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VII: ~ 9. . 3.1.50.1)..9.‘ . . .. u .n’hiifighr all... iéfi . u 1.. 3.9.2.... in; , :Ummwav 7. Mi .. ‘ . u. ‘ii 2 B§3§u¥hfig Ix§.3>wvr37‘.£vs 721i! n.5711v1.§1lr?fhlxl.££ 7 LZC 3)):Ilvrfr’wk.‘ . ZLIIIIDS. . 2.)..532212 553.“)? L. 1‘5. .3... ll/ll/l/l/ll/Ill/I/l/l/I/l/I/I/lll/lll/I/llI/II/Illll / 3 1293 10437 5385 This is to certify that the thesis entitled ‘IETARY SELF—TREATMENT PRACTICES AND ATTITUDES AMONG A GROUP OF MICHIGAN FINNISH-AMERICANS presented by Mary Anne Burke has been accepted towards fulfillment of the requirements for M.S Human Nutrition ' degree in C) jor rofessor Date /2(2/z :2 0-7639 MS U is an Affirmative Action/Equal Opportunity Institution RETURNING MATERIALS: MSU Fiace inhib'oolihargp tof remove t s c ec out mm w your record. FINES W111 be charged if book is returned after the date stamped be'low. PF! DIETARY SELF—TREATMENT PRACTICES AND ATTITUDES AMONG A GROUP OF MICHIGAN FINNISH—AMERICANS By Mary Anne Burke A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Food Science and Human Nutrition 1982 é/a9057i ABSTRACT DIETARY SELF-TREATMENT PRACTICES AND ATTITUDES AMONG A GROUP OF MICHIGAN FINNISH—AMERICANS By Mary Anne Burke Selected demographic and dietary self—treatment data were collect— ed from a non—random sample of 30 elderly, first— and second—generation Finnish—Americans in Michigan's Keweenaw Peninsula. Proper diet was the health maintenance practice most frequently mentioned by the sample. Reported dietary practices involved traditional and modern food usage for health maintenance and certain acute and chronic conditions. Viilia was currently used by 72% of the sample for health maintenance. Treatment for acute ailments included old family remedies. Non— traditional practices included vitamin and herbal remedies. Seventy— seven percent of the sample reported using vitamin/mineral supplements for health maintenance with 57% mentioning vitamin C. Modern arthritis remedies, reported by 83% of the sample, most commonly involved aloe vera juice and vitamin C. Thirty percent of the sample mentioned using harmless herbal remedies and diet modifications to treat hyper— tension. The sample indicated a positive attitude toward self—treatment for less serious health problems. To my loved ones ii ACKNOWLEDGEMENTS The author wishes to acknowledge the following individuals and institutions for the many contributions they have made to this research project: Carolyn Lackey, for being a delightful major professor and for pro- viding expert guidance and continuous encouragement for the successful completion of this research project. Kathryn Kolasa, for her valuable assistance as guidance committee member during the planning, implementation, and analysis phases of this project. Ann Millard and Shirley Johnson, for the perspectives each brought to the guidance committee and for the thoughtful contributions each made toward the completion of this project. The Department of Food Science and Human Nutrition, for its financial contribution to this research project. The residents of the Keweenaw Peninsula, for so generously opening their community and their homes to the author. Without their friendly encouragement, advice, and participation, this research project simply could not have been done. Lillian Richards and Dennis and Dorothy Sotala, for their stead- fast friendship during my stay in the Keweenaw Peninsula. All my loved ones, whose love, support, and interest in this project helped to insure its successful completion. iii TABLE OF CONTENTS Page LIST OF TABLES . . . . . . . . . . v LIST OF FIGURES . . . . . . . . . . vii INTRODUCTION . . . . . . . . . . 1 REVIEW OP THE LITERATURE . ' . . . . . . . 3 METHODS . . . . . . . . . . . 9 THE RESEARCH SITE . . . . . . . . . 16 RESULTS AND DISCUSSION . . . . . . . . 25 FIELD METHODS . . . . . . . . . 25 DEMOGRAPHIC DATA . . . . . . . . . 31 DIETARY PREVENTIVE HEALTH BEHAVIOR , , , , , 43 DIETARY SELF—TREATMENT OF ILLNESS . . _ , , 64 SELF—CARE ATTITUDES . . . . . . . . 85 SUMMARY . . . . . . . . . . . 90 CONCLUSION . . . . . . . . . . . 95 APPENDICES APPENDIX A. CONSENT FORM . . . . . . . 100 APPENDIX B. INTERVIEW SCHEDULE . . . . . . 101 LIST OF REFERENCES . . . . . . . . . 