Keywords

parental self-care behaviors, parental self-efficacy, parenting, personal health behaviors, self-care, self-management, substance use, substance use disorders

 

Authors

  1. Raynor, Phyllis PhD, PMHNP-BC, APRN
  2. Pope, Charlene PhD, MPH, RN, FAAN

Abstract

Background: Lack of stress modifiers, such as self-care behaviors (SCBs), can increase vulnerability to drug use for parents in recovery from substance use disorders (SUDs).

 

Purpose: The purpose of this integrative review was to determine how the existing literature describes, conceptualizes, and measures SCB for parents in the general population for its application to parents with a history of SUD.

 

Methods: Framed by Bandura's Social Cognitive Theory of Substance Abuse, four qualitative and five quantitative studies identify SCB, although only one study describes SCB of parents in recovery.

 

Results: Few studies addressed parental SCB, and most of those studies focused on behaviors for new mothers with or without SUDs during the early child years.

 

Conclusions: Exploring the role of SCB in relation to parental well-being for the general population is a needed area for further research, even more so for parents who are recovering from SUDs.

 

Article Content

INTRODUCTION

Obtaining precise and current statistics on the number of parents affected by substance use disorders (SUDs) is challenging because there is no current standardized, national registry on the topic (Child Welfare Information Gateway, 2014). However, it is estimated that more than 8 million (an estimated 12%) children in America lived with at least one parent who was dependent on or abused alcohol or illicit drugs (Substance Abuse and Mental Health Services Administration [SAMHSA], 2009). According to the results from the 2013 National Survey on Drug Use and Health (SAMHSA, 2014), approximately 5.4% of pregnant women were current illicit drug users based on data averaged across 2012 and 2013.

 

Parental SUD is a major risk factor for negative child outcomes, including increased risks for child maltreatment, developmental and behavioral problems, and SUDs (U.S. Department of Health and Human Services, 2009). Consistent evidence from early childhood studies support a strong link between parents' overall health and well-being and their children's growth and development (Shonkoff, Phillips, & Committee on Integrating the Science of Early Childhood Development, 2000). More recent evidence similarly concludes that children's health practices and health outcomes are directly affected by their home environment, which includes their parents' modeling of specific health-related behaviors over time (Lloyd, Lubans, Plotnikoff, Collins, & Morgan, 2014; Rhee, 2008).

 

Family-based skills training programs result in positive health outcomes for the entire family, including support to parents as well as children (Kumpfer, 2014). As an example of support to parents, parental self-care behaviors (SCBs) include those personal health behaviors that build a parent's self-esteem and sense of well-being (Sanders, 2008). Taking care of oneself in a way that facilitates better health outcomes as a parent (e.g., parental self-care) may be an important aspect to effectively parent one's children (Cederbaum, Guerrero, Barman-Adhikari, &Vincent, 2015; Shambley-Ebron & Boyle, 2006). Very little is known about the intentional SCB that parents employ over time to maintain their well-being and positive parental functioning (Mendias, Clark, Guevara, & Svrcek, 2011). Thus, the purpose of this integrative review was to determine how the existing research conceptualizes and measures SCBs for parents in the general population and how those behaviors might contribute to parenting and recovery outcomes in parents recovering from SUDs. The goals of this review are to (a) explore the similarities and differences of SCBs for parents with and without SUDs; (b) examine studies for the application of Bandura's concepts of self-regulation, self-efficacy, and collective self-efficacy; and (c) draw conclusions regarding how SCBs might be applied in future research and practice venues.

 

Background and Significance

Currently, no single construct of self-care has been broadly accepted in the literature, although the term generally refers to personal health behaviors adopted over time to improve individual or family outcomes. Definitions vary according to the individual engaging in self-care, the motivation behind SCBs, and the extent of healthcare involvement (Godfrey et al., 2011). All of these conceptions share a common core component that affirms self-care as a broad multidimensional behavioral construct that represents a wide range of intentional behaviors employed by individuals to promote, restore, or maintain health in the context of long-term health management (Godfrey et al., 2011). Commonly recognized SCBs to promote wellness in the general population include physical activity, good nutrition, stress management, smoking cessation, limited alcohol use, and adequate sleep (Ryan, 2009).

