the role of self-care for parents in recovery from

The Role of Self-Care for Parentsin Recovery From SubstanceUse DisordersAn Integrative Review of Parental Self-Care

Phyllis Raynor, PhD, PMHNP-BC, APRN m Charlene Pope, PhD, MPH, RN, FAAN

AbstractBackground: 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.

Keywords: parental self-care behaviors, parental

self-efficacy, parenting, personal health behaviors, self-care,

self-management, substance use, substance use disorders

INTRODUCTIONObtaining precise and current statistics on the number of

parents affected by substance use disorders (SUDs) is chal-

lenging 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 Admin-

istration [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 out-

comes, including increased risks for child maltreatment,

developmental and behavioral problems, and SUDs (U.S. De-

partment 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 chil-

dren’s growth and development (Shonkoff, Phillips, &

Committee on Integrating the Science of Early Childhood De-

velopment, 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) in-

clude 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 dif-

ferences of SCBs for parents with and without SUDs; (b)

examine studies for the application of Bandura’s concepts

Phyllis Raynor, PhD, PMHNP-BC, APRN, and Charlene Pope, PhD, MPH,RN, FAAN, College of Nursing, Medical University of South Carolina, Irmo.

This research is paid for, in part, by Grant #5T06SM060559-03through the Substance Abuse and Mental Health Services Adminis-tration at the American Nurses Association.

The authors report no conflicts of interest. The authors alone are re-sponsible for the content and writing of the article.

Correspondence related to content to: Phyllis Raynor, 2900 SunsetBoulevard, West Columbia, SC 29169.E-mail: [email protected]

DOI: 10.1097/JAN.0000000000000133

2.5 ANCCContact Hours

180 www.journalofaddictionsnursing.com July/September 2016

Original ArticleJournal of Addictions Nursing & Volume 27 & Number 3, 180Y189 & Copyright B 2016 International Nurses Society on Addictions

Copyright © 2016 International Nurses Society on Addictions. Unauthorized reproduction of this article is prohibited.

of self-regulation, self-efficacy, and collective self-efficacy;

and (c) draw conclusions regarding how SCBs might be ap-

plied in future research and practice venues.

Background and SignificanceCurrently, 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 compo-

nent 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 manage-

ment (Godfrey et al., 2011). Commonly recognized SCBs to

promote wellness in the general population include physical

activity, good nutrition, stress management, smoking cessa-

tion, limited alcohol use, and adequate sleep (Ryan, 2009).

Parenting and parental self-care. Improving parenting skills

and parentYchild 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 con-

tributing 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 popula-

tion 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 parent-

ing stress, incarceration, health problems, decreased coping,

and family and domestic conflict (Skinner, Haggerty, Fleming,

Catalano, & Gainey, 2011). For these reasons, parents who im-

plement 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 informa-

tion 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 COGNITIVETHEORY OF SUBSTANCE ABUSEBandura’s Social Cognitive Theory of Substance Abuse em-

phasizes 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 interpre-

tation 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 pro-

ducers of thought patterns that influence their motivation,

desires, and behaviors and products of their life situations

that are influenced by intrapersonal and environmental fac-

tors (Bandura, 1999). Three identified outcomes of successful

recovery for parents with SUDs include (a) self-regulatory

agency, which encompasses cognitive, emotional, and behav-

ioral 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 frame-

work broadens the conception of parental self-care and

provides useful terms to search the literature for SCBs poten-

tially applicable to parents recovering from SUDs.

Search Methods for Integrative ReviewAn 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 com-

prehensive 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 fol-

lowing search term phrases: ‘‘parental self-care,’’ ‘‘parenting

and self-care,’’ ‘‘parent self-care and psychometrics,’’ ‘‘parent-

ing health practices and psychometrics,’’ ‘‘parenting and stress

reduction,’’ and ‘‘self-care behaviors and mothers and fathers.’’

The author expanded the search using broader keywords: ‘‘per-

sonal health behaviors,’’ ‘‘chronic disease and health behaviors,’’

Journal of Addictions Nursing www.journalofaddictionsnursing.com 181


‘‘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 918 years old and primary custo-

dians, 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 con-

text 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

FIGURE 1. Search strategy.



analysis of the selected studies. Studies were analyzed and cat-

egorized based on the identified self-care measure.

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 ap-

praisal checklists have been developed for various types of

study designs (e.g., qualitative, quantitative studies, and sys-

tematic 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 pa-

rental 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 pur-

pose for measuring or exploring parental SCBs, whether

primary or secondary outcomes; and (d) conceptualization

and theoretical frameworks referenced for parental SCBs.

SEARCH RESULTS: SCB FOR PARENTSNine 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 stud-

ies (see Figure 1).

