in their own language using an interpreter.

D e r n o ~ ~ h i c Characteristics of the Samole

Descriptive statistics for the demographic variables are summarized in table

format. Percentages reported are based upon the number of compiete cases for each

variable.

12

Mothers ranged in age fiom 20 to 84 years. with a mean of 40.3 years

(== 13 2 5 ) One mother did not know her age The number of years of education for

these women raneed fiom 4 to 12 years with a mean of 6.7 years (==1 89). None of the

women had post-secondary education. The majority of the women (86.1%. g=3 1 ) were

unemployed. The 5 women who were employed (3 part time. 2 full time) worked in blue-

collar or service related positions. M o a of the women listed Mexico as their place of binh

(91 7%. ~ 3 ; ) . Length of time resident in Canada ranged fi-om 1 to 44 years (M=14.9.

== 10.96). Time resident in Mexico ranged fiom 4 to 66 years (M=22.6. == 1 3 64). The majority of mothers were mamed (80.6%. n=29), while the remaining women were

separated/divorced ( 1 1.1%. Q+) or widowed (8.3%. ~ = 3 ) . The length of time for

mothers' current marital statu ranged fiom 1 to 40 years. with a mean of 16.6 years

(== 1 O. 7) (Table 1 ).

Siightly more than one-third of mothen' partners were unemployed (3 6.1 7%. n=

1 3 ) The twenty remaining panners who were employed worked as farm labourers

(33.370, '=1?). factory workers ( 1 94%. n=7), and as skilled tradesmen (?3.3'&, n=8) At

the time of the interview, seven partners who were ernployed as farm labourers and

factory workers were unemployed due to the seasonal nature of their work. .4nnual farnily

income ranged fiom $7,000.00 to $54,000.00 yearly, with a mean of $29.98 1 .O0

(==SI 1.886.00) (Table 2). Over 60% of the families (n=22) received social assistance.

half of these (n= I 1 ) as the primary income source ar.d the remainder (n= 1 I ) as a

supplement to low employment income.

Table 1

Demoeraphic Profile of Motherr RJ=36)

Variable Range Mean SD

Age (years) 20-83 40.3 13 -25

Education (years) 4-12 6 .7 1.89

Time Resident in Canada (years) 1 -44 14.9 10.96

Time Resident in Mexico (years)

Length of Marital Status (years) 1 -40 16.6 1 O. 7

Marital Status Frequency Percentage

Widowed 3 5.3

Employment Status

Full Time

Part Time

Unemployed 3 1 86.1

Occupation

Home Maker 28 77.8

Seasonal Farrn Work 3 8.3

Retail

Service - 3 5.6 Factory

Country of Birth

Canada 3 8.3

Mexico 33 91.7

Table 2

Partner Occupation and Income Profile for Sam le Families (N=36)

- - - -- - -

Variable Frequency Percentage

Partner Employment Status

Full-time 19 52.8

Part-time 1 2.8

Unemployed 13 36.1

Partner Occupation

Farm Labourer

Factory Worker

S killed Tradesman

Incorne Source

Emplo yment

SociaI Assistance

Employment and Social .Assistance 11

Pension 1

Family size raqed fiom