Research
Circumstances surrounding deaths from the perspective of bereaved Honduran families Arianna Stone, Cara P LaMotta, Marissa N Baudino, Terrah Foster Akard and Mary Jo Gilmer
This article has been subject to double-blind peer review.
Arianna Stone, Student Research Assistant, Vanderbilt University, School of Nursing, Nashville, Tennessee, US; Cara P LaMotta, Student Research Assistant; Marissa N Baudino, Graduate Student Research Assistant; both at Vanderbilt University, Peabody College, Nashville; Terrah Foster Akard, Assistant Professor of Nursing and Medicine; Mary Jo Gilmer, Professor of Nursing and Director of Pediatric Palliative Care Research Team; both at Vanderbilt University, School of Nursing, Nashville Correspondence to: [email protected]
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ore than 7 billion people inhabit the world and more than 56 million die annually (Cenral Intelligence Agency (CIA), 2014). Many bereaved individuals mourn the loss of a loved one each day. While death is an inevitable part of life, challenges of bereaved family members may be dismissed as something to ‘get over’ and families may be left to grieve alone. As we seek to understand circumstances surrounding deaths and components of a good death as perceived by bereaved Hondurans, we may learn more about ways to help families through their unavoidable journeys. The purpose of this study was to examine: ●●Circumstances surrounding the death of a loved one in Honduras ●●Responses of bereaved Hondurans to the death ●●Use of support systems, continuing bonds, meaning-making ●●Prevalence of comforting and discomforting effects associated with continuing bonds.
Background Literature has begun to focus on the role of culture and religion in response to deaths of loved ones. These studies surveyed the continued bond of meaning-making and support systems among grieving people from a variety of geographic areas, such as China (Woo and Chan, 2010), US (Lalande and Bonanno, 2006; Foster et al, 2011), Australia (Meert et al, 2015), Ireland (Roberts and McGilloway, 2008), Ecuador (Foster et al, 2012b) and Iran (Khosravan et al, 2010). Many methods of meaning-making and use of support systems, such as continuing bonds by keeping photographs and making scrapbooks, using physician/nurse-guided support groups, or feeling the presence of the deceased in a spiritual way, are seen in a majority of cultures and religions and may have different outcomes. For example, research in Ecuador suggests that Ecuadorians find continued bonds and memories more discomforting than other cultures, possibly due to the lack of effective coping strategies or differences in the cause of death (Foster et al, 2012a). Even with the growing body of research on bereavement, a better understanding of the cultural and religious influence on bereavement is needed. There is very little published literature on continued bonds or support systems for bereaved individuals within South American countries, particularly Honduras. Spirituality within Honduras is influenced by Spanish colonisation, Native American culture, and ancient Mayan beliefs, along with Catholic and Protestant doctrine. The vast majority (~97%) of Hondurans are Roman Catholic, but not all are devout and practising their faith. The continuum
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Abstract
Purpose: This qualitative study examined how bereaved individuals from Honduras responded to deaths of loved ones, particularly through exploring circumstances surrounding deaths and various coping strategies. Methods: With the help of a translator, bereaved family members in Honduras were interviewed using a semi-structured format. The interactions were audio-recorded and later translated and transcribed. Results: Some 60% of individuals spent time with other family members during their loved one’s end of life and 22.5% of grieving individuals took solace in spirituality or religious practices and connecting with God. Some 40% wanted to speak with others through support groups. When individuals spoke about remembering the deceased, both comforting and discomforting effects were expressed. Conclusions: Further research is needed to learn more about coping strategies in various cultures and support mechanisms that health professionals can use or suggest when working with bereaved individuals. Key words: Coping l Bereavement l Continuing bonds l Support l Culture l Qualitative
Using qualitative methods, the authors described categories, frequencies, and perceived consequences of factors surrounding death, support systems, and coping mechanisms, either present or wished for, among bereaved individuals in Honduras.
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of religious beliefs may affect the manifestation of bereavement in each individual differently. Grieving individuals experience positive outcomes (e.g. personal growth, search for meaning of life, valuing interpersonal relationships (Riley et al, 2007)) and negative results (e.g. decline in health, damage to selfimage (Riley et al, 2007)). Meert et al (2015) proposed that meaning-making (including sensemaking, giving back by helping others, and continuing bonds) conducted with the help of a physician after the loss of a loved one can provide comfort and lead to positive coping strategies among bereaved parents. Other support systems may include family member presence, support groups with other bereaved individuals, and religious guidance or contact with a religious leader (Mather et al, 2008). Although many of these systems provide emotional support and examples of how to restructure one’s life following the death of a loved one (Meert et al, 2015), some discomforting effects have been noted among some grieving individuals related to continuing bonds (Foster et al, 2011) and sense-making (Meert et al, 2015) (Figure 1).
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Methods Researchers partnered with Shoulder to Shoulder, a non-profit, community-based nongovernmental organisation that provides health care services to rural Hondurans, and works with local community leaders to strengthen community bonds, creating support for one another’s positive health. As part of Shoulder to Shoulder’s mission, the volunteer staff implement basic and advanced medical care, dental services and medical education, along with nutrition classes and community health initiatives. After obtaining approval from the institutional review board (equivalent of an ethics board), researchers worked with Shoulder to Shoulder and local leaders to identify potential participants for the study. These leaders used a script to explain the study and eligibility criteria to the community. Leaders of the community understood that the study aim was to learn from those who had recently lost a family member, to provide support for the bereaved in Honduras. Community members were informed of the possibility of researchers asking to talk with them about the death of a loved one and had time to think about whether they would approve of taking part or not. Once researchers arrived in the community, specific participants were shown sample questions after meeting inclusion criteria based on age, timeline
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of death, and language abilities. These potential participants were aware that taking part would last approximately 15 minutes and was completely voluntary. Consent was then obtained in the native language from those identified participants.
Participants Recruited participants were: ●●34–68 years old ●●Fluent in English or Spanish ●●Experienced death of a loved one within the past year. Shoulder to Shoulder representatives scheduled times for data collection before the US researchers arrived for interviews at a clinic in Honduras, which took place over several days in 2014. Participants included in this analysis (n=9) represented seven different families. Participants averaged 53.56 years of age (SD=12.82), with the majority being female (n=6) and self-reported their religious affiliations as Catholic (n=7) or Protestant (n=2). Educational level averaged 9.75 (SD=6.43) years, although one participant did not report an education level. The majority of families earned an average family income of less than 2000 US dollars per year. Participants’ relationship to the deceased varied from death of a son to death of a grandparent (Figure 2). The causes of death included acute and chronic illness and trauma (Figure 3).