115 iv Table Table Table Table Table Table Table Table Table Table 10 LIST OF TABLES Selected demographic data for Finnish-American sample population, Keweenaw Peninsula, Michigan (N=30) Number of children per family reported by Finnish- American sample population, Keweenaw Peninsula, Michigan, for themselves and their parents (N=30) Language spoken in the home currently and during childhood reported by Finnish—American sample population, Keweenaw Peninsula, Michigan (N=30) Annual income per household reported by Finnish— American sample population, Keweenaw Peninsula, Michigan (N=20) Frequency of doctor visits over time, reported by Finnish—American sample population, Keweenaw Peninsula, Michigan (N=30) General preventive health behaviors reported by Finnish—American sample population, Keweenaw Peninsula, Michigan (N=30) Categories of healthful food and their components reported by Finnish—American sample population, Keweenaw Peninsula, Michigan as used during child— hood (N=29) Categories of healthful food currently used, as reported by Finnish—American sample population, Keweenaw Peninsula, Michigan (N=30) Components of Vitamin/Mineral Supplement group currently used, reported by Finnish—American sample population, Keweenaw Peninsula, Mich. (N=30) Components of Dairy, Fruit/Juice and Vegetable categories currently used, reported by Finnish— American sample, Keweenaw Peninsula, Michigan (N=30) Page 32 35 37 39 4O 44 48 51 52 54 Table Table Table Table Table Table Table Table Table Table ll 12 13 14 15 l6 l7 l8 19 20 Components of Bread/Cereal, Meat/Vegetable, Food Items Avoided, and Meat/Fish categories currently used, reported by Finnish-American sample, Keweenaw Peninsula, Michigan (N=30) Comparison of past and current healthful food categories reported by Finnish—American sample population, Keweenaw Peninsula, Michigan Benefits for components of Vitamin/Mineral Supple- ment group reported by Finnish—American sample population, Keweenaw Peninsula, Mich (N=23) Ailments and conditions for which self—treatment practices were reported by Finnish—American sample population, Keweenaw Peninsula, Michigan (N=30) Response distribution of food-related remedies for colds and fevers, reported by Finnish—American sample population, Keweenaw Peninsula, MI (N=30) Response distribution of food—related remedies for diarrhea, reported by Finnish—American sample population, Keweenaw Peninsula, Michigan (N=30) Response distribution of food—related remedies for constipation, reported by Finnish—American sample population, Keweenaw Peninsula, Michigan (N=30) Response distribution of food—related remedies for upset stomach, reported by Finnish-American sample population, Keweenaw Peninsula, Michigan (N=30) Response distribution of current food-related practices reported for arthritis by Finnish- American sample, Keweenaw Peninsula, Michigan (N=30) Response distribution for Self—Care Attitude Instrument, ranked in order of agreement with items, as reported by Finnish—American sample population, Keweenaw Peninsula, Michigan (N=30) vi Page 55 57 59 65 67 71 72 74 77 86 Figure 1 Figure 2 Figure 3 LIST OF FIGURES Map of Michigan. Darkened area is Keweenaw Peninsula research site. Map of Finland. Most Finnish immigrants in the Keweenaw Peninsula, Michigan, research site were from the provinces of Vaasa and Oulu, shown in bold outline. Adapted from Hoglund (1960:22). Flow chart showing number of referral chains initially established for subject selection and number of respondents, including pretest popula— tion, which each referral chain contributed to total sample population of 30 Finnish—Americans, Keweenaw Peninsula, Michigan. vii Page l7 19 27 INTRODUCTION Self-treatment practices involving food are widespread among ethnic subcultures in the United States, but they differ from group to group (Band, 1976: Hill, 1973: Everett, 1971). The Finnish—Americans repre— sent an ethnic group whose traditional food—related self—treatment practices have been described anecdotally (Lunden, 1979: Vachon, 1973). Kleinman (1980) and Bradshaw (1977) have noted that the prevalence of home self—treatment remains relatively constant over time, even though some practices modify or change. For example, it has been suggested that 70 to 90 percent of all illness occurrences in the United States are self—treated exclusively within the home (Hulka et al., 1972: Zola, 1972, 1973). Thus, it is likely that Finnish—Americans con— tinue to use food for health maintenance and in treatment of illness currently. In addition, since acculturation is an inevitable process, it is reasonable to expect that this group's current health beliefs and behaviors involving food include a mixture of ethnically traditional and "American" practices (Kolasa, 1978). Knowledge of an ethnic group's current self—treatment practices is an important part of a community's nutrition assessment. Once practices are known,health and education interventions can be developed which emphasize positive, overlook neutral, and minimize or change negative practices in a culturally sensitive way. Thus, this study was designed to document the current practices and beliefs regarding the preventive and therapeutic uses of food within a specific Finnish—American population in Michigan's Upper Peninsula. The primary objective of the study was to determine food—related practices for health maintenance and for self—treatment of selected ailments and conditions. Secondary objectives were to describe food-related