The family and health care: explorations in cross-cultural settings.

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THE FAMILY AND HEALTH CARE Ann Brownlee PhD

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Medical Sociologist, Health Policy Institute, and Boston University African Studies Center, Boston University, Boston, MA, 02215 Published online: 26 Oct 2008.

To cite this article: Ann Brownlee PhD (1979) THE FAMILY AND HEALTH CARE, Social Work in Health Care, 4:2, 179-198, DOI: 10.1300/J010v04n02_05 To link to this article: http://dx.doi.org/10.1300/J010v04n02_05

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THE FAMILY AND HEALTH CARE: EXPLORATIONS IN CROSS-CULTURAL SETTINGS

Downloaded by [Monash University Library] at 03:03 07 March 2015

Ann Brownlee,PhD

ABSTRACT. This article discusses what a social worker or healthpmctitionershould know about the family and its influence on health care among various ethnic groups, focusing first on basic information on family organization and interrelationships and thenon the family's roleduring healthcare. The material ispresented inaformatdesigned to be useful to thepmctitionerin thefield, discussing what important aspects of various topics the worker mightinvestigate, why the information is important, and how togatherit

-In Korea if a young wife is found to have active tuberculosis and a p proval must be obtained for hospitalization, the health practitioner must first explain the problem to her parents-in-law,as they are the key figures of authority within the family. The husband does not have the power to make this decision, nor does his wife (Foster,1973, p. 119). -In the Mexican-American bamo of Sal Si Puedes in San Jose, California, an individual often cannot decide to seek medical care or even, in many cases, decide that he is ill, without the involvement of his circle of extended family and friends (Clark,1959,pp. 203-204,231). -In rural Appalachian areas of the United States many people with medical problems may never see a doctor but are cared for either entirely by their families or perhaps with the assistance of lay healers active in the local community. The importance of understanding the influence of the family on health care cannot be underestimated, and when social workers or health professionals are working in communities with people of cultures different than their own, the urgency of developing this understanding becomes all the more critical. As examples such as those above Dr. Brownlee, a medical sociologist, is currently at the Health Policy Institute, Boston University. 53 Bay State Road. Boston, Massachusetts 02215. and also at the Boston University African Studies Center. Material in this article is adapted from one section of Community, Culture, and Care: A Cross-Cultuml Guide for Health Workers,a book by theauthor published by C. V. Mosby. Saint Louis. 1978. SaiaiWarkiaHealth Cars. Vol.412). Winter 1018 O 1018 byTheHaworthha.AUrlghtareaerved.

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illustrate clearly, the family may have a quite decided influence on the health care of its members, and yet the nature of that influence is often unclear to workers servingculturalgroupsother than their own. Numerous studies of family influence on health care in different cultures have produced insights and developed techniques of analysis that could be useful to social workers and other health professionals working in the community. But often suggestions and tools of practical importance are deeply buried among the particulars of various studies and not presented in forms useful to the worker on the job. This article attempts to present techniques that will be useful in an exploration of the family and its influence on health care in a wide variety of cultural settings, presenting the material in a format that will be i f ~racticaluse to workers in the field. The studv focuses f i s t on basic iniormation on the family: its organization and ;hanging nature; conflicts and coalitions among family groups; and the process of family decision making.Then it investigates the role of the family during health care, exploring the effect of status on the care various family members receive, and the roles different family members play whena member is ill at home or is treated inan outpatient health facility or hospital. Ineach section within the article, the discussion focuses first on what questions one should explore on the topic, then why the information is important in practical health program terms, and finally, how the information could begatheredin the local area. The material presented below was developed after both m extensive searchof theliterature on the subject and firsthand field investigationin a number of different cultural settings both in the United States and abroad. During the field research, tapes were made of the stories that both local and outside health workers gave of the problems they had experienced in this area and others. Thus, in the discussions that follow, &my of the examples given are from community health programs currently hoperation andare given in the words of the workers themselves. BASIC INFORMATION Family Life What to findout