❛There is very little published literature on continued bonds or support systems for bereaved individuals within South American countries ... ❜
Conditions of death
Support
Bereavement
Coping strategies
Comforting and discomforting effects
Figure 1: Some components of the bereavement process 83
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3 Number of losses
2 1
us in Co
Sis te r
at he r ra nd f G
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ra nd m
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❛The majority of participants reported keeping photographs of the deceased, but a few individuals stated that they did not believe in physical representations.❜
Figure 2. Deceased’s relationship to bereaved (n=9)
Informed consent was obtained from each adult at the beginning of the data collection visit. Researchers conducted semi-structured interviews via two Spanish translators, asking four openended questions that were audio-recorded for transcription and coding. Questions covered topics such as circumstances surrounding the death of a loved one, ways support was provided, and use of continuing bonds. Subsequent questions were asked based on previous the responses. Prior to data collection, the principal investigator (PI) and translators examined each interview question to ensure that the intended meaning was properly conveyed to the participants.
Analysis Three researchers independently reviewed the interview transcripts through content analysis, a qualitative approach to examining data from open-ended questions (Hickey and Kipping, 1996; LoBiondo-Wood and Haber, 2006). The authors used an a priori coding scheme based on previous work with bereaved individuals and continuing bonds (Foster et al, 2011), while adding new categories for data that did not fit the a priori coding scheme. Content analysis started with immersion in the transcripts, reading them repeatedly to get a sense of the data as a whole. Three researchers independently reviewed the suggested coding scheme (Foster et al, 2011), and marked the presence or lack of presence for each code within the participant’s response. The three researchers then met to compare their coding decisions, resulting in 78% agreement. They discussed
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reasoning behind all discrepancies until a consensus was reached. Responses that could not be placed in an existing category but were determined to have significance were marked as ‘other’, and following coding consensus, the three researchers created three new categories under which these ‘other’ responses could be included. The new categories were: ●●Location of death ●●Support from other bereaved individuals ●●Support from health professionals. All data were examined based on the final coding scheme with the final categories. Researchers counted the coded responses to provide frequencies for each category and identified exemplar quotes from each category. Results indicated how bereaved individuals cope with the death of a loved one, the helpfulness of these coping mechanisms, and the support systems that are in place or could in place to be positive influences for healthy bereavement.
Findings After content analysis, participant reports were categorised into an adjusted coding scheme, which included four major themes: ●●Conditions surrounding a death ●●Coping mechanisms ●●Comforting and discomforting effects of continuing bonds ●●Support for a good death (Figure 1). The large majority of bereaved individuals reported important support systems and coping mechanisms specifically during the period after the death of their loved one, in comparison to before death or at end-of-life. Bereaved individuals perceived both comforting and
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Procedures and measures
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discomforting effects from these incidents, but never comforting effects only. Finally, bereaved family members had specific wishes for support concerning their loved one’s dying process and subsequently, their own healing process. Types of loss are shown in Figure 2 and reported causes of death in Figure 3.
Timing All nine participants reported on the timing of components that play a role in a family member’s good death. There were 52 responses regarding positive components that were identified by the nine participants. As many as 39 out of the 52 responses (75%) included factors that were important to participants after their loved one’s death, a category that had responses mentioned by every interviewee. Only 25% of responses focused on factors before death or at end of life.
Coping mechanisms
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There were 34 responses that indicated the use of coping skills for the nine bereaved individuals with all participants reporting specific coping activities. Some of these behaviours were purposeful while others were less cognizant, such as fleeting memories or involuntary dreams. Six major coping mechanisms were identified that were used by participants to promote positive outcomes after a loved one’s death. The most commonly used coping mechanisms were: ●●Being present with family members ●●Engaging in funerary activities ●●Having a physical representation of the deceased ●●Having non-physical reminders of the deceased ●●Spirituality, religion, and faith in God ●●Having relationships with health professionals. Participants who kept physical representations of the deceased reported that they kept items such as photos of the deceased, letters from them, and articles of clothing that belonged to the deceased. Participants also reported experiencing non-physical reminders. These included having dreams about the deceased loved one and reminiscing about lessons learned from the deceased. Presence with family Eight participants indicated that spending time with other family members was important after the death of a loved one. For instance, a 34-yearold female mentioned that the presence of other family members, such as a mother or father, helped fill the empty space left behind after her
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grandfather died. Similarly, a 65-year-old mother stated that, in difficult times: ‘I talk to my family. My family gives me comfort.’
Many grieving individuals mentioned particular family members that they spent time with when they felt sad and noted that reminiscing together was a significant activity in their home. Funerary activities There were five bereaved individuals who mentioned participation in funerary activities to cope with the death of a loved one. Such activities included burying the dead/funeral, visiting the cemetery, and changing the grave flowers. Three family members (ages 63, 58, and 50) whose mother died noted that visiting their mother’s grave regularly was very important. In addition, a 65-year-old mother identified the ‘iron cross at the cemetery’ as a place she visits to connect with and remember her son.
❛There is very little published literature on continued bonds or support systems for bereaved individuals within South American countries, particularly Honduras.❜
Physical representation As many as six participants used looking at physical representations as a means of coping with their relatives’ deaths. When researchers asked a 36-year-old woman: What helps you remember [your grandmother]? she identified a photograph and a skirt as being helpful objects. A 34-year-old, whose grandfather passed away, stated: ‘We remember through a photo. We see the photo and remember the person we have lost. We also remember through a wood carving.’
A 68-year-old homemaker mentioned reading ‘a little letter’ to remember her late sister. The majority of participants reported keeping photographs of the deceased, but a few individuals stated that they did not believe in physical representations. These participants described the importance of staying in touch with their loved ones through memories and other non-physical representations. Non-physical reminders There were six participants who described remembering deceased family members through intangible thoughts, dedications or dreams. For instance, a bereaved mother said she remembers her son through ‘the respect that he had for me’. Another participant said: ‘I dream about her […] my sister says to go visit my daughter in the dream.’
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One of the group of three bereaved siblings who lost their mother distinctly stated:
expressed that health professionals were her ‘source of happiness’, and said:
‘We think about the good times that we had with her and we are going to keep those memories for the rest of our lives.’
‘I felt like they were important and greeted me regarding my sister’s death. They cared about her.’
A 38-year-old said: ‘I will remember the good things mama taught me.’
These reminders were employed as coping strategies that allowed family members to think about their deceased relatives. Other nonphysical reminders of deceased family members included remembering teachings their relative passed onto them, personality traits that were endearing (such as respect) and fond memories. Spirituality, religious practices and God Eight individuals in this study reporting coping skills, stated that prayer, God, and overall spirituality were important to them after a relative died. Participants were predominantly Roman Catholic, with two participants identifying as Protestant. A 36-year-old woman stated that she did ‘not talk to anyone besides God’ and identified the church and prayer as an important influence in dealing with her grief. A 63-year-old bereaved woman similarly noted that she goes ‘to church to pray’. Prayer was an important coping mechanism for many participants. A 34-year-old mentioned: ‘Each year there is a prayer to remember the time that he died because each year it seems as if it were yesterday that he died.’