Description of Parental SCBs: Summary ofQualitative FindingsFour 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 in-

quired 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 tak-

ing 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 con-

cept 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 inter-

views were conducted using a standardized semistructured

interview guide. Interviews were audio-recorded, transcribed,

and analyzed using Miles and Huberman’s qualitative re-

search methods by two experienced qualitative researchers

(Mendias et al., 2011). SCBs were described as rest, engage-

ment 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 col-

lected 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 fa-

tigue. 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 re-

covering 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



TABLE

1‘‘D

esc

riptive’’Pare

nta

lSelf-C

are

Behaviors

(FourQualitative

Stu

dies)

Desc

ribe

dSe

lf-Ca

reBe

havi

orCon

text

Met

hod

Par

ent

Sam

ple

Chi

ldAge

Theo

retica

lFra

mew

ork

Bar

kin

&W

isner

,2

01

3;B

arki

n,

Wis

ner

,B

rom

ber

ger,

Bea

ch,Ter

ry,et

al.,

201

0;B

arki

n,

Wis

ner

,B

rom

ber

ger,

Bea

ch,&

Wis

nie

wsk

i,2

01

0

Tak

ing

tim

eou

tfo

ron

esel

f,en

gagi

ng

inple

asura

ble

acti

viti

es,

del

egat

ing

infa

nt

care

task

sat

tim

es,

taki

ng

care

ofon

e’s

self

phys

ical

lyan

dem

otio

nal

ly

New

mot

her

hoo

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efo

cus

grou

ps;

use

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ethod

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2‘‘M

easu

red’’Pare

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are

Behaviors

(SCBs;

FourQuantita

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Obse

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tudiesand

One

RCT)

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text

ofSCB

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ent

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Per

inea

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and

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mar

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tpar

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(new

mot

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multip

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The

Mat

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and

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nt

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mot

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participants. Interviews were tape-recorded, transcribed, and

then coded during data analysis. Constant comparative anal-

ysis 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 pro-

tective 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 dur-

ing 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 un-

able 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 function-

ing 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 bound-

aries (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 1Y3 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 ofQuantitative StudiesFive 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, 2012) 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 ma-

ternal 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. Peri-

neal 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 postpar-

tum 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

(2012) cross-sectional population-based survey study exam-

ined SCBs within the context of parenting fatigue for 1,276

parents over the age of 18 years with at least one child who

was 0Y5 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 phys-

ical health, and lower levels of exercise. Study limitations

included potential sampling bias and an inability to general-

ize 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 pat-

terns, exercise, weight, and BMI for mothers and fathers

(838 women, 682 men) from diverse ethnic and socioeco-

nomic 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 Ac-

tivity in Teens and Young Adults), a cohort study designed



to explore nutrition, exercise, and weight management be-

haviors for the cohort prior to and after parenthood. The

observational cohort study method did not control for inter-

vening 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 com-

pared 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 in-

strument 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 pa-

rental 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) psycholog-

ical 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 post-

partum 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 elimi-

nation; 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 da-

tabases may have been inconsistently applied, thus yielding

unrepresentative samples. About half of the studies looked

at SCBs as secondary outcomes or lacked theoretical frame-

works that addressed self-care (see Tables 1 and 2).

DISCUSSION: SCB AND APPLICATIONTO PARENTS IN RECOVERY FROM SUDSelf-care plays a central role in the management of health and

chronic illness. Few studies since the 1990s have examined pa-

rental SCBs specifically. As an area for future research, social

support, mental health, and tangible resources are health do-

mains linked to positive maternal well-being and functioning,

as described in a qualitative exploratory study of 18 postpar-

tum 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 experi-

ences 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 sub-

stance misuse over longer periods is strongly associated with

environmental influences, situational context, personal charac-

teristics, and tangible and intangible resources that are available

to that individual. Reflecting on Bandura’s components for indi-

viduals recovering from SUDs, self-regulatory agency, perceived

efficacy, and collective self-efficacy, these concepts were un-

derrepresented 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 LiteratureThere is a paucity of research on SCBs for parents in the gen-

eral 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 partic-

ularly 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 ResearchStudies of the relationships between parental SCBs and recov-

ery 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 popu-

lations and U.S. parent populations and particularly for

fathers in recovery from SUDs.

Implications for PracticeSelf-management strategies are encouraged within addictions

recovery support programs for recovery maintenance, al-

though 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, fundamen-

tal element to addictions recovery knowledge about parenting

factors in recovery from SUDs, specifically regarding per-

ceived SCBs that may contribute to long-term recovery and

improved parenting.

ConclusionsThe extended search period of this integrative review

(1980Y2013) resulted in only 9 studies for the current anal-

ysis, 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 par-

ents. 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 evi-

dence to identify strengths and weaknesses of studies and

determine the overall usefulness and validity of research find-

ings 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 rele-

vance, description, and types of SCBs for parents with

SUDs remain to be determined and may vary based on con-

textual factors and social health determinants. None of the

studies in the review address the impact of SCBs on child out-

comes, 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 re-

lationships 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 suc-

cessfully 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 hy-

potheses and future self-care interventions for parents in

the early stages of recovery.