-How are f d e s and kinship groups typically organized within the culture? What is the pattern of residence?Who is a part of typical badly households, and what are the usud living mangements? What are the d e s of descent and irnheritannce? -What types of udorns or marriagee are common, and what customs


and rules govern these arrangements? What are the attitudes toward and rules governingseparation and divorce? -What roles do the father, mother, son, daughter, grandparents (or other persons typically a part of the family withinacertainculture) commonly play within the family? What tasks do they perform? Who is in a position of authority? Submission? Where and how do various family members typically spend their time? -What events are considered important within the life cycle of an individual (birth, baptism, circumcision, puberty, mamage, death)? Are these events accompanied by rituals or ceremonies of any type? What part do various family members play in theseevents? Why it'simportant An anthropologist doing a census on the Papago Reservationwas inquiring as to who was the "grandmother" in a certain family. In talking &th tihe "grandmother" the anthropologist found that the woman had no children. Yet several little boys and girls came by, and the woman would point them out as her "grkdchil&en." The anthropologist discovered that in that culture the "grandmother" could be the sister of thegrandmother inour terms. The organization of family life varies widely from culture to culture. Since the familv mav have an im~ortantinfluence on the health of individual members, knowledge of fa&ly organization can be of great use to both social service and health care workers. As the worker contacts the family in the clinic or hospital and attempts to tailor treatment plans to the situation at home;knowledge of the ways in which a family typically functionscan be invaluable. Events in the life cycle of a family member may have an important effect on physical and mental health. Infection, for example, may be caused by certainpractices duringbirth or circumcision,mental or physical difficulties at puberty aggravated or lessened by custom and ceremony accompanying this stage, and anguish during terminal illness assuaged by customary ritual. Knowledge of events accompanying the life cycle ofthe individualis important asthe worker begin& deal-kth the patient in the context of family and sociallife.

How to do it -Arrange to spend some time actually living with a "typical" family. You might do this early in your stay in the area, but if community members are somewhat apprehensive about outsiders, it may be well to wait until they are somewhat comfortablewith you and your role. While living in the family, gradually explore the areas suggested above, leaning from observationandactual participation in daily family life.

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-Make visits to a number of patients' homes, either to counsel sick family members or simply to get to know them better. While there, observe as much as possible about family life. -Participate in or observe ceremonies held to celebrate various events within the life cycle (whenoutsiders are permitted). Observe the parts various family members play within the events. If possible, talk with various people about the meaning of these events within the culture and the significance of various aspects of the ceremonies accompanying them. The Navajo, who have a very dry sense of humor, have a saying that the Navajo family, on the average, consists of the mother, the bather. two or three children, one or two grandparents, and one anthropologist. Some communitiesmay feel they have been studied too much. The worker should be sensitive & the e&ts visits and possible questioning may have, kiloringeach inquiry to the situation. A Cameroonian doctor, supervising health students during a field experience, comm.ented on the effects their contacts with community families could have: When the students visit homes to learn about the effects of the environment on health, it can Rave a reor1 effect on the lives of the people. For instance, some students have visited certain homes for a time and then find the people have left to live somewhere else. I n one case the family moved to find a better house because the student's visiting and asking questions made them very conscious o f how they were living. But another family had to kave because the landlord kicked themout. He said, "We've beenpeacefulfor years here. Now you come and suddenly there are many strangers coming and going, and it isn't good " So he made them leave. So making contact withpeople like this in their homes can have bothgoodand badeffects.

Hn the majority of cases home visits by considerate workers should have a positive effect on family life, but it is well to be alert to potential problems visits may cause. Varietyand Change What to findout

-What varying types of families are common in the comunity? W h t variety of beliefs anduractices are common within families themselves? To w-hat degree are hdcen homes, separation, or divorce of hue band and wife common in the comunity"lre trends in types of fdlies and relationships withinn&hemc%lanp;ing?

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-In what ways may the styleor type of family life and changes within it affect thementalandphysical healthof itsmembers? -In what ways may changes within the community affect the mental and physical health of family members?

Why its important A newcomer to a community and culture, fresh from studies of the "typical family" found in anthropology and sociology books, may fall into the error of assuming that all families are more or less alike and unchanging. Nothing is usually further from the truth. One Navajo health worker told of attending community meetings that a few years ago would have been dominated by "traditional" family leaders. Today a wide mixture of orientations toward the church, peyote cults, and traditionalism is common. Even within one family, he mutioned, beliefs and orientation may vary, with great effect on the actions of individual members. Cultural considerations that may be important in providing care to various family members in a particular ethnic group today may change substantially in time, as the younger family members, with experiences quite different from their elders, become older. In her study of elderly Japanese-Americans and health care utilization, for example, Fujii (1974)cautioned that in working with members of this minority group it is important to work through "cultural mechanismswhichare not static but constantly changing. . . . The (health) service responses," she suggests, "that are appropriate for the present generation of elderly Japanese will be inappropriate for those who are now middle age (Niseis)and who represent the succeeding cohort of elderly. Because the Niseis have been socialized in the United States, they will not experience the same problems (i.e, language, lack of knowledge about American social customs) which the Isseis have encountered when using health care r e sources" (pp. 168-169).I t is important when working with any cultural group to investigate what changes of this type may affect health and s e cia1service delivery over time. I t is essential, in addition, to explore to what extent the traditional structures of family life have begun to disintegrate in some areas because of the pressures of new and difficult situations. In urban and semiurban poverty areas, for example, many families, some of them recent arrivals from rural areas and other cultures, are divided and disoriented, their cohesiveness lost in the battle with new and overwhelming problems. Immigrant groups such as Italians, Irish, Mexicans, Puerto Rimns, Asians, and rural southern blacks who have moved into urban areas of the United State have often found that the move has drastically