 

Parenting and parental self-care.

Improving parenting skills and parent-child interactions is an essential component for successful parenting programs (Kaminski, Valle, Filene, & Boyle, 2008); still, SCBs employed by parents to foster a sense of well-being during and after parenting program completion need further investigation. In addition, although an estimated 8.6% of Americans needed treatment for SUDs in 2013, only about 0.9% actually received treatment (SAMHSA, 2014), with less known about the effects on SCBs and parenting. This percentage could be lower among parents of small children, with greater demands, making it imperative that other contributing factors to positive parenting and recovery outcomes be explored for this high-risk population.

 

In addition, the types of SCB that parents in recovery from SUDs need and employ may differ from the general population as well as differ from the standard SUD treatment (e.g., medications, cognitive behavioral therapy, support for stable housing and employment, attending recovery meetings, and intentionally abstaining from alcohol and drugs). Parents in recovery from SUDs are thought to have other sources of stress that complicate long-term recovery, including parenting stress, incarceration, health problems, decreased coping, and family and domestic conflict (Skinner, Haggerty, Fleming, Catalano, & Gainey, 2011). For these reasons, parents who implement SCBs in long-term recovery from SUDs have lessons to teach other parents in early recovery. As a preface for exploring SCBs for parents with SUDs, which has been underinvestigated, this article will explore how parental SCBs were conceptualized and measured in the literature for parents without SUDs. The term "parents in recovery from SUDs" is defined as mothers and fathers who are in recovery from both licit and/or illicit drugs, which include alcohol, heroin, stimulants, prescription opioids, sedatives, cocaine, and hallucinogens. The information obtained in this review will inform future self-care interventions that support recovery and parenting outcomes for parents in recovery from SUDs.

 

BANDURA'S SOCIAL COGNITIVE THEORY OF SUBSTANCE ABUSE

Bandura's Social Cognitive Theory of Substance Abuse emphasizes intentional cognitive, emotional, and behavioral strategies employed by individuals with SUDs over time that influence recovery and other health outcomes (Bandura, 1999). Because Bandura's theory more closely aligns with the research application guiding this review, it was used to frame an interpretation of parental SCBs in the literature. For the purposes of this review, parental SCBs are defined as the cognitive, emotional, and behavioral strategies deliberately employed by parents with and without a history of SUD to maintain their health, well-being, and parental functioning in response to the balance of intrapersonal and socioecological stressors.

 

In Bandura's theory, human agency is conceptualized as the mechanisms by which individuals come to be both producers of thought patterns that influence their motivation, desires, and behaviors and products of their life situations that are influenced by intrapersonal and environmental factors (Bandura, 1999). Three identified outcomes of successful recovery for parents with SUDs include (a) self-regulatory agency, which encompasses cognitive, emotional, and behavioral SCBs that promote recovery from SUD; (b) perceived efficacy, which conceptualizes a personal belief in one's ability to quit misusing substances while parenting effectively; and (c) collective self-efficacy, which conceptualizes shared belief in the ability to improve life circumstances through common efforts and community supports (Bandura, 1999). This review will examine parental SCBs and the interventions that promote them for these three components, because their influence may be primary for SUD recovery maintenance. Thus, this framework broadens the conception of parental self-care and provides useful terms to search the literature for SCBs potentially applicable to parents recovering from SUDs.

 