One participant, 68, confirmed church attendance as a way to ‘receive forgiveness from God’. In addition, to prayer and the church being important support mechanisms for bereaved individuals, two siblings, aged 63 and 50, noted the support of their pastor during difficult times. Lastly, a 50-year-old bereaved woman described asking ‘God what he wants me to do to get better
Participants reported both comforting and discomforting effects when engaging in the six identified coping mechanisms. Four participants who mentioned outcomes, reported only discomforting effects and none of those that took part experienced only comforting effects. Overall, three individuals specifically mentioned experiencing both comforting and discomforting effects from their coping strategies after a relative died. Three individuals specifically stated that looking at a photograph of their deceased family member did not console them and instead made them sad. For example, a 45-year-old bereaved cousin said: ‘It makes me sad because that’s just the way it is. It’s a recent loss.’
For this individual, the death was 5 days before the interview. The time passed since death is an important factor to note, as another participant explained: ‘She only died yesterday, [so] having the memories makes it difficult and makes us feel sad.’
The 68-year-old woman, who reported having dreams about her deceased sister, also mentioned: ‘It only makes me more sad.’
Discomforting effects happened when the coping mechanisms stimulated reminders of loss rather than positive memories. These discomforting results also occurred more frequently with the more recent deaths.
in my life [and] with my family’.
Support
The topics of religion and God yielded the most detailed responses to the interview questions concerning coping mechanisms after the death of a family member.
Presence with the family member before or at time of death When participants reflected on their experiences of losing a loved one, four participants wished they could have been with their loved one before death. Two individuals expressed a desire to have been present at the family member’s end-of-life. A mother whose son was murdered explained:
Relationship with medical professionals One individual described her relationship with doctors and nurses as being a positive influence during and after her sister’s end of life. She
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Effects and outcomes
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❛In addition to prayer and the church being important support mechanisms for bereaved individuals, two siblings, aged 63 and 50, noted the support of their pastor during difficult times.❜
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❛Few of those that took part were able to take steps to prepare for the death of their loved ones.❜
Number of deaths
2
1
0
Cancer
Murder
Accident
Cardiac
Old age
Figure 3: Reported causes of death (n=7) ‘I wish he had died in my house at home. He died at night and he didn’t die in the house. [I wanted to] keep on looking at him, but he went rapidly.’
He also stated that ‘it would depend on a person’s beliefs or faith’ for support groups to be helpful.
This pattern was evident as other bereaved individuals stated they would want their relatives to die in the home rather than in a distant location. Sisters, aged 63 and 58, expressed that it was important for their mother to be home when she died, but their brother added:
This study sought to learn more about circumstances surrounding deaths of loved ones as perceived by bereaved Honduran families. Participants discussed the manner in which their loved one died, circumstances surrounding the end of life, and factors found to be most important after the family member’s death. Comforting and discomforting effects have been found in other studies that examined continuing bonds in bereaved individuals (Field and Friedrichs, 2004; Neimeyer et al, 2006; Ronen et al, 2009; Foster et al, 2011). Participants in this study reported continuing bonds that elicited both comforting and discomforting effects, but interestingly, never comforting effects alone. Few of those that took part were able to take steps to prepare for the death of their loved ones. Most participants had family members who died outside of the home, without family members present. Only one participant reported spending time with the dying loved one before the death and only three participants reported spending time with other family members and the dying loved one at the time of death. It is interesting to note that no participants took steps to prepare for the death of a loved one. This gap in preparation could be a potential opportunity for physicians and other health providers to help prepare or counsel individuals with a terminally ill loved one, if timing allows. The authors can speculate that the lack of expressed priorities before or at end of life may correlate with
‘It was important for her to be where people could attend to her.’
Support groups When asked, four of the participants stated that it might be helpful to talk to a support group or others who have lost family members. Specifically, two participants would have liked to talk to other women who lost the same type of family member, i.e. a son or grandmother. A 45-year-old teacher said:
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‘[A support group] would be helpful because of the sentiment that would be expressed because of the passing.’
Another person mentioned the importance of circumstantial similarities surrounding the death to be considered for support groups. The bereaved 50-year-old noted: ‘There are several ways to help, but sometimes there are different types of death like by accident. The experiences are very different and need different support.’
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Discussion
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spontaneous deaths (i.e. murder) rather than a more predicted and expected course of disease in which individuals could mentally prepare. The lack of expressed factors important before or at death could also originate from open-ended interview questions, as opposed to a more closed, multiple-choice formatting. Deceased family members were often remembered in non-physical ways, such as through rituals or memories. Most participants reported keeping material items such as photographs, letters, and articles of clothing to remember their family members. Many of the participants who reported keeping material possessions to remember the deceased said that they only kept a few very special belongings. This was consistent with Foster et al’s (2012a) study that examined continuing bonds in deceased individuals in Ecuador. A previous study (Foster et al, 2011) that was completed in the US found that the majority of participants kept several material possessions of the deceased. It is possible that this cultural difference is due to the different socioeconomic statuses of participants. More than 50% of Hondurans and over 25% of Ecuadorians live below the poverty line (CIA, 2015), in comparison to only 14.5% of US citizens (United States Census Bureau, 2015). Keeping few physical reminders of the deceased could be the result of having a lower socioeconomic status and thus, less material capital. While some participants specifically said that they experienced comforting effects when remembering a deceased loved one, four said that they only experienced discomforting effects and no one reported feeling only comforting effects. Similar findings emerged in Foster et al’s (2012a) study in Ecuador. It is possible that discomforting effects were related to the nature of deaths. Previous studies suggest that bereaved individuals have a difficult time grieving when a family member died in such a sudden way (Riches and Dawson, 1998; Guy and Holloway, 2007). When participants were asked whom they turned to at the time of the death of a loved one, eight reported turning to other family members. It was also common for participants to turn to religion or God after the death of a loved one. Many said that it would be helpful to talk to others who have experienced the death of a loved one, which suggests that there was a lack of support for participants during the grieving process. This differs from the way some other cultures support bereaved individuals (e.g. through the use of support groups, bereavement counselling, etc.).