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affected family life. One nurse in a Mexican-American poverty area spoke of the problems of singleparent homes with children left to fend for themselves: "I was calling one mother, and a little girl answered. 'How oldare you?' I asked. She said, 'I'm4.' I asked, and no oneelse was there. She said she was alone taking care of the baby. There isn't child care-so there will be accidents a t home." Other workers in the same community mentioned the problems of school dropouts, drug addiction, venereal disease of epidemic proportions, and the isolation and consequent emotional and psychosomatic difficulties of women not used to the absence of close-knit families. The physical and mental health of the individual is so closely tied to the health of family and community that the worker's awareness of where the strains and stresses lie is essential. The typical"tensionpoints" within family life may vary from culture to culture, and the worker should be aware of these variations, since an understanding of typical strains within families may help in providing adequate care. A Chinese-Americansocial worker employed in a clinic serving an eastern United States Chinese community. for example, suggested that when patients come to their mental health center, it is important to ask them whether they live with their in-laws and then to get some feeling of whether they get along or not. This is important, she said, because in the Chinese community extended f a d e s often do live together, and conflicts with in-laws often lead to development of a high number of psychosomatic complaints. Another important question in of sepathat commix&y, she suggested concerns the number of ration" because, due to harsh United States immigration laws, family members had often been separated for many and reunions oft& mean difficult adjustments that a t times lead to emotional or physical illness. Workersalsoask whether the father is theonlv sonin the familv. If so, it is likely that he developed a very dependent reiationship with his mother in earlier years, especially if he had lived alone with her in China, as many did, after his father emigrated to the United States. This close dependent relationship of "only sons" to their mothers often, this worker said, leads to marital and emotionalproblems later on. As this example of considerations important in one cultural group illustrates, an understanding of family relationships and typical strains within aparticular culture may assist the worker inunderstanding some of the reasons for the types of mental and physical illness exhibited by certain patients. How todoit -Get anideaof the typesof familieswithin the community by observing a t health facilities, in community or special group meetings, at the marketplace, a t religious functions. Walk around town and see who lives


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in various sections of the community. Look at any census materials available,and talkwith longtimeor knowledgeableresidents. -Visit a variety of homes, making an attempt to know families of many different social classes, ethnic groups, religious beliefs. Concentrate both on what seem to be the major types of families within the health program and others that are involved little or not at all, comparingdifferencesbetween these twogroups. -Talk with older family members about the changes they have seen in family life. -Talk with other community workers who may deal with problems in the homes-educators, health workers, community organizers, law enforcement agents, religious leaders-and attempt to develop an understanding of where current family problems lie and why. -Take time to talk with patients and workers of the local culture about family problems that may affect family members' mental and physical health. Explore with them, amongother things, where the typical "tension points" lie within family life in the culture in question and what types of problems these strains typically cause. Conflictsand Coalitions amongFamily Groups What to find out -Which families within the community are related by kinship, marriage, or other ties? How important are the relationships? What obligations are involved? -How important is' family membership in community life? Are families within the community arranged in any hierarchical structure? Which families (if any) are most powerful in important areas of community life suchaspolitics, religion, andeconomics? -Are there any rivalries, conflicts, or coalitions between family groups that might affect community healthwork? Why it b important Coalitions and rivalries between family groups may greatly affect attempts a t organizing for community health projects, thus making family membership an important factor to consider. But the importance of interrelationships and their meaning may vary greatly from culture to culture. One social worker, who knew the Navajo family setup well, told of a public health group's attempt to hold immunization clinics in the homes of his community. Reasoning from the stereotypes of the Anglo culture, they decided it: would be wise to hold the clinics in the homes of prominent families. But this did not work well in Navajo culture, in which the extended family, consisting of a number of nuclear families, is the unit

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that lives and works together. Another family of the same clan may be living nearby, but there is little interchange between the two, and not muchvisiting outside the extended family. The worker o b s e ~ e d"They : picked a lady's family near where we live. Well, the lady.. .is feuding with her neighbors.. .over grazing rights, as she's taken over their cornfield. (The health group]was going to have the shots a t her place. . . .after it was over, I asked them, 'How did it work?' They said, 'Well, not verymany people showedup."' He didn't think it made sense to have it that way. If the group had asked community workers from the area to identify the extended family groups and then worked through their leaders to hold the clinics for the family groups only, it would have been a natural thing and most likely a successfulventure. How to do it with knowledgeable family members, who have learned to know and trust you, about family obligations, interrelationships, and rivalries. When actual community health projects are attempted, ask family leaders themselves for advice on "how to do it." -Attend community meetings and observe roles played by various families, as well as any tensions, rivalries, or coalitions that may be e d dent.