Search Methods for Integrative Review

An approach to the integrative review of the literature (Whittemore & Knafl, 2005) was employed to (a) explore SCBs and their measures in the general parent population and (b) explore the evidence of SCBs of parents in recovery from SUDs in experimental and nonexperimental research studies. To determine the state of the science on the role and types of self-care for parents, this review included a comprehensive sample of selected studies, published from 1980 to 2013 within the Cumulative Index for Nursing and Allied Health, PsychInfo, and PubMed databases (see Figure 1). The extensive period of the search coupled with inclusion of all ages of children broadened the search as an attempt to capture all relevant studies in this underinvestigated area. The initial and repeated searches were conducted with the following search term phrases: "parental self-care," "parenting and self-care," "parent self-care and psychometrics," "parenting health practices and psychometrics," "parenting and stress reduction," and "self-care behaviors and mothers and fathers." The author expanded the search using broader keywords: "personal health behaviors," "chronic disease and health behaviors," "self-care practices," "health promotion," "positive parenting," and "health practices." Subject headings included "parenting," "mothers and fathers," "self-care," "health promotion," and "health practices." The original search strategy yielded 1,842 articles. Inclusion criteria for the initial review were peer-reviewed full-text articles of studies as well as reference and abstract availability. Source types were academic journals and periodicals. Articles were included if SCBs were centered on improving the physical health and emotional well-being of the parent, if parents were >18 years old and primary custodians, and if self-care was not solely acute or chronic disease focused (i.e., infections, diabetes self-care, or heart failure self-management). Studies were excluded if they were not accessible in English, discussed SCBs only within the context of child illnesses (child epilepsy, autism, etc.), did not include potential contextual factors or health conditions that influenced self-care practices (e.g., depression, SUD), or did not describe or measure SCBs specifically. In addition, the final collection was searched with the inclusion criteria "substance-related disorders," "substance use disorders," "alcohol," "drugs," and "recovery and parenting" to determine studies involving parents in recovery from SUDs. The final search yielded 10 articles after the application of inclusionary criteria. Matrices were created to facilitate the organization and analysis of the selected studies. Studies were analyzed and categorized based on the identified self-care measure.

  
Figure 1 - Click to enlarge in new windowFIGURE 1. Search strategy.

The authors also used the Critical Appraisal Skills Programme Checklist (CASP) to systematically appraise the various types of evidence to identify strengths and weaknesses of studies and determine the overall usefulness and validity of research findings (Critical Appraisal Skills Programme, 2010). The CASP is a systematic approach of examining research that is used to guide an individual's appraisal of scientific evidence (Critical Appraisal Skills Programme, 2010). A set of eight critical appraisal checklists have been developed for various types of study designs (e.g., qualitative, quantitative studies, and systematic reviews) to cover validity, results, and relevance (Critical Appraisal Skills Programme, 2010).

 

Data from the selected qualitative and quantitative studies were grouped by study type (Whittemore & Knafl, 2005). Figure 1 explains data reduction and data display. Tables 1 (qualitative) and 2 (quantitative) provide a means for data comparison to examine conclusion drawing and verification focused on the following: (a) the description of specific parental SCBs and whether SCBs were described by the sample or predefined by the researcher; (b) the context in which parental SCBs were measured or explored; (c) the purpose for measuring or exploring parental SCBs, whether primary or secondary outcomes; and (d) conceptualization and theoretical frameworks referenced for parental SCBs.

  
Table 1 - Click to enlarge in new windowTABLE 1 "Descriptive" Parental Self-Care Behaviors (Four Qualitative Studies)
 
Table 2 - Click to enlarge in new windowTABLE 2 "Measured" Parental Self-Care Behaviors (SCBs; Four Quantitative Observational Studies and One RCT)

SEARCH RESULTS: SCB FOR PARENTS

Nine studies were selected for this review, as illustrated in Figure 1. The final selections were scholarly publications with data-driven research (e.g., no dissertations, editorials, or published professional opinions). The selected studies included five quantitative studies and four qualitative studies (see Figure 1).

 

Description of Parental SCBs: Summary of Qualitative Findings

Four qualitative studies were selected for this review (see Table 1). Three addressed the perceived impact of maternal SCB and motherhood on the identity and general mood of women (see Table 1). Only one qualitative study explored the experiences of 11 White mothers in recovery from SUDs while they transitioned into the role of motherhood (Brudenell, 1997). The SCBs identified for parents in the general population have been described primarily by new parents in exploratory descriptive qualitative studies using one-to-one interviews with new mothers (Mendias et al., 2011), focus groups (Barkin & Wisner, 2013; Barkin, Wisner, Bromberger, Beach, Terry, et al., 2010; Barkin, Wisner, Bromberger, Beach, & Wisniewski, 2010), and open-ended questions on mailed surveys (Taylor & Johnson, 2010). In three of the four qualitative studies of mothers in the general population, interview questions generally inquired about maternal identity, motherhood, and SCBs that new mothers were doing or felt they should be doing to take care of their physical and emotional well-being (Barkin & Wisner, 2013; Mendias et al., 2011; Taylor & Johnson, 2010). One study of parents in recovery from SUDs explored "protective strategies" used by 11 White mothers to preserve their recovery while transitioning into the maternal role (Brudenell, 1997). The specific SCBs, protective strategies, and critical appraisal of each study are described below.