More research is needed to determine how best to support this population. Some of the coping mechanisms that were used by participants were purposeful (such as spending time with family, going to church, keeping physical reminders of the deceased, and engaging in funerary activities). Other coping mechanisms occurred without the intention of participants. These included having dreams about the deceased or feeling the nonphysical presence of the deceased. The use of the identified coping mechanisms gave participants a way to handle the death of a loved one. Some coping mechanisms also provided ways for participants to have continuing bonds with their deceased family members. Findings suggest that the six identified coping mechanisms may be helpful for this specific population with the addition of peer or medical support groups.
Limitations A number of factors limit the interpretation of the authors’ findings. Having a small sample size limits the generalisability of the findings. A variety of factors such as age, cause of death, location of death and relationship to the deceased may contribute to differences. An interpreter conducted interviews with participants, and these sessions were then translated and transcribed. Qualitative analysis began with a review of the literature and an a priori coding scheme that was developed with a different South American culture. As a result, some data could have been misinterpreted due to language and cultural differences. Despite limitations, this study addressed a gap in the current literature about experiences of bereaved family members in Honduras. Due to the qualitative analysis, the study was able to identify participant-specific experiences of a loved one’s death. The open-ended questions and explorative nature allowed for participants to discuss any factor or component of the death experience that they found lacking, important, comforting or discomforting. From these explorative interviews, common themes were identified regarding factors that contributed to a good death, without interviewer bias. Although an interpreter was used, leading to possible translation differences, the actual interview did take place in the participants’ own dialect to minimise miscommunication.
Implications for practice Findings revealed that participants put much more thought and effort into coping after the death of a loved one, rather than prior to death,
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❛Deceased family members were often remembered in non-physical ways, such as through rituals or memories.❜
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suggesting that Hondurans may not be preparing for the death of a loved one, even if there is knowledge of a terminal or critical diagnosis. Contrary to literature regarding North American culture and bereavement in which coping mechanisms and continuing bonds lead to a more positive outcome (Foster et al, 2011), findings suggest that Hondurans do not typically have this same positive experience. Hondurans who used continuing bonds as coping mechanisms experienced more discomforting effects. Therefore, future work with families of dying patients in Honduras should focus on normalising the bereavement process. Some families may find certain continuing bonds, such as keeping a photograph of the deceased, helpful and comforting, while other families may not. Providers and counsellors must recognise these differences and work with each family to support coping skills and bonds that will be most beneficial to each person. Family members of the critically or terminally ill may be a potential target population for counselling by a nurse or case manager about the disease progression, expectations, and future outcomes that could aid in positive coping and understanding of a family member’s illness. This population could also benefit from assistance in preparing for the death of a loved one and the introduction of coping outlets and skills, such as providing support groups for conversation or keeping a journal with thoughts and memories of the deceased. Furthermore, findings suggest that post-death support should be aimed towards those bereaved individuals who unexpectedly lose a loved one, as this population has difficulty grieving and coping with the sudden death.
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Conclusion This study used interviews with bereaved individuals in Honduras to describe circumstances surrounding the deaths of their loved ones and components they considered contributed to a good death. In addition, frequencies and nature of coping strategies, including the use of continued bonds and their effects, were described. The findings suggest that bereaved individuals in Honduras are similar to other cultures, using a variety of coping mechanisms, such as familial support and prayer, and that use of continuing bonds may be comforting or discomforting. It is important to note that Hondurans expressed more prevalent discomforting effects than other cultures, pointing to the opportunity for further research to provide insight on how to increase the positive effects of coping mechanisms in this population.
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Challenges with conducting this study included locating bereaved family members who were willing to talk about their experiences and use of translators. Further research is needed to explore responses to death of a loved one of individuals from different cultures and to learn about useful strategies to provide beneficial care for this vulnerable population. Conflicts of interest The authors have no conflicts of interest to declare
❛Some coping mechanisms also provided ways for participants to have continuing bonds with their deceased family members.❜
Central Intelligence Agency (CIA) (2014) The World factbook. http://tinyurl.com/zyx8nt6 (accessed 4 February 2016) Central Intelligence Agency (CIA) (2015) Ecuador population below poverty line. http://tinyurl.com/ zrkfv5y (accessed 4 February 2016) Field NP, Friedrichs M (2004) Continuing bonds in coping with the death of a husband. Death Stud 28(7): 597–620 Foster TL, Gilmer MJ, Davies B et al (2011) Comparison of continuing bonds reported by parents and siblings after a child’s death from cancer. Death Stud 35(5): 420–40 Foster TL, Contreras R, Gordon JE et al (2012a) Continuing bonds reported by bereaved individuals in Ecuador. Bereave Care 31(3): 120–8 Foster TL, Gordon J, Contreras R et al (2012b) Reports from Ecuador on continuing bonds with the deceased. J Pain Symptom Manage 43(2): 343–44 Guy P, Holloway M (2007) Drug-related deaths and the ‘special deaths’ of late modernity. Sociology 41(1): 83– 96 Hickey G, Kipping C (1996) A multi-stage approach to the coding of data from open-ended questions. Nurse Res 4(1): 81–91 Khosravan S, Salehi S, Ahmadi F et al (2010) Experiences of widows with children: a qualitative study about spousal death in Iran. Nurs Health Sci 12(2): 205–11 Lalande KM, Bonanno GA (2006) Culture and continuing bonds: a prospective comparison of bereavement in the US and the People’s Republic of China. Death Stud 30(4): 303–24 LoBiondo-Wood G, Haber J (2006) Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. 6th edn. Mosby Elsevier, St Louis MO Mather MA, Good PD, Cavenagh JD et al (2008) Survey of bereavement support provided by Australian palliative care services. Med J Aust 188(4): 228–30 Meert KL, Eggly S, Kavanaugh K et al (2015) Meaning making during parent-physician bereavement meeting after child’s death. Health Psychol 34(4): 453–61 Neimeyer RA, Baldwin SA, Gillies J (2006) Continuing bonds and reconstructing meaning: mitigating complications in bereavement. Death Stud 30(8): 715–38 Riches G, Dawson P (1998) Spoiled memories: problems of grief resolution in families bereaved through murder. Mortality 3(2): 143–59 Riley LP, LaMontagne LL, Hepworth JT et al (2007) Parental grief responses and personal growths following the death of a child. Death Studies 31(4): 277–99 Roberts A, McGilloway S (2008) The nature and use of bereavement support services in a hospice setting. Palliat Med 22(5): 612–25 Ronen R, Packman W, Field NP et al (2009) The relationship between grief adjustment and continuing bonds for parents who have lost a child. Omega 60(1): 1–31 United States Census Bureau (2015) Poverty: 2014 highlights. http://tinyurl.com/o89ogck (accessed 4 February 2016) Woo IMH, Chan CLW (2010) Management of survival guilt by a Chinese widower through the use of continuing bonds. Mortality 15(1): 38–46
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Circumstances surrounding deaths from the perspective of bereaved Honduran families Arianna Stone, Cara P LaMotta, Marissa N Baudino, Terrah Foster Akard and Mary Jo Gilmer
This article has been subject to double-blind peer review.