self— treatment practices that have changed over time and current attitudes toward self-care. REVIEW OF THE LITERATURE A number of comparative studies concerning the health beliefs and practices of different ethnic subcultures within the United States have been reported in the past decade (Bullough and Bullough, 1972: Spicer, 1977). These researchers and others, such as Bauwens (1977) and Snow (1974), have shown that ethnic subcultures differ both in their concep— tion of well—bing and in their health maintenance practices. Similarly, American ethnic groups such as low—income blacks, southern whites, Puerto Ricans, and Mexican—Americans, among others, were likely to arrive for professional health—care after self—treating or "doctoring" themselves first (Snow, 1974: Bauwens, 1977). The terms self—treatment and self—care are used interchangeably in this paper to mean the various ways in which individuals and families take care of themselves, usually in the home, during illness and in health. Because self—treatment usually takes place at home, health—care professionals are most often unaware of the extent to which it occurs (Bradshaw, 1977: Bauwens, 1977: Kleinman, 1980). Hulka et a1. (1972) and Zola (1972, 1973) suggested that 70 to 90 percent of illness occur— rences in the United States are managed exclusively at home, usually without the involvement of health—care professionals. Low—income whites in the American southwest commonly treated themselves with food (Bauwens, 1977). For example, they treated coughs with honey and lemon, or with an onion boiled in sugar and salt: they treated colds by drinking horseradish tea or by taking large doses of vitamins: and they stimulated laxation by eating stewed rhubarb. Certain conditions appear to be commonly treated at home cross- culturally. They are generally minor and self—limiting problems less addressed by professional medicine (Harwood, 1981). Both Harwood (1981) and Bauwens (1977) noted similar common symptoms and conditions that were routinely self-treated. Among them were digestive problems, cold symptoms, sinus trouble, minor upper respiratory infections, arthritis, occasional headaches, trivial burns and cuts, and muscular aches. Although much of the literature focused on the illnesses that are self-treated, Kleinman (1980) emphasized that most of the lay sector is not preoccupied with sickness and its care but rather with health main— tenance. For example, in the Chinese culture Kleinman (1975) studied in Taiwan and among low-income whites in the American southwest (Bauwens, 1977), health maintenance was viewed as a process that must be worked at continuously,taking more of a family's time and energy than sickness beliefs and practices. The Finnish-American Example The Finnish-Americans of Michigan's Upper Peninsula provide an example of an ethnic group whose beliefs and practices involving food and health have not been formally assessed. The purpose of this section is to describe their immigration history as well as some traditional health beliefs and food—related self—treatment practices. Finnish immigration into Michigan's Upper Peninsula peaked in the early 1900's (Hoglund, 1960; Jalkanen, 1969). The Finnish immigrants were largely from the rural uneducated classes of western Finland, and many returned to farming in this country (Nelson, 1975). Because of their relatively recent arrival and resumption of semi-agricultural lifestyles, the acculturation process moved rather slowly. Thus, many customs and traits persisted intact, at least among the first generation Finnish—Americans (Armstrong, 1976). Anecdotal reports indicated that traditional health beliefs and practices persisted among Finnish—American immigrants (Lunden, 1979; Vachon, 1973). The "sauna", which is a small building or room heated up to as much as 200 degrees Fahrenheit to promote sweating, has an ancient history among the Finnish and was a cultural focus of strongly held beliefs about health among immigrants (Armstrong, 1976). Besides keeping one clean, the sauna was reported to have beneficial psychological effects (Viherjuuri, 1965). Other traditional uses of the sauna were carried from the 01d COuntry to the new. It was the gathering place for family and friends and served the purpose of stabilizing social networks (Viherjuuri, 1965). In addition, the sauna was a place for healing the sick, giving birth, and preparing the dead (Armstrong, 1976). The cultural attribute of "sisu" also influenced health-related behavior and attitudes. An individual who persevered through an illness stolidly and without complaint demonstrated "sisu" (Lunden, 1979). This kind of endurance was a highly—valued characteristic among Finnish immigrants (Viherjuuri, 1965). Resourcefulness and self-sufficiency were often required of the early immigrant homsteaders. Family members often assumed roles as "bonesetters", midwives, and eye specialists (Lunden, 1979). Minor ailments were treated with resources and food items at hand. Headaches were treated by placing a row of raw potato slices across the forehead, covered by a folded towel. Boils and infections were brought to a head by a poultice of masticated rye bread and bandaged with a clean fragment of dish towel. Thick cream was used to soothe chapped legs, and for any undiagnosed ailment, homemade wild raspberry sauce was administered (Lunden, 1979). Traditional Finnish Diet and Eating Pattern Because ethnic subcultures retain at least some ethnically tradi— tional food practices and beliefs as acculturation proceeds (Kolasa, 1978), it is appropriate to describe the traditional Finnish diet and eating pattern. Most Finnish—American in the northern United States emigrated from rural, western Finland (Hoglund, 1960). The traditional diet of that region was dependent primarily on dairy products, grains, and potatoes (Pelto et al., 1981), with salt fish and meat holding posi— tions of lesser but consistent importance (Kolehmainen, 1968). The core grains of the traditional diet were rye, barley, and oats. The core dairy products consisted of fluid milk, cheese, fermented milk, and butter. Sugar, salt, coffee, rice for desserts, and a few spices had to be purchased (Pelto et al., 1981). The recent work of Pelto et a1. (1981), concerning modern and traditional food use in western Finland, characterized the traditional diet as high—protein and high calorie, with few fruits and leafy vegetables. The researchers also noted that by World War II the Finnish considered sugar, coffee, and Finnish coffee bread (pullaa) as part of the traditional diet. Modern additions to their dietary pattern were commercially prepared sausage and a great variety of fruits and vege— tables. The traditional meal pattern in rural Finland among the tenant farmers was to eat three "Square" meals a day, one upon rising early in the morning, with the noon and evening meal being of equal importance. In addition, from the turn of the century onward, coffee and coffee bread were served at mid—morning and mid—afternoon, although a pot of warm coffee was usually available throughout the day (Ojakangas, 1964). The elements of the traditional Finnish diet were easily transferred to the new environment by the Finnish immigrants, many of whom chose to settle in environments and adopt lifestyles similar to the agrarian life left behind in western Finland (Nelson, 1975). Both Lunden (1979) and Kolehmainen (1968) noted widespread reliance on traditional foods and meal patterns among the Finnish immigrants in Michigan and Minnesota, especially among those who resumed the agricultural lifestyle typical of rural Finland. Some Implications of Self-Treatment Health—care professionals in the United States are noting a wide- spread activity in home health—maintenance and self—management of illness (Harwood, 1981). One concern for health professionals is that patient compliance with standard medical regimens may be compromised. For example, those individuals who have developed confidence in their ability to treat themselves are more likely to disregard the advice of health professionals (Bauwens, 1977). In addition, patients generally do not tell physicians the components of their self-care, because they are aware that modern medicine often discredits the value of "home remedies" (Bauwens, 1977). When a patient also has specific expectations of a consultation's coutcome which does not come about, the treatment tends to suffer also (Wadsworth, 1974). Health beliefs and practices are usually based in culture (Harwood, 1981), and an ethnic patient's com— pliance is often compromised because the beliefs and practices of scientific medicine are at odds with his own set of beliefs (Snow, 1974). A second issue of some importance in lay self—treatment is that it will go on in spite of what the doctor says. Therefore, it should be asked if there is any evidence of specific ill—judged or dangerous self—treatment practices being used (Bradshaw, 1977). A third issue, which may become increasingly important in the United States is overcrowding of health—care services. Considered a fact of life in England, it has been suggested (Morrell and Wale, 1976) that, of the complaints presently managed in the lay sector, even a minor shift from lay management to doctor care could make intolerable demands on England's National Health Service. Therefore, in England, at least, it is clear that self—treatment of illness is, in a crucial sense, appropriate, since the alternative would almost certainly be grossly in— adequate health care (Bradshaw, 1977). Thus, for a number of reasons it is advisable for health—care professionals to learn to work with lay health practices and beliefs as they inevitably exist among their clientele. A