 

Barkin and Wisner (2013) described maternal SCBs as taking time out for oneself, doing exercises, engaging in pleasurable activities, periodically delegating infant care tasks, and taking care of one's self physically and emotionally. The study included three focus groups with 31 new mothers over 18 years old. Most mothers (80%) were White, employed, and well educated. All focus group sessions were audio-recorded and transcribed for data analysis. A coding method was employed to analyze the focus group data (Barkin & Wisner, 2013). The objective of the study was threefold: to explore the women's perceived role of maternal self-care, how SCB was applied in new motherhood, and the perceived barriers in practicing SCBs (Barkin & Wisner, 2013). One emerging concept was that self-care was of primary importance to effective mothering. Women also reported significant amounts of self-sacrifice with the role of motherhood. Barriers to self-care were time restraints, limited resources such as money and social support, and difficulty accepting help and setting boundaries (Barkin & Wisner, 2013).

 

Mendias et al. (2011) interviewed 10 low-income White mothers using a standardized semistructured interview guide about maternal SCBs. The exploratory study design was meant to identify SCBs for potential health promotion interventions to increase health equity. Face-to-face interviews were conducted using a standardized semistructured interview guide. Interviews were audio-recorded, transcribed, and analyzed using Miles and Huberman's qualitative research methods by two experienced qualitative researchers (Mendias et al., 2011). SCBs were described as rest, engagement in pleasurable activities, physical exercise, and stress management. Participants reported barriers to SCBs such as limited financial and social support.

 

In Taylor and Johnson's (2010) qualitative descriptive survey study, data regarding personal behaviors were collected from 59 well postpartum women in Australia (of unidentified ethnicity) using open-ended survey questions mailed at 6, 12, and 24 weeks after childbirth. The data were drawn from a larger study looking at postnatal fatigue. SCBs identified by participants included sleep, rest, conserving energy, getting help, planning, and lowering maternal expectations. Barriers to self-care included limited access to social support and financial resources at times (Taylor & Johnson, 2010).

 

Brudenell's (1997) sole exploratory study explored the concurrent experiences of 11 White women who were recovering from SUDs while transitioning into the role of motherhood, using grounded theory. The participants were individually interviewed twice between September 1992 and May 1993. Data were collected through semistructured in-depth interviews, observation, and the diary entries of participants. Interviews were tape-recorded, transcribed, and then coded during data analysis. Constant comparative analysis method by Glaser and Strauss (1967) and Stern (1980) was employed. Data were clarified with participants both in individual sessions and in small focus groups. Balancing emerged as the major theme, which was described as the protective processes or strategies that these women used to successfully integrate recovery and motherhood into their overall identity. According to Brudenell (1997), a part of balancing was the use of "protective strategies" in unique ways during the antepartum and postpartum periods as SCBs. These strategies included the practice of spirituality through prayer, daily contact with a higher power, bible study, and 12-step meetings. Women in the study reported implementing these protective strategies at some point during pregnancy and/or up to a year after delivery, oftentimes having to balance recovery activities with personal and child care needs (e.g., talking frequently with a sponsor when unable to attend 12-step meetings).

 

Summary of qualitative findings.