Arianna Stone, Student Research Assistant, Vanderbilt University, School of Nursing, Nashville, Tennessee, US; Cara P LaMotta, Student Research Assistant; Marissa N Baudino, Graduate Student Research Assistant; both at Vanderbilt University, Peabody College, Nashville; Terrah Foster Akard, Assistant Professor of Nursing and Medicine; Mary Jo Gilmer, Professor of Nursing and Director of Pediatric Palliative Care Research Team; both at Vanderbilt University, School of Nursing, Nashville Correspondence to: [email protected]
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ore than 7 billion people inhabit the world and more than 56 million die annually (Cenral Intelligence Agency (CIA), 2014). Many bereaved individuals mourn the loss of a loved one each day. While death is an inevitable part of life, challenges of bereaved family members may be dismissed as something to ‘get over’ and families may be left to grieve alone. As we seek to understand circumstances surrounding deaths and components of a good death as perceived by bereaved Hondurans, we may learn more about ways to help families through their unavoidable journeys. The purpose of this study was to examine: ●●Circumstances surrounding the death of a loved one in Honduras ●●Responses of bereaved Hondurans to the death ●●Use of support systems, continuing bonds, meaning-making ●●Prevalence of comforting and discomforting effects associated with continuing bonds.
Background Literature has begun to focus on the role of culture and religion in response to deaths of loved ones. These studies surveyed the continued bond of meaning-making and support systems among grieving people from a variety of geographic areas, such as China (Woo and Chan, 2010), US (Lalande and Bonanno, 2006; Foster et al, 2011), Australia (Meert et al, 2015), Ireland (Roberts and McGilloway, 2008), Ecuador (Foster et al, 2012b) and Iran (Khosravan et al, 2010). Many methods of meaning-making and use of support systems, such as continuing bonds by keeping photographs and making scrapbooks, using physician/nurse-guided support groups, or feeling the presence of the deceased in a spiritual way, are seen in a majority of cultures and religions and may have different outcomes. For example, research in Ecuador suggests that Ecuadorians find continued bonds and memories more discomforting than other cultures, possibly due to the lack of effective coping strategies or differences in the cause of death (Foster et al, 2012a). Even with the growing body of research on bereavement, a better understanding of the cultural and religious influence on bereavement is needed. There is very little published literature on continued bonds or support systems for bereaved individuals within South American countries, particularly Honduras. Spirituality within Honduras is influenced by Spanish colonisation, Native American culture, and ancient Mayan beliefs, along with Catholic and Protestant doctrine. The vast majority (~97%) of Hondurans are Roman Catholic, but not all are devout and practising their faith. The continuum
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Abstract
Purpose: This qualitative study examined how bereaved individuals from Honduras responded to deaths of loved ones, particularly through exploring circumstances surrounding deaths and various coping strategies. Methods: With the help of a translator, bereaved family members in Honduras were interviewed using a semi-structured format. The interactions were audio-recorded and later translated and transcribed. Results: Some 60% of individuals spent time with other family members during their loved one’s end of life and 22.5% of grieving individuals took solace in spirituality or religious practices and connecting with God. Some 40% wanted to speak with others through support groups. When individuals spoke about remembering the deceased, both comforting and discomforting effects were expressed. Conclusions: Further research is needed to learn more about coping strategies in various cultures and support mechanisms that health professionals can use or suggest when working with bereaved individuals. Key words: Coping l Bereavement l Continuing bonds l Support l Culture l Qualitative
Using qualitative methods, the authors described categories, frequencies, and perceived consequences of factors surrounding death, support systems, and coping mechanisms, either present or wished for, among bereaved individuals in Honduras.
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of religious beliefs may affect the manifestation of bereavement in each individual differently. Grieving individuals experience positive outcomes (e.g. personal growth, search for meaning of life, valuing interpersonal relationships (Riley et al, 2007)) and negative results (e.g. decline in health, damage to selfimage (Riley et al, 2007)). Meert et al (2015) proposed that meaning-making (including sensemaking, giving back by helping others, and continuing bonds) conducted with the help of a physician after the loss of a loved one can provide comfort and lead to positive coping strategies among bereaved parents. Other support systems may include family member presence, support groups with other bereaved individuals, and religious guidance or contact with a religious leader (Mather et al, 2008). Although many of these systems provide emotional support and examples of how to restructure one’s life following the death of a loved one (Meert et al, 2015), some discomforting effects have been noted among some grieving individuals related to continuing bonds (Foster et al, 2011) and sense-making (Meert et al, 2015) (Figure 1).
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Methods Researchers partnered with Shoulder to Shoulder, a non-profit, community-based nongovernmental organisation that provides health care services to rural Hondurans, and works with local community leaders to strengthen community bonds, creating support for one another’s positive health. As part of Shoulder to Shoulder’s mission, the volunteer staff implement basic and advanced medical care, dental services and medical education, along with nutrition classes and community health initiatives. After obtaining approval from the institutional review board (equivalent of an ethics board), researchers worked with Shoulder to Shoulder and local leaders to identify potential participants for the study. These leaders used a script to explain the study and eligibility criteria to the community. Leaders of the community understood that the study aim was to learn from those who had recently lost a family member, to provide support for the bereaved in Honduras. Community members were informed of the possibility of researchers asking to talk with them about the death of a loved one and had time to think about whether they would approve of taking part or not. Once researchers arrived in the community, specific participants were shown sample questions after meeting inclusion criteria based on age, timeline
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of death, and language abilities. These potential participants were aware that taking part would last approximately 15 minutes and was completely voluntary. Consent was then obtained in the native language from those identified participants.
Participants Recruited participants were: ●●34–68 years old ●●Fluent in English or Spanish ●●Experienced death of a loved one within the past year. Shoulder to Shoulder representatives scheduled times for data collection before the US researchers arrived for interviews at a clinic in Honduras, which took place over several days in 2014. Participants included in this analysis (n=9) represented seven different families. Participants averaged 53.56 years of age (SD=12.82), with the majority being female (n=6) and self-reported their religious affiliations as Catholic (n=7) or Protestant (n=2). Educational level averaged 9.75 (SD=6.43) years, although one participant did not report an education level. The majority of families earned an average family income of less than 2000 US dollars per year. Participants’ relationship to the deceased varied from death of a son to death of a grandparent (Figure 2). The causes of death included acute and chronic illness and trauma (Figure 3).