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Decision Making What to findout -How and by whom are f d y decisions within the cultwe t y p i d y made? -Who generally makes various health-related decisions within the f f d l y(i.e.,what to do when a member is sick, whether to take certain preventive measures, what the family will eat, what money can be alb t b d fforhealth-related expenses, whether a sick member m y follow certain medical advice)?Do children ever make health-related decisions? --How will howledge of the family decision-making process affect the worker's decisions concerning which f a d y members should be the focus for instmctions and advice? Why it's impo~tant ]If hedth and social servicepersomeP do not have suff-

ficient knowledge of the typical authority and decision-making stmctunre within a family, they m y direct iwstmctions, health education advice, anad other efforts a t persuasion toward the wrong family member. It may be diffficnnt, at times, to debemninejust where the real power with-

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in a family lies, but an exploration of cultural differences in who typically makes decisionscan a t least help the worker avoid making the most obvious errors when approaching a family for a decision. Many workers, for example, have emphasized the importance of understanding the traditional ~ e x i c a n - ~ m e r i c woman's an subservience to her husband. One Anglodoctor told of his frustration:


The mother can bring the baby in, and you'll say, "This child is sick and needs togo into the hospitaL "Many of thelMezican-American] mothers will say, "We&Idon 'tknow...." You'll say, "Well look, there's no argument about it. You have no option The child is so sick I cannot treat him at home." Their reaction is, "Well, 1'11 have to ask my husband [firstl. " The husband may be out somewhere in the fields, and you can't get hoM of him until night, orhemay beaway forthe week.

Reactionsto knowledgeof this decision-making process differ. That of the Anglo doctor was to change it: "That really presents a very commonrecurringproblemof getting these mothers so they'll make the decision without hassling the husband." Some of the Mexican-American workers had an approach bordering more on acceptance of the typical decision-making p k e s s within theu culture. One worker observed: "Someone who has been in the culture will understand [the position of the wife]and not ask the women, 'Well, why can't you make this decision?' You'll say, 'Well, OK, that's fine, I'll call your husband and talk to him.' You'll agree with her because there's nothing she can actually do tochange the situation." A physician working with black families coming from inner-cityenvironments in the United States suggested that within that setting the woman may often be the dominant member of the family, since the father often comes and goes. As this health professional suggested, "broken-home" situations are common among many ethnic groups in lower economic classes, and in cases in which the mother may have children by several different men, the woman may be the important person with whom to deal. The most a m r o-~ r i a t decision e maker for the worker to relate to may vary, depending on special circumstances influencing the specifichealth care decision involved. A Peace Corns volunteer working in a West AfriA n v i a & , for &le. told of crisis that developed after many months of health work in the community. When an old woman who was obviously in critical condition could not go to the hospital because her husband forbade it. the volunteer searched for someone who might - have the power to persuade the old man to reconsider his position and found that in the particular circumstances involved, the couple's son was an appropriate choice:

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A woman motioned to me to follow her. We wound in between the huts and suddenly found an OM woman writhing inpain on the mat at thedoor ofher home. She showed me her stomach, swollen way out ofpmportion with an infection of some sort. She pleaded that she wanted to go to the hospital, but her husband, who soon arrived, forbade it. We debated and discussed for many minutes, finally learning that the husband would give permission if his son, the secretary o f the party in the village, would give assent I knew the son would be favorable to a trip to the hospitat as he had recently returned from a good experience there himself. So we sent for the son in the fields. He came and spoke, and his fatheraccepted his advice thathis mother bedlowed togo.