In all of these qualitative studies (see Table 1), SCBs or protective strategies were perceived as essential for positive health outcomes of the mothers in terms of maternal role adjustment, identity, and maternal functioning with their children. SCBs described by mothers included taking time out for oneself, engaging in pleasurable activities (Barkin & Wisner, 2013; Mendias et al., 2011), periodically delegating child care, taking care of one's physical and emotional health (Barkin, Wisner, Bromberger, Beach, & Wisniewski, 2010), sleep, rest, planning, and lowering expectations (Mendias et al., 2011; Taylor & Johnson, 2010). Barriers to practicing SCBs included limited time, limited financial and social support (Mendias et al., 2011; Taylor & Johnson, 2010), and difficulty getting and accepting help and setting boundaries (Barkin, Wisner, Bromberger, Beach, Terry, et al., 2010; Taylor & Johnson, 2010). Most women in the qualitative studies perceived parental self-care as necessary and beneficial to their maternal health and well-being. Most mothers in the selected studies were White, so the engagement and adoption of these parental SCBs for women of color remains unknown. These study participants for three of four studies were mothers of babies of young children (first 1-3 years of the child's life), so the application of these SCBs to parents of older children is unknown. The ages of the children were not reported in Mendias et al.'s (2011) study. Finally, no fathers were included in the qualitative studies describing parental SCBs.

 

Measures of Parental SCBs: Summary of Quantitative Studies

Five quantitative studies (four observational studies and one randomized control trial) were included in this review (see Table 2). SCBs were examined either as one single construct designed to include a wide range of health behaviors (Cooklin, Giallo, & Rose, 2011) or identified as a single parental SCB examined at a single data point (i.e., perineal care 14 days after hospital discharge; Kapp, 1998). Certain SCBs were preselected by the researchers, measured at several data points over time, and compared with those of other adults without children (Berge, Larson, Bauer, & Neumark-Sztainer, 2011). Two studies were selected based on measurement scales used with mothers to examine their perceived ability to engage in positive SCBs during pregnancy and the postpartum period, namely, the Self-rated Abilities for Health Practices Scale and the Health Promoting Lifestyle Profile II (Ko & Chen, 2010; Huang, Yeh, & Tsai, 2011; see Table 2).

 

Kapp's (1998) observational cohort study measured maternal SCBs and infant care behaviors within the context of the early postpartum period for 104 new mothers (80% White) in Long Island, New York. SCBs were operationalized as total scores on the Maternal and Infant Care Confidence (Visual Analog) Scale, and baseline scores were obtained before hospital discharge and 2 weeks after discharge. Perineal care, breast care, knowledge of nutrition, elimination, activity and exercise, and postpartum blues were measured as maternal SCBs. Kapp (1998) found that new mothers had greater confidence for performing maternal SCBs when comparing measures at the time of birth and 2 weeks postpartum for perineal and breast care and elimination. However, no significant differences were found in perceived confidence with longer-term SCBs (after postpartum), such as nutrition and exercise.

 

Two quantitative observational studies (one cross-sectional study and one longitudinal cohort study) included fathers and mothers as part of the sample (Berge et al., 2011; Cooklin et al., 2012). Specific health-promoting behaviors as SCBs were preselected (Berge et al., 2011) or measured broadly as one single construct (Cooklin et al., 2012). Cooklin et al.'s (2011) cross-sectional population-based survey study examined SCBs within the context of parenting fatigue for 1,276 parents over the age of 18 years with at least one child who was 0-5 years old. Parental SCBs were operationalized as total parent scores on a two-item measure focusing on diet and physical activity. SCBs were secondary outcomes to parental fatigue, and there were no psychometric data reported on the two-item self-care measure used in the study. Sleep patterns and parental coping were measured as different constructs, not as part of parental SCBs. Using Pearson correlation and bivariate analysis statistical analysis, mothers reported higher fatigue levels than fathers. Poor sleep quality and lower self-care were independently and significantly associated with higher fatigue, including more sleep disturbance, worse physical health, and lower levels of exercise. Study limitations included potential sampling bias and an inability to generalize to parents with children older than the age of 5 years (Cooklin et al., 2012).

 

In Berge et al.'s (2011) longitudinal population-based cohort study conducted in the US, the SCB of dietary patterns, exercise, weight, and BMI for mothers and fathers (838 women, 682 men) from diverse ethnic and socioeconomic backgrounds with children younger than five years old were examined. Data for this analyses were taken from the second and third waves of Project EAT (Eating and Activity in Teens and Young Adults), a cohort study designed to explore nutrition, exercise, and weight management behaviors for the cohort prior to and after parenthood. The observational cohort study method did not control for intervening barriers to these SCBs, such as geographical location, employment, and community supports. Sample mothers had higher BMIs, and reported consuming greater amounts of sugary drinks, calories, and saturated fat compared to non-mothers. Both mothers and fathers reported less exercise compared to participants who were not parents (Berge, et al, 2011). Physical activity was significantly less for fathers as compared with nonfathers. Mothers had higher mean BMIs than women without children. No difference was observed in BMIs between fathers and men without children.