❛There is very little published literature on continued bonds or support systems for bereaved individuals within South American countries ... ❜
Conditions of death
Support
Bereavement
Coping strategies
Comforting and discomforting effects
Figure 1: Some components of the bereavement process 83
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3 Number of losses
2 1
us in Co
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at he r ra nd f G
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ra nd m
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ot he r
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❛The majority of participants reported keeping photographs of the deceased, but a few individuals stated that they did not believe in physical representations.❜
Figure 2. Deceased’s relationship to bereaved (n=9)
Informed consent was obtained from each adult at the beginning of the data collection visit. Researchers conducted semi-structured interviews via two Spanish translators, asking four openended questions that were audio-recorded for transcription and coding. Questions covered topics such as circumstances surrounding the death of a loved one, ways support was provided, and use of continuing bonds. Subsequent questions were asked based on previous the responses. Prior to data collection, the principal investigator (PI) and translators examined each interview question to ensure that the intended meaning was properly conveyed to the participants.
Analysis Three researchers independently reviewed the interview transcripts through content analysis, a qualitative approach to examining data from open-ended questions (Hickey and Kipping, 1996; LoBiondo-Wood and Haber, 2006). The authors used an a priori coding scheme based on previous work with bereaved individuals and continuing bonds (Foster et al, 2011), while adding new categories for data that did not fit the a priori coding scheme. Content analysis started with immersion in the transcripts, reading them repeatedly to get a sense of the data as a whole. Three researchers independently reviewed the suggested coding scheme (Foster et al, 2011), and marked the presence or lack of presence for each code within the participant’s response. The three researchers then met to compare their coding decisions, resulting in 78% agreement. They discussed
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reasoning behind all discrepancies until a consensus was reached. Responses that could not be placed in an existing category but were determined to have significance were marked as ‘other’, and following coding consensus, the three researchers created three new categories under which these ‘other’ responses could be included. The new categories were: ●●Location of death ●●Support from other bereaved individuals ●●Support from health professionals. All data were examined based on the final coding scheme with the final categories. Researchers counted the coded responses to provide frequencies for each category and identified exemplar quotes from each category. Results indicated how bereaved individuals cope with the death of a loved one, the helpfulness of these coping mechanisms, and the support systems that are in place or could in place to be positive influences for healthy bereavement.
Findings After content analysis, participant reports were categorised into an adjusted coding scheme, which included four major themes: ●●Conditions surrounding a death ●●Coping mechanisms ●●Comforting and discomforting effects of continuing bonds ●●Support for a good death (Figure 1). The large majority of bereaved individuals reported important support systems and coping mechanisms specifically during the period after the death of their loved one, in comparison to before death or at end-of-life. Bereaved individuals perceived both comforting and
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Procedures and measures
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discomforting effects from these incidents, but never comforting effects only. Finally, bereaved family members had specific wishes for support concerning their loved one’s dying process and subsequently, their own healing process. Types of loss are shown in Figure 2 and reported causes of death in Figure 3.
Timing All nine participants reported on the timing of components that play a role in a family member’s good death. There were 52 responses regarding positive components that were identified by the nine participants. As many as 39 out of the 52 responses (75%) included factors that were important to participants after their loved one’s death, a category that had responses mentioned by every interviewee. Only 25% of responses focused on factors before death or at end of life.
Coping mechanisms
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There were 34 responses that indicated the use of coping skills for the nine bereaved individuals with all participants reporting specific coping activities. Some of these behaviours were purposeful while others were less cognizant, such as fleeting memories or involuntary dreams. Six major coping mechanisms were identified that were used by participants to promote positive outcomes after a loved one’s death. The most commonly used coping mechanisms were: ●●Being present with family members ●●Engaging in funerary activities ●●Having a physical representation of the deceased ●●Having non-physical reminders of the deceased ●●Spirituality, religion, and faith in God ●●Having relationships with health professionals. Participants who kept physical representations of the deceased reported that they kept items such as photos of the deceased, letters from them, and articles of clothing that belonged to the deceased. Participants also reported experiencing non-physical reminders. These included having dreams about the deceased loved one and reminiscing about lessons learned from the deceased. Presence with family Eight participants indicated that spending time with other family members was important after the death of a loved one. For instance, a 34-yearold female mentioned that the presence of other family members, such as a mother or father, helped fill the empty space left behind after her
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grandfather died. Similarly, a 65-year-old mother stated that, in difficult times: ‘I talk to my family. My family gives me comfort.’
Many grieving individuals mentioned particular family members that they spent time with when they felt sad and noted that reminiscing together was a significant activity in their home. Funerary activities There were five bereaved individuals who mentioned participation in funerary activities to cope with the death of a loved one. Such activities included burying the dead/funeral, visiting the cemetery, and changing the grave flowers. Three family members (ages 63, 58, and 50) whose mother died noted that visiting their mother’s grave regularly was very important. In addition, a 65-year-old mother identified the ‘iron cross at the cemetery’ as a place she visits to connect with and remember her son.
❛There is very little published literature on continued bonds or support systems for bereaved individuals within South American countries, particularly Honduras.❜
Physical representation As many as six participants used looking at physical representations as a means of coping with their relatives’ deaths. When researchers asked a 36-year-old woman: What helps you remember [your grandmother]? she identified a photograph and a skirt as being helpful objects. A 34-year-old, whose grandfather passed away, stated: ‘We remember through a photo. We see the photo and remember the person we have lost. We also remember through a wood carving.’
A 68-year-old homemaker mentioned reading ‘a little letter’ to remember her late sister. The majority of participants reported keeping photographs of the deceased, but a few individuals stated that they did not believe in physical representations. These participants described the importance of staying in touch with their loved ones through memories and other non-physical representations. Non-physical reminders There were six participants who described remembering deceased family members through intangible thoughts, dedications or dreams. For instance, a bereaved mother said she remembers her son through ‘the respect that he had for me’. Another participant said: ‘I dream about her […] my sister says to go visit my daughter in the dream.’
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One of the group of three bereaved siblings who lost their mother distinctly stated:
expressed that health professionals were her ‘source of happiness’, and said:
‘We think about the good times that we had with her and we are going to keep those memories for the rest of our lives.’
‘I felt like they were important and greeted me regarding my sister’s death. They cared about her.’
A 38-year-old said: ‘I will remember the good things mama taught me.’
These reminders were employed as coping strategies that allowed family members to think about their deceased relatives. Other nonphysical reminders of deceased family members included remembering teachings their relative passed onto them, personality traits that were endearing (such as respect) and fond memories. Spirituality, religious practices and God Eight individuals in this study reporting coping skills, stated that prayer, God, and overall spirituality were important to them after a relative died. Participants were predominantly Roman Catholic, with two participants identifying as Protestant. A 36-year-old woman stated that she did ‘not talk to anyone besides God’ and identified the church and prayer as an important influence in dealing with her grief. A 63-year-old bereaved woman similarly noted that she goes ‘to church to pray’. Prayer was an important coping mechanism for many participants. A 34-year-old mentioned: ‘Each year there is a prayer to remember the time that he died because each year it seems as if it were yesterday that he died.’