In this case the traditional decision maker (the father) deferred to his son, who was important in the new political system and knew more of the "ways of the whites." A search for a Wendy decision maker may not always end as successfully as the volunteer's, but clarification of who holds the real power in particular circumstances can a t least ensure that attempts a t p~rsuasiox&e aimed a t the right party. In some cultures even small children can make medical decisions. An Anglo worker on the Navajo Reservation tells of this "prob8em": One of your dificulties with the older generation is that sometimes you go in and ask for a small child to have surgery, and they'll say, "No, he doesn't want to go. " A s soon as a child is able to talk, he's an i n d i v d u d The older folks feel that at thatpoint he is an individual and should make up his own mind-and i f he doesn't want to go in and have his tonsils out, that is his decision I t caused a lot ofproblems with our people. We couldn't understand why a3-yea~oldchildwas even consulted

In some societiesan important decision maker in the f a d y m y typicaUv - -~ l "a av articular role in relation to the health or social serviceworker. In clinks serving Chinese populations in the U d e d States, %orexample, e patient may come in with a f a d y "translatm" who is, in reality, his "spokesman." American practitioners who don't understand this f d v member's role m v often direct d their conversation to the patient, virtually ignoring the spokesman, who is often e very powerful gersonwithin the familv a e t u ~The . worker who can bedn to unmdem&annd i a t k w s of relationships sack as these will become m k h more competent indealingwith the patient in the context of his f d y . Wnaowledge of the typical style and speed of decision m a b g is important if the worker is t .workprducMvely ~ with f a d y goups. A docetoah the Zuni area observed: "You h o w , we wmt kt get things done h e & ably-this is the A r n e way. ~ ~ The Indlian people prefer to &scuse, nooh at, it, think about it. And a dwieiom t h t we would make in k m t h n a week may take them 5 months tomake. This wuses p~~bh~lms." Another worker ha s h d a r a m emphshed the hporhmce off patieme: "Iff

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they don't want to give you an answer, you can always count on a 'no' if you push for it." How to do it -When giving advice or instructions to patients, explore with them whether they can follow the advice on their own or need the consent of another family member or other outside person. Explore how this consent can best be obtained and whether it involves action on your part in any way. -When giving health education lessons or social service counseling, ask thegroup what their families would doif they went homeand tried to follow your advice on various subjects. Note who seems to make decisions related to these matters and problems your clients may face if they try to make changes alone. -When doing fieldwork that involves asking the family for a decision, sit back and listen. While there, observe as much as possible how the decision is made, who is consulted, who (if anyone) seems to have final authority. As you begin to gather ideas on "where the family power lies," keep in mind that the structure of decisionmaking may vary from family to family and problem to problem and may be in a state of flux as the culture gradually changes.

ROLES DURING HEALTH CARE Family Status and Health Care What to findout -What status and value do various members have within the family? How might this affect their health? The care they receive? How likely they are tocome for treatment? -Is there a typical order in which various family members seem to receive health care? What may account for underutilization of health care by various family members? Why it's important The value placed on various family members can greatly affect the health of these individuals and the care they receive. The attitude toward children in various cultures is a case in point. Within certain cultures the child may be the center of attention. A Cameroonian health official suggested that within his tribe if workers make d e mands on a family "for the sake of the child." they would have more success than if they emphasized the well-beingof any other family member.

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But an American nurse in southern Africa felt that this was not the case where she worked.


You really think they should do something for the child, but they don't always think that way. A small child does not have as much status in the family. The older they get, the more valuable they are because they can work and care for cattle.. . . Children are often fed last, and you can sense their attitude toward a small baby. They are not always willing to invest in this little thing. I think they think they can always have another if one dies and accept that they willloseacertain numberofbabies.

The order in which family members receive care may be greatly a%tected by their status and role within the family. Workers in Chicano clinics, for example, complained that the Mexican-Americanadult male was often the last in his family tsreceive care and cited a number of possible reasons related to status and role. One worker observed that "it's very difficult in the Mexican culture for the men to come in. . . . They fed it's a definite insult, an affront htheir masculinity to Rave to $uccusn$ to 'interference' from someone outside." Another worker stated: "When we get our males, they're redly sick. They haven't been sick for 1or 2 days either. It they aren't redly ill,they won't come in because they feel they can't afford it. Most hold downjobs where they can't afford to miss -as they don't havebenefits a lot of the Anglos do, Pike sick lave." These workers were worrie4 because in their areas the ffather is the key his illness is not treated, it cmM be to economic stability of the family. 1% catastrophic for the entire badly. IIn identifying the reasons for the father's reluctance to come for m e they had made tan impoutcanat finst step in a process that might evemtudy Pad tm a t Beast a partial sonution to the probBem. How to do it -Observe relationships among ffmdy ~membeussand their possibh efffects om h d t h and h d t h care dwing both honnne visits and contacts withthe ffamilywithin the healthme facilitiesthemselves. -Explore the questions above indepth with several good dwPonmmts from the cultwe. Possibly s m c h ffoutheir o p ~ o m of w h t might h a p pen in hypothetical situations. Ask, ffon exanmph: 'W the nnnotheu, father9 sand child iir a certain ffmdy were equdUy sick and mediche were a v d a b b for only one off them, whowoddmceive it mdwhy?" -Observe which ffsamily members seem to receive w e most and Ileast offten within t b health ffacility, md begin to explore with the patients &hemsshesthe reasons ffou these &ff ff wemces.