 

Ko and Chen's (2010) cross-sectional comparative study examined the health-promoting lifestyles of ethnic Han Taiwanese and indigenous women in Taiwan. These parental SCBs were operationalized as the total parent score on the Health Promoting Lifestyle Profile II scale. This 52-item instrument measures perceived ability to engage in health-promoting behaviors related to the theorized dimensions of spiritual growth, personal relationships, nutrition, physical activity, health responsibility, and stress management as SCBs. This was a secondary data analysis built on an original study, which did not focus on variables related to the scale as SCBs. The second study also measured perceived ability in engaging in broad health domains and did not address continued parental SCBs beyond 6 weeks postpartum. Significant differences were found in health responsibility and exercise for the two groups, which indicated the role of culture as a significant factor in influencing health-promoting behaviors (Ko & Chen, 2010).

 

In Huang et al.'s (2011) randomized control trial, parental SCB was operationalized as total scores on the Self-Rated Abilities for Health Practices (SAHP) Scale for a sample of 189 Taiwanese mothers. The SAHP is a 28-item, 5-point scale used to measure perceived ability to engage in health-promoting behaviors. The SAHP contains four subscales: (a) exercise, (b) nutrition, (c) responsible health practice, and (d) psychological well-being. The following SCBs also were measured: postpartum weight, diet, and physical activity. The results supported the efficacy of using dietary and physical activity interventions during pregnancy to reduce postpartum weight retention but did not look at SCBs beyond the 6-month postpartum period. However, high attrition rate and a short study period (16 weeks gestation to 6 months postpartum) were noted limitations of the study.

 

Summary of quantitative findings.

In summary, the quantitative studies measured the following parental SCBs: dietary patterns (Berge et al., 2011; Cooklin et al., 2012; Huang et al., 2011; Ko & Chen, 2010); physical activity (Berge et al., 2011; Cooklin et al., 2012; Huang et al., 2011; Ko & Chen, 2010); healthy weight (Berge et al., 2011; Huang et al., 2011); health responsibility, spiritual growth, and stress management (Ko & Chen, 2010); perineal care; breast care; knowledge of nutrition and elimination; and exercise (Kapp, 1998). No studies were found for fathers or mothers with SUDs and with preadolescent or adolescent children.

 

As with any method of literature review, limitations exist. The inclusion of Kapp's (1998) study examining maternal self-care and infant care presents a limited view of parental SCBs, looking only at 6 weeks of postpartum care. Although this study met the inclusionary criteria for this review, maternal self-care was limited to the immediate postpartum period and was not structured to assess the ongoing self-care needs of the mothers. The search for this integrative review was primarily limited to available full-text articles with reference and abstract availability that were available in the English language. The method and search term phrases for determining relevant articles may have contributed to an exclusion of other clinically relevant articles applicable to both the general parent population and parental SCBs for parents with SUDs. Key phrases used in research databases may have been inconsistently applied, thus yielding unrepresentative samples. About half of the studies looked at SCBs as secondary outcomes or lacked theoretical frameworks that addressed self-care (see Tables 1 and 2).

 

