Family world view in a context of chronic diseases : concept 1 analysis

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.


INTRODUCTION
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.

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 1 st 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).
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.

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.

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 http://www.redcps.com.br/ e-mail: revista@redcps.com.brRev. Enf.2015 Jan-Jun; 1(1):13-18 Sales PC, Chyun DA Visao de mundo para doenças cronicas 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 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.

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 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 http://www.redcps.com.br/ e-mail: revista@redcps.com.brRev. Enf.2015 Jan-Jun; 1(1):13-18

Visao de mundo para doenças cronicas
Sales PC, Chyun DA 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).

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.

Conceptual Framework -Family Management Style Framework (FMSF)
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".

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 Sales PC, Chyun DA Visao de mundo para doenças cronicas 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.

CONCLUSION
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.

Table 1 .
Article selected to analyze the concept of Family World View.
* The article n. 3 was the only article in our sample to use the term of Family World View as a domain.

Table 2 .
Summary of findings.