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Illness a t Home What to findout -Within various families in the community, how important is health compared to other needs and values? -How much a family matter is illness? What is the usual attitude of a family toward a member who is sick? -What types of actions do various families take when a member becomes ill? Are families or particular family members involved in the p r e vention, diagnosis, or treatment of certain illnesses of other family members? Are there any special family medicines,remedies, treatments? -Do family health beliefs and practices clash with the teachings and practices of the healthprogram? If so, shouldanything bedone? -Can the health program and its social service program better adapt its policies to take acccount of the roles family members may wish to play when a sick family member remains a t home? Better utilize the resources and support of the family for the benefit of the patient? Why it's important

The care sick family members receive a t home may affect their health much more than any treatment received through a formal health care facility. Thus both social service and health care workers should be aware of the values various families place on health and the roles family members play when one of their group is ill. Only with a knowledge of what is happenng a t home can the worker most effectively treat thepatient in thefacility. The worker may be able to encourage families to contribute in ways that willcomplement the health facility'sefforts. In theNavajo area, for example, one social worker suggested asking the extended family for helpin treatment, since this iaa role they traditionally play: "You would begin to touch a social consciousness that is very much a part of the culture-their sense of responsibility to other extended family members. And by doing this you've mobilized a social unit that that culture has set up to solve the kinds of problems that thepersonwhocame to you had." The degree to which the extended family plays a part in caring for a family member who is ill varies for noncultural as well as cultural reasons. A hospital worker in Boston observed, for example, that there was a difference between the degree to which black and Jewish families she dealt with were able to offer support to elderly patients who were under her care. She had found that often the children of her elderly Jewish patients lived out in the suburbs somewhere, were often working fulltime in professional occupations, and did not seem to be able to come in

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easily and help care for their parents. The children of the elderly black patients she served, on the other hand, often lived close by in the urban center, might not be working, were often at home, and generally seemed more available to care for their kin. She felt that probably both economic position and geography influenced the varying responses of these families. In some cases the worker may find that certain family actions are detrimental to the health of the patient. One British doctor practicing in southern California commented on this difficulty with some of his MexiTheirs is a much more family-oriented society. You can spendhalfan hourgiving the motheradviceaboutfeeding of the baby, and she'll go back into her family setting and the advice that she willget will be their timehonored concepts, and these will be drummed into her in much of a repetitive fashion, and if she doesn'tdo their way rather than my way she wiU be criticized What I say to American mothers goes in one ear, and most of it comes out the other. What I say to Mexican mothers goes in one ear, and a lot ofit is knocked out theother by grandparents.

A worker in a clinic serving Italian-American clients in an eastern United States city spokeof similar difficulties: What happens is that the girls come in, and they 'rejust exb u s t e d from all the things they 're being told by their families. Italian families are stillpretty close-knit, so they may be living in the same house with at least one set ofparents, and they 'llget a tremendous amount ofinput. When the doctor implies that certain things they have been told aren't so or suggests they makeparticuhrchanges, they 'Usay, "But my mother says, or my mothepin-law says.. . "They may try to follow thephysician's suggestions, but when they ret u n home, their families get upset and say, "But that's not how it was for mel" They really do haveadifficult time.

Workers should become aware of conflicts such as these and determine w h t effects such conflicts may have on treatments prescribed. If the conflicts seem likely to threaten critically the patient's well-being, the workers may begin to explore how they might influence important members of the patient's family in the directiondesired.

How t o do it -Question the patients themselves concerning the attitudes of various f d y members toward one who is ill, the roles family members -play. in diagn&is, treatment, care of the ill, and thelike. -When making a "house call" or home visit because someone in the family is ill, notice other family members and how they relate to the one