DISCUSSION: SCB AND APPLICATION TO PARENTS IN RECOVERY FROM SUD

Self-care plays a central role in the management of health and chronic illness. Few studies since the 1990s have examined parental SCBs specifically. As an area for future research, social support, mental health, and tangible resources are health domains linked to positive maternal well-being and functioning, as described in a qualitative exploratory study of 18 postpartum women with co-occurring SUDs and depression (Kuo et al., 2013). These domains focus particularly on social health areas thought to promote or sustain recovery outcomes (i.e., group treatment, safe environment, transportation) and did not address parental SCBs directly (Kuo et al., 2013). Brudenell's (1997) study explored women's recovery experiences while transitioning into the parenting role; the results indicated that women used protective strategies during the antepartum and postpartum periods. According to Cloud and Granfield (2008), a person's ability to abstain from substance misuse over longer periods is strongly associated with environmental influences, situational context, personal characteristics, and tangible and intangible resources that are available to that individual. Reflecting on Bandura's components for individuals recovering from SUDs, self-regulatory agency, perceived efficacy, and collective self-efficacy, these concepts were underrepresented in the studies presented for parents in the general population but were identified in Brudenell's study for new mothers' recovery from SUDs and may be important components for parents in recovery from SUDs in future studies. The role of parental SCBs may contribute to treatment regimens for SUDs but requires further study regarding their perceived benefits to recovery maintenance and parenting outcomes.

 

Gaps in the Literature

There is a paucity of research on SCBs for parents in the general population and its relationship to parental well-being. Although one descriptive qualitative study addressed early parenting and recovery outcomes for women with SUDs, more research is needed to describe and measure specific SCBs of mothers and fathers in long-term recovery and whether those behaviors are related to positive parenting or sobriety outcomes. Most evidence has shown the benefits of adopting SCBs in promoting positive health outcomes particularly when managing other chronic diseases (Gillard et al., 2012; Barlow, Wright, Sheasby, Turner, & Hainsworth, 2002). Parents who manage SUDs may benefit particularly from SCBs because of their priority health needs and socioecological stressors.

 

Implications for Research

Studies of the relationships between parental SCBs and recovery from SUDs are needed to determine the significance of SCBs to parenting and sobriety outcomes and for potential dissemination to parents who are newly entering recovery. Very few studies have examined factors associated with the health and well-being of fathers. Most studies describing SCBs focused on predominantly White or non-U.S. parent populations (Barkin & Wisner, 2013; Brudenell, 1997; Mendias et al., 2011; Taylor & Johnson, 2010). Future research is needed on the role and types of SCBs for minority populations and U.S. parent populations and particularly for fathers in recovery from SUDs.

 

Implications for Practice

Self-management strategies are encouraged within addictions recovery support programs for recovery maintenance, although these strategies may not include parental SCBs. Exploring the role of parental self-care in relation to parenting and recovery outcomes will contribute a missing, fundamental element to addictions recovery knowledge about parenting factors in recovery from SUDs, specifically regarding perceived SCBs that may contribute to long-term recovery and improved parenting.

 

Conclusions

The extended search period of this integrative review (1980-2013) resulted in only 9 studies for the current analysis, given the topic's scarce evidence. Most of the conceptual terms of SCBs have been used in relation to the management of chronic diseases of oneself (Heo, Moser, Lennie, Riegel, & Chung, 2008), one's child (Aujoulat et al., 2014), or one's role as a caregiver (Bussing, E Koro-Ljungberg, Williamson, Gary, & Wilson Garvan, 2006), rather than promoting general health and well-being or focusing on the specific needs of parents. In addition, most of these studies looked at SCBs only in immediate postpartum or early child years. As a result, few studies met inclusionary criteria for this review. The CASP was used to systematically appraise the various types of evidence to identify strengths and weaknesses of studies and determine the overall usefulness and validity of research findings presented.

 

The evidence suggests that personal and environmental factors (Marmot & Wilkinson, 2006; Seymour et al., 2013) influence mothers' and fathers' decisions to engage in and adopt SCBs over time (employment status, work hours, etc.). However, there is a striking absence of conceptual and measurement clarity to assess parental SCBs. Because SCBs were measured for parents without known SUDs, the relevance, description, and types of SCBs for parents with SUDs remain to be determined and may vary based on contextual factors and social health determinants. None of the studies in the review address the impact of SCBs on child outcomes, especially in recovery from SUDs.

 

In terms of parental self-care and its application to parents who are in recovery from SUDs, the exploration of these relationships will expand the current knowledge in addiction recovery by helping to understand the role of self-care for parents who are attempting to maintain sobriety while successfully transitioning back into a favorable parenting role from active addiction. Given that few studies have identified SCBs for parents in recovery, more research is needed about self-care of parents who have achieved successful recovery maintenance. This information will assist in generating hypotheses and future self-care interventions for parents in the early stages of recovery.

 

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