REFERENCESAujoulat, I., Janssen, M., Libion, F., Charles, A. S., Struyf, C., Smets, F.,I

Reding, R. (2014). Internalizing motivation for self-care: Amultifaceted challenge for young liver transplant recipients.Qualitative Health Research, 24, 357Y365.

Bandura, A. (1999). A sociocognitive analysis of substance abuse: Anagentic perspective. Psychological Science, 10(3), 214Y217.

Barkin, J. L., & Wisner, K. L. (2013). The role of maternal self-care innew motherhood. Midwifery, 29, 1050Y1055.

Barkin, J. L., Wisner, K. L., Bromberger, J. T., Beach, S. R., Terry, M. A., &Wisniewski, S. R. (2010). Development of the Barkin index ofmaternal functioning. Journal of Women’s Health, 19(12), 2239Y2246.

Barkin, J. L., Wisner, K. L., Bromberger, J. T., Beach, S. R., & Wisniewski,S. R. (2010). Assessment of functioning in new mothers. Journal ofWomen’s Health, 19(8), 1493Y1499. doi:10.1089=jwh.2009.1864

Barlow, J., Wright, C., Sheasby, J., Turner, A., & Hainsworth, J. (2002).Self-management approaches for people with chronic conditions:A review. Patient Education and Counseling, 48, 177Y187.

Berge, J. M., Larson, N., Bauer, K. W., & Neumark-Sztainer, D. (2011). Areparents of young children practicing healthy nutrition and physicalactivity behaviors? Pediatrics, 127(5), 881Y887.

Brudenell, I. (1996). A grounded theory of balancing alcohol recoveryand pregnancy. Western Journal of Nursing Research, 18(4), 429Y440.

Brudenell, I. (1997). A grounded theory of protecting recovery duringtransition to motherhood. The American Journal of Drug and AlcoholAbuse, 23(3), 453Y466.

Brudenell, I. (2000). Parenting an infant during alcohol recovery. Journalof Pediatric Nursing, 15(2), 82Y88.

Bussing, R., E Koro-Ljungberg, M., Williamson, P., Gary, F. A., & WilsonGarvan, C. (2006). What ‘‘Dr. Mom’’ ordered: A community-basedexploratory study of parental self-care responses to children’s ADHDsymptoms. Social Science & Medicine, 63(4), 871Y882.

Cederbaum, J. A., Guerrero, E. G., Barman-Adhikari, A., & Vincent, C. A.(2015). Maternal HIV, substance use role modeling, and adolescentgirls’ alcohol use. The Journal of the Association of Nurses in AIDS care,26(3), 259Y270.

Child Welfare Information Gateway. (2014). Parental substance use andthe child welfare system. Retrieved from https://www.childwelfare.gov/pubPDFs/parentalsubabuse.pdf

Cloud, W., & Granfield, R. (2008). Conceptualizing recovery capital:expansion of a theoretical construct. Substance Use & Misuse,43(12Y13), 1971Y1986.



https://www.childwelfare.gov/pubPDFs/parentalsubabuse.pdf

https://www.childwelfare.gov/pubPDFs/parentalsubabuse.pdf

Cooklin, A. R., Giallo, R., & Rose, N. (2012). Parental fatigue andparenting practices during early childhood: An Australian communitysurvey. Child: Care, Health and Development, 38(5), 654Y664.doi:10.1111/j.1365-2214.2011.01333.x

Critical Appraisal Skills Programme. (2010). Critical appraisal skillsprogramme: Making sense of the evidence. Retrieved from http://www.casp-uk.net/about-casp/

Gillard, S., Adams, K., Edwards, C., Lucock, M., Miller, S., Simmons, L.,I Self Care in Mental Health research team. (2012). Informing thedevelopment of services supporting self-care for severe, long termmental health conditions: A mixed method study of communitybased mental health initiatives in England. BMC Health ServicesResearch, 12, 189. doi:10.1186/1472-6963-12-189

Glaser, B., & Strauss, A. (1967). The discoven& of grounded theocv.&Strategies for qualitative research. New York: Aldine.

Godfrey, C. M., Harrison, M. B., Lysaght, R., Lamb, M., Graham, I. D., &Oakley, P. (2011). Care of selfYcare by otherYcare of other: Themeaning of self-care from research, practice, policy and industryperspectives. International Journal of Evidence-Based Healthcare, 9, 3Y24.

Graneheim, U.H., Lundman, B, (2004). Qualitative content analysis innursing research: concepts, procedures and measures to achievetrustworthiness. Nurse Education Today, 24, 105Y112.