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who is sick. Also observe whether others in the family have conditions you feel might need professional care, and explore the family's attitudes toward seeking treatment for this person and what, if anything, they have done for him or her a t home. -If through questioning it is found that certain family members commonly diagnose or treat certainillnesses, seek out several of these people and try tolearn from them what they do. If questioning about health practices a t home is begun too early in relationships with patients, they may see you as a possibly critical repre sentative of the formal health system and resist any confidences that divulge things of which they feel you might disapprove. Move slowly after you feel the trust is there. When visiting possible informants on family treatment, consider taking along a "go-betweenM-someone who trusts and understands your purpose and is also known and trusted by the possible informant-tomake the introduction. If the circumstanceis one in which you sense that a quick entry into the questions you have come to ask would cause resentment or mistrust, it may be wise to spend the first few minutes, or even visits, purely socializing. Begin your questioningonly when theinformant begins to know and trust you. TimingofHome Visits What to findout -What aspects of family life and custom might influence the type and timing of home visits? Why i t ' s important "It's bad if the timing is wrong," one Mexican-American community health worker observed in speaking of home visits, and went on tocomment: You may have come at a time when they are in the midst of something. Some people are very polite, but you can tell you're imposing on them. The Mexiccmpeopk, especially, are not rude, but they may be acting one way because they are gracious but feeling some hostility and resentment because you've comeatan inopportune time. So you huve to really kindofdevelopa senseofbeingawareof this. Zfyou're accustomed togoing out in the homes, you develop this, but if you've nevergone out into a home, you may go in like a bullin a china closet.

An American health educator in Ivory Coast, West Africa, spoke of factors influencinghome visits she found important there:

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SOCIAL WORK IN H E A L T H CARE

The cycle of fanning-planting, weeding, harvestingdmstically influenced whut visiting wecoulddo. During thedry season, after the cmps were harvested, we could easily visit in the homes during most of the day. When the miny season came, a few lonely dayspokingaround a muddy, deserted village where only a few older people, young children, and stmy animals remained convinced us we'd have to chunge our tactics. W e spent a lot o f time out weeding with the women on the farms aradaroundcourtyardcookingfires lateat night,


How todoit

-A sensitivity to the type and timing of home visits that will fit best within the culture will come asyou begin to develop an understanding of what family life involves and learn from family reactions to visits at varying times. -A sense of the "typically" inopportune times-early morning hours in ta welfare community where people get up late, during a "sing" or other traditional ceremony for the family member who is ill, the times of day when the family is usually involved in meal preparation and consumption-will gradually develop. But many untypical situations will also arise, and then you can only rely on an ability gradually developed to read the signs of uneasiness or resentment members of a particular culture give whenvisitors are not wanted. HealthFacility Visits

What to fi n d o u t -When a family member goes for diagnosis andlor treatment a t a health facility, what roles do family members usually wish to play in the process? Can the health program better adapt its policies to take a c count of thepartthe family wishes toplay during thesevisits? Why i t ' s i m p o r t a n t Health care and social service workers who understand the part families may wish toplay in visits for diagnosis or treatment can often do much to adapt the program in a way to make both patients and their kinrnuchmore at ease. Chicano staff in a small barrio c h i c told d the comfortable and "homey" atmosphere of their waiting room, where mothers were made to feel a t ease in bringing all their children, in contrast with other more "Anglicized" settings: Most of the Chicano women have a tendency to carry their kids wherever they go. It's known that's common for Chicanos. I know myself1

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used to take my kids everywhere with me. I guess some of the nurses /in the Anglo clinic1 didn't like all these kids running around-here we don't mind it. They'd ask them to leave the children at home. Same with the welfare department. They'd put at the bottom, "Please don't bring your children with you," and it makes it bad 'Cur what happens ifyou don'thave a baby-sitter?


In another Chicano clinic, staff told of the Mexican tradition that a young woman, even after marriage, be accompanied to the gynecologist by her mother, sister, or possibly husband: "This is a social custom, a thing that women don't go to the doctor alone." Women and their families were more comfortable in clinics that easily accommodated to this custom. H o w to d o it -Observe the roles family members attempt to play in health facility visits. Be alert to tensions and misunderstandings that seem to develop regularly, and begin to search for their causes. -Question patients and family members themselves concerning adaptations they would like to see within the program. Hospitalization W h a t to findout -What effect will the hospitalizationof various family members have on those who are left at home? -When a family member is hospitalized, what roles do family and kin wish toplay during that period? Can the health program better adapt its policies to take account of their wishes? -What are the expectations of various families concerning medical treatment? Where beliefs and practices of the family vary from that of the health facility, will family members attempt to make changes in the care prescribed? If so, should anything be done about it?

Whyit's important The effect that hospitalization may have on the rernainingmembersof a family depends, of muse, on the role the sick family member usually plays within the home. A hospital worker in the Boston area observed, for example, that the effect of the absence of the elderly Jewish wife because of illness was different than the effect of the absence of the husband: We've found that elderly Jewish women have tended to pamper their husbands, taken care of them, so that i f an elderly Jewish woman

1%



gets sick and her husband's left alone, that's usually more of a p m b k m than if the husband gets sick. I f the husband fis hospitalized or] dies first, usually the wife is at least capabk o f maintaining the household and she's not likely to fall apart.. ..B u t we've found that i f an elderly womangets sick, is hospitalized, or dies first, the man feels more helpless.. .andmuch more dependent.