One participant, 68, confirmed church attendance as a way to ‘receive forgiveness from God’. In addition, to prayer and the church being important support mechanisms for bereaved individuals, two siblings, aged 63 and 50, noted the support of their pastor during difficult times. Lastly, a 50-year-old bereaved woman described asking ‘God what he wants me to do to get better
Participants reported both comforting and discomforting effects when engaging in the six identified coping mechanisms. Four participants who mentioned outcomes, reported only discomforting effects and none of those that took part experienced only comforting effects. Overall, three individuals specifically mentioned experiencing both comforting and discomforting effects from their coping strategies after a relative died. Three individuals specifically stated that looking at a photograph of their deceased family member did not console them and instead made them sad. For example, a 45-year-old bereaved cousin said: ‘It makes me sad because that’s just the way it is. It’s a recent loss.’
For this individual, the death was 5 days before the interview. The time passed since death is an important factor to note, as another participant explained: ‘She only died yesterday, [so] having the memories makes it difficult and makes us feel sad.’
The 68-year-old woman, who reported having dreams about her deceased sister, also mentioned: ‘It only makes me more sad.’
Discomforting effects happened when the coping mechanisms stimulated reminders of loss rather than positive memories. These discomforting results also occurred more frequently with the more recent deaths.
in my life [and] with my family’.
Support
The topics of religion and God yielded the most detailed responses to the interview questions concerning coping mechanisms after the death of a family member.
Presence with the family member before or at time of death When participants reflected on their experiences of losing a loved one, four participants wished they could have been with their loved one before death. Two individuals expressed a desire to have been present at the family member’s end-of-life. A mother whose son was murdered explained:
Relationship with medical professionals One individual described her relationship with doctors and nurses as being a positive influence during and after her sister’s end of life. She
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Effects and outcomes
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❛In addition to prayer and the church being important support mechanisms for bereaved individuals, two siblings, aged 63 and 50, noted the support of their pastor during difficult times.❜
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❛Few of those that took part were able to take steps to prepare for the death of their loved ones.❜
Number of deaths
2
1
0
Cancer
Murder
Accident
Cardiac
Old age
Figure 3: Reported causes of death (n=7) ‘I wish he had died in my house at home. He died at night and he didn’t die in the house. [I wanted to] keep on looking at him, but he went rapidly.’
He also stated that ‘it would depend on a person’s beliefs or faith’ for support groups to be helpful.
This pattern was evident as other bereaved individuals stated they would want their relatives to die in the home rather than in a distant location. Sisters, aged 63 and 58, expressed that it was important for their mother to be home when she died, but their brother added:
This study sought to learn more about circumstances surrounding deaths of loved ones as perceived by bereaved Honduran families. Participants discussed the manner in which their loved one died, circumstances surrounding the end of life, and factors found to be most important after the family member’s death. Comforting and discomforting effects have been found in other studies that examined continuing bonds in bereaved individuals (Field and Friedrichs, 2004; Neimeyer et al, 2006; Ronen et al, 2009; Foster et al, 2011). Participants in this study reported continuing bonds that elicited both comforting and discomforting effects, but interestingly, never comforting effects alone. Few of those that took part were able to take steps to prepare for the death of their loved ones. Most participants had family members who died outside of the home, without family members present. Only one participant reported spending time with the dying loved one before the death and only three participants reported spending time with other family members and the dying loved one at the time of death. It is interesting to note that no participants took steps to prepare for the death of a loved one. This gap in preparation could be a potential opportunity for physicians and other health providers to help prepare or counsel individuals with a terminally ill loved one, if timing allows. The authors can speculate that the lack of expressed priorities before or at end of life may correlate with
‘It was important for her to be where people could attend to her.’
Support groups When asked, four of the participants stated that it might be helpful to talk to a support group or others who have lost family members. Specifically, two participants would have liked to talk to other women who lost the same type of family member, i.e. a son or grandmother. A 45-year-old teacher said:
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‘[A support group] would be helpful because of the sentiment that would be expressed because of the passing.’
Another person mentioned the importance of circumstantial similarities surrounding the death to be considered for support groups. The bereaved 50-year-old noted: ‘There are several ways to help, but sometimes there are different types of death like by accident. The experiences are very different and need different support.’
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Discussion
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spontaneous deaths (i.e. murder) rather than a more predicted and expected course of disease in which individuals could mentally prepare. The lack of expressed factors important before or at death could also originate from open-ended interview questions, as opposed to a more closed, multiple-choice formatting. Deceased family members were often remembered in non-physical ways, such as through rituals or memories. Most participants reported keeping material items such as photographs, letters, and articles of clothing to remember their family members. Many of the participants who reported keeping material possessions to remember the deceased said that they only kept a few very special belongings. This was consistent with Foster et al’s (2012a) study that examined continuing bonds in deceased individuals in Ecuador. A previous study (Foster et al, 2011) that was completed in the US found that the majority of participants kept several material possessions of the deceased. It is possible that this cultural difference is due to the different socioeconomic statuses of participants. More than 50% of Hondurans and over 25% of Ecuadorians live below the poverty line (CIA, 2015), in comparison to only 14.5% of US citizens (United States Census Bureau, 2015). Keeping few physical reminders of the deceased could be the result of having a lower socioeconomic status and thus, less material capital. While some participants specifically said that they experienced comforting effects when remembering a deceased loved one, four said that they only experienced discomforting effects and no one reported feeling only comforting effects. Similar findings emerged in Foster et al’s (2012a) study in Ecuador. It is possible that discomforting effects were related to the nature of deaths. Previous studies suggest that bereaved individuals have a difficult time grieving when a family member died in such a sudden way (Riches and Dawson, 1998; Guy and Holloway, 2007). When participants were asked whom they turned to at the time of the death of a loved one, eight reported turning to other family members. It was also common for participants to turn to religion or God after the death of a loved one. Many said that it would be helpful to talk to others who have experienced the death of a loved one, which suggests that there was a lack of support for participants during the grieving process. This differs from the way some other cultures support bereaved individuals (e.g. through the use of support groups, bereavement counselling, etc.).