Heo, S., Moser, D. K., Lennie, T. A., Riegel, B., & Chung, M. L. (2008).Gender differences in and factors related to self-care behaviors: Across-sectional, correlational study of patients with heart failure.International Journal of Nursing Studies, 45, 1807Y1815.

Huang, T. T., Yeh, C. Y., & Tsai, Y. C. (2011). A diet and physical activityintervention for preventing weight retention among Taiwanese child-bearing women: A randomized trial. Midwifery, 27(2), 257Y264.

Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training programeffectiveness. Journal of Abnormal Child Psychology, 36(4), 567Y589.

Kapp, M. (1998). Mother’s perception of confidence with self-careand infant care. Journal of Perinatal Education, 7(4), 17Y25.

Ko, S. H., & Chen, C. H. (2010). Comparison of health-promotinglifestyles between postnatal Han Taiwanese and indigenous women.The Journal of Nursing Research, 18(3), 191Y198. doi:10.1097/JNR.0b013e3181edef18

Kumpfer, K. L. (2014). Family-based interventions for the prevention ofsubstance abuse and other impulse control disorders in girls. ISRNAddiction, 2014, 308789. http://dx.doi.org/10.1155/2014/308789

Kuo, C., Schonbrun, Y. C., Zlotnick, C., Bates, N., Todorova, R., Kao, J. C.,& Johnson, J. (2013). A qualitative study of treatment needs amongpregnant and postpartum women with substance use and depression.Substance Use & Misuse, 48, 1498Y1508. doi:10.3109/10826084.2013.800116

Lloyd, A. B., Lubans, D. R., Plotnikoff, R. C., Collins, C. E., & Morgan, P. J.(2014). Maternal and paternal parenting practices and their in-fluence on children’s adiposity, screen-time, diet and physical activity.Appetite, 79, 149Y157.

Marlatt, G. A., & Donovan, D. M. (2005). Relapse prevention:Maintenance strategies in the treatment of addictive behaviors (2nd ed.).New York, NY: The Guilford Press.

Marmot, M., & Wilkinson, R. G. (2006). Social determinants of health.Oxford, England: Oxford University Press.

Mendias, E. P., Clark, M. C., Guevara, E. B., & Svrcek, C. Y. (2011). Low-income Euro-American mothers’ perceptions of health and self-carepractices. Public Health Nursing, 28(3), 233Y242.

Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis.(2nd ed.). Thousand Oaks, CA: Sage.

Rhee, K. (2008). Childhood overweight and the relationship betweenparent behaviors, parenting style, and family functioning. TheAnnals of the American Academy of Political and Social Science,615(11), 12Y37. doi:10.1177/0002716207308400

Ryan, P. (2009). Integrated theory of health behavior change:Background and intervention development. Clinical NurseSpecialist, 23(3), 161Y172.

Sanders, M. (2008). Triple P-Positive Parenting Program as a publichealth approach to strengthening families. Journal of FamilyPsychology, 23(3), 506Y517.

Seymour, M., Dunning, M., Cooklin, A., & Giallo, R. (2013). Socioecologicalfactors associated with fathers’ well-being difficulties in the early parent-ing period. Clinical Psychologist. 38(5), 654Y664. doi:10.1111/cp.12016

Shambley-Ebron, D. Z., & Boyle, J. S. (2006). Self-care and motheringin African American women with HIV/AIDS. Western Journal ofNursing Research, 28(1), 42Y60.

Shonkoff, J. P., Phillips, D. A., & Committee on Integrating theScience of Early Childhood Development. (2000). From neuronsto neighborhoods: The science of early childhood development.Washington, DC: National Academies Press,

Skinner, M. L., Haggerty, K. P., Fleming, C. B., Catalano, R. F., &Gainey, R. R. (2011). Opiate-addicted in methadone treatment:Long-term recovery, health, and family relationships. Journal ofAddictive Diseases, 30(1), 17Y26. doi:10.1080/10550887.2010.531670

Stern, P. (1980). Grounded theory methodology: Its uses and processes.lmage, 12(1), 20Y23.

Substance Abuse and Mental Health Services Administration. (2009). Thenational survey on drug use and health (NSDUH). Rockville, MD: Author.

Substance Abuse and Mental Health Services Administration. (2014).Results from the 2013 National Survey on Drug Use and Health:Summary of national findings. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf

Taylor, J., & Johnson, M. (2010). How women manage fatigue afterchildbirth. Midwifery, 26, 367Y375.

U.S. Department of Health and Human Services. (2009). Parentalsubstance use and the child welfare system. Retrieved from http://www.childwelfare.gov/pubs/factsheets/parentalsubabuse.cfm#3

Whittemore, R., & Knafl, K. (2005). The integrative review: Updatedmethodology. Journal of Advanced Nursing, 52(5), 546Y553.

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