Problems in the home may be even more difficult if those family members left a t home are children too young to care for themselves,unless m extended family group is there to @arefor the remaining members. If the worker is concerned with the health of the family as a whole, the effect of hospitalizationon thoseleft at homeis animportant consideration. When a person is hospitalized, the part the family may wish to play during that period can vary drastically from d t w e to culture. One doctor who had worked with both Zuniand Navajo patients spoke of the apparent differenceinfamily concernin the twocultures: The Zuni react very much as we would expect. They Rave a child who is ikh Theparents are concerned, thegmndparents are concerned They want to be there. . . . The Navajo can bring in a child who is just as ill, perhaps more ill-critically ilh YOUknow, it's n question of whether he'll live or die. There is no apparent concera They bring the child i n He's going to stay here. "How long is hegoing to be here?" Thnt's the first question they ask. And they want a definite arsswer-5 days, 10 days, 20 dnys. And then they leave. And they may not show up until the lOdays you told themlareoved

He went on to explain that the concern may still be there, dthough manifested differently, but his illustration points up red differences among cultures in the amount of family involvement with a patientdifferences staff should take into account when planning for visits, gatient w e , and so forth. A worker in Cameroon spoke of tRe necessity in African hospitals of permitting the mother to stay with thechild: I n Ppancophcne Africa the mothers must stay in the hospitalwith their infants. I t is necessary, for one thing, because the African child is much more attached to his mother. You can't brutally tear the infant from his mother because children are carried on the back, nursed at the breast so long that to cut offthechild from his mother would be to make him much sicker than he is. And, in addition, the hospitals are often so poorly staffed that it is necessary for the mother to be there eo take care of herchild

A hospital administrator in the Zuni area spoke of adaptations to the needs of parents and children that included a policy of encouraging "rooming-in" of newborns with the mother, urgiig to stay with sick children when they wished, and dowing children to visit their hos-


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pitalized parents at a younger age than usually permitted, when public health standards would allow. Informants in several cultures spoke of the needs of adult patients, as well, to have family and friends close by, citing a variety of reasons. In some cases it is the emotional or psychologicalsupport provided in cultures where family ties are strong. In others. practical considerations, such as family care and feeding of the patientwhen hospital personnel and supplies are scarce, are foremost. In one African culture a worker suggested that family and friends must allvisit because to stay away is to indicate they may have caused the patient to get sick and thus open themselves to accusations of witchcraft afterward. These workers spoke of a variety of adaptations to family custom that they found useful within their own programs. A Papago nurse told of the flexibility of visiting hours needed when relatives may come to visit from great distances on the reservation and a thoughtless "come back tomorrow" means great hardship. Workers in both the Papago and several West African cultures spoke of the efforts of hospitals to provide overnight facilities for close family members, but also of the difficulties that sometimes arose because of lack of space and resources. In some cultures the family does not require much, since those who stay can sleep on the floor with their own mats and cook from their own supplies on a fire outside. But adaptations may require relaxation of certain cherished public health notions on the part of some Western personnel so that a balance, taking into account both the physical andemotional needs of thepatients, can bereached. Althoughvisitingrelatives, for the most part, play a very positive role in the recovery of the patient, they may have some negative effects on the patient's care. One West African doctor observed that, a t times, a relative from the village caring for the patient may have differing ideas or beliefs than the doctor and change the medication or care prescribed to fit his or her own notions of the proper treatment. The worker who is aware of such practices can begin to investigate which changes may be beneficial and which detrimental and plan any health education that may benecessary.

How

to do it

-In the hospital setting observe who accompanies andlor visits the patient. Find out who the visitors and com~anionsare. what roles thev play, and how long they plan to stay. -Ask the patients and visitors themselves what would be the most convenient visiting hours, arrangements for persons staying with the patient, and other possible adjustments of the clinic or hospital system to the needs of the family.

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-Explore with patients and relatives their views of the treatment prescribed and any changes they would like to make. Inquire among local health personnel concerning changes in treatment made by patients and relatives that they m y be aware of. Explore whether the changes are harmful or beneficial, and develop tactics to provide any education


REFERENCES Clark, M. Health in the Mexican-American culture. Berkeley: University of California Press. 1959. Foster, G. M. Tnaditional societies and technologicalchange (2nded.). New York: Harper &Row. 1973. Fujii. S. M. An exploratory-descriptive study of socio-cultural "barriers" to health services utilization forelderly JapaneseAmen'cans (Dissertationpresented to the faculty of the Florence Heller Graduate School for Advanced Studies in Social Welfare). Waltham, Mass.: Brandeis University. 1974.

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