More research is needed to determine how best to support this population. Some of the coping mechanisms that were used by participants were purposeful (such as spending time with family, going to church, keeping physical reminders of the deceased, and engaging in funerary activities). Other coping mechanisms occurred without the intention of participants. These included having dreams about the deceased or feeling the nonphysical presence of the deceased. The use of the identified coping mechanisms gave participants a way to handle the death of a loved one. Some coping mechanisms also provided ways for participants to have continuing bonds with their deceased family members. Findings suggest that the six identified coping mechanisms may be helpful for this specific population with the addition of peer or medical support groups.
Limitations A number of factors limit the interpretation of the authors’ findings. Having a small sample size limits the generalisability of the findings. A variety of factors such as age, cause of death, location of death and relationship to the deceased may contribute to differences. An interpreter conducted interviews with participants, and these sessions were then translated and transcribed. Qualitative analysis began with a review of the literature and an a priori coding scheme that was developed with a different South American culture. As a result, some data could have been misinterpreted due to language and cultural differences. Despite limitations, this study addressed a gap in the current literature about experiences of bereaved family members in Honduras. Due to the qualitative analysis, the study was able to identify participant-specific experiences of a loved one’s death. The open-ended questions and explorative nature allowed for participants to discuss any factor or component of the death experience that they found lacking, important, comforting or discomforting. From these explorative interviews, common themes were identified regarding factors that contributed to a good death, without interviewer bias. Although an interpreter was used, leading to possible translation differences, the actual interview did take place in the participants’ own dialect to minimise miscommunication.
Implications for practice Findings revealed that participants put much more thought and effort into coping after the death of a loved one, rather than prior to death,
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❛Deceased family members were often remembered in non-physical ways, such as through rituals or memories.❜
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suggesting that Hondurans may not be preparing for the death of a loved one, even if there is knowledge of a terminal or critical diagnosis. Contrary to literature regarding North American culture and bereavement in which coping mechanisms and continuing bonds lead to a more positive outcome (Foster et al, 2011), findings suggest that Hondurans do not typically have this same positive experience. Hondurans who used continuing bonds as coping mechanisms experienced more discomforting effects. Therefore, future work with families of dying patients in Honduras should focus on normalising the bereavement process. Some families may find certain continuing bonds, such as keeping a photograph of the deceased, helpful and comforting, while other families may not. Providers and counsellors must recognise these differences and work with each family to support coping skills and bonds that will be most beneficial to each person. Family members of the critically or terminally ill may be a potential target population for counselling by a nurse or case manager about the disease progression, expectations, and future outcomes that could aid in positive coping and understanding of a family member’s illness. This population could also benefit from assistance in preparing for the death of a loved one and the introduction of coping outlets and skills, such as providing support groups for conversation or keeping a journal with thoughts and memories of the deceased. Furthermore, findings suggest that post-death support should be aimed towards those bereaved individuals who unexpectedly lose a loved one, as this population has difficulty grieving and coping with the sudden death.
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Conclusion This study used interviews with bereaved individuals in Honduras to describe circumstances surrounding the deaths of their loved ones and components they considered contributed to a good death. In addition, frequencies and nature of coping strategies, including the use of continued bonds and their effects, were described. The findings suggest that bereaved individuals in Honduras are similar to other cultures, using a variety of coping mechanisms, such as familial support and prayer, and that use of continuing bonds may be comforting or discomforting. It is important to note that Hondurans expressed more prevalent discomforting effects than other cultures, pointing to the opportunity for further research to provide insight on how to increase the positive effects of coping mechanisms in this population.
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Challenges with conducting this study included locating bereaved family members who were willing to talk about their experiences and use of translators. Further research is needed to explore responses to death of a loved one of individuals from different cultures and to learn about useful strategies to provide beneficial care for this vulnerable population. Conflicts of interest The authors have no conflicts of interest to declare
❛Some coping mechanisms also provided ways for participants to have continuing bonds with their deceased family members.❜
Central Intelligence Agency (CIA) (2014) The World factbook. http://tinyurl.com/zyx8nt6 (accessed 4 February 2016) Central Intelligence Agency (CIA) (2015) Ecuador population below poverty line. http://tinyurl.com/ zrkfv5y (accessed 4 February 2016) Field NP, Friedrichs M (2004) Continuing bonds in coping with the death of a husband. Death Stud 28(7): 597–620 Foster TL, Gilmer MJ, Davies B et al (2011) Comparison of continuing bonds reported by parents and siblings after a child’s death from cancer. Death Stud 35(5): 420–40 Foster TL, Contreras R, Gordon JE et al (2012a) Continuing bonds reported by bereaved individuals in Ecuador. Bereave Care 31(3): 120–8 Foster TL, Gordon J, Contreras R et al (2012b) Reports from Ecuador on continuing bonds with the deceased. J Pain Symptom Manage 43(2): 343–44 Guy P, Holloway M (2007) Drug-related deaths and the ‘special deaths’ of late modernity. Sociology 41(1): 83– 96 Hickey G, Kipping C (1996) A multi-stage approach to the coding of data from open-ended questions. Nurse Res 4(1): 81–91 Khosravan S, Salehi S, Ahmadi F et al (2010) Experiences of widows with children: a qualitative study about spousal death in Iran. Nurs Health Sci 12(2): 205–11 Lalande KM, Bonanno GA (2006) Culture and continuing bonds: a prospective comparison of bereavement in the US and the People’s Republic of China. Death Stud 30(4): 303–24 LoBiondo-Wood G, Haber J (2006) Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. 6th edn. Mosby Elsevier, St Louis MO Mather MA, Good PD, Cavenagh JD et al (2008) Survey of bereavement support provided by Australian palliative care services. Med J Aust 188(4): 228–30 Meert KL, Eggly S, Kavanaugh K et al (2015) Meaning making during parent-physician bereavement meeting after child’s death. Health Psychol 34(4): 453–61 Neimeyer RA, Baldwin SA, Gillies J (2006) Continuing bonds and reconstructing meaning: mitigating complications in bereavement. Death Stud 30(8): 715–38 Riches G, Dawson P (1998) Spoiled memories: problems of grief resolution in families bereaved through murder. Mortality 3(2): 143–59 Riley LP, LaMontagne LL, Hepworth JT et al (2007) Parental grief responses and personal growths following the death of a child. Death Studies 31(4): 277–99 Roberts A, McGilloway S (2008) The nature and use of bereavement support services in a hospice setting. Palliat Med 22(5): 612–25 Ronen R, Packman W, Field NP et al (2009) The relationship between grief adjustment and continuing bonds for parents who have lost a child. Omega 60(1): 1–31 United States Census Bureau (2015) Poverty: 2014 highlights. http://tinyurl.com/o89ogck (accessed 4 February 2016) Woo IMH, Chan CLW (2010) Management of survival guilt by a Chinese widower through the use of continuing bonds. Mortality 15(1): 38–46
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