step to developing this kind of awareness is to acquire knowledge of the ways in which individuals and ethnic groups treat themselves in health and illness. METHODS The methods employed in researching the dietary self-treatment practices and attitudes of a group of Finnish-Americans in Michigan's Keweenaw Peninsula are described in this section. Criteria for inclu— sion in the sample and protection of subject's rights are given. The field research methods chosen for this study are also discussed. They involved: 1) notification of local civil authorities in the study area of the researcher's presence and project; 2) use of ethnographic tech— niques; 3) subject selection by referral sampling ; and 4) use of a structured interview schedule. In addition, data analysis methods are described. The Sample -— Criteria and Definitions The sample group was defined by the following criteria: an immigrant, first— or second—generation Finnish—American, either male or female, claiming at least one parent of Finnish ethnicity, living in Michigan's Keweenaw Peninsula, including and bounded on the south by the city of Houghton and its rural environs, and on the north, west and east by Lake Superior. An immigrant Finnish—American was defined as one who emigrated from Finland, settled in this country and became a United States citizen. First generation Finnish—Americans were defined as being born in this country of at least one immigrant Finnish—American parent. The second generation Finnish-Americans were defined as those born in this country and having at least one set of immigrant Finnish—American grandparents. The concept of Finnish ethnicity followed Schermerhorn's definition of an ethnic group. He stated that: 10 ...an ethnic group is...a collectivity within a larger society having a real or putative common ancestry, memories of a shared historical past, and a cultural focus on one or more symbolic elements defined as the epitome of their peoplehood....A necessary accompaniment is some conscious- ness of kind among members of the group (1978:12). Protection of Subjects The field study proposal was submitted to the Michigan State University Committee on Research Involving Human Subjects (UCRIHS). Approval was granted before initial contact with participants was made. All respondents signed the UCRIHS—approved consent form (Appendix A). Ethnographic Techniques The ethnographic techniques employed in the field were: 1) par— ticipant observation; 2) "networking" into the community;3) identification of key informants; and 4) the use of a field diary. These techniques were used in the study area for a two month period prior to actual data collection. This period was assigned to allow the researcher time to refine impressions of the people and area and to establish the necessary community contacts, while working within the limitations of time and budget. Participant Observation Participant observation was accomplished by direct involvement in community life, observing and talking with people to learn from them their view of reality (Agar, 1980). Participant observation also assisted the primary researcher, a non—Finnish—American, in developing the final data collection instrument and interviewing style most likely to elicit accurate information from the Finnish—Americans interviewed. 11 'Networking In" "Networking in" (Agar, 1980) was used to establish the researcher's presence in the community and to help identify potential subjects for inclusion in the study. The process involved locating well—respected people or institutions within the study area to facilitate the researcher's entrance and acceptance into the community. Key Informants Two key informants (Agar, 1980) were identified in the study area. As individuals who were well informed about the practices and beliefs of the community, they functioned as information resources throughout the study. Having more than one key informant allowed comparison of information to assure accuracy (Bass et al., 1979). Field Diary A field diary (Agar, 1980) was kept to detail personal impres- sions, daily activities, and other insights that could assist in explaining research results later. Sample Selection by Referral The method used for subject selection was best characterized as 'referral sampling', a non—probability technique. 'Referral sampling' was a modification of the snowball sample technique described by Bailey (1979). The first stage of referral sampling involved identifying and interviewing a few individuals meeting sample criteria. These sub— jects were asked to refer the interviewer to others qualifying for inclusion in the sample. These in turn suggested still others to be 12 interviewed, until the required number of interviews had been collected. Unlike snowball sampling, the referral sampling method did not require discrete stages of interviewing or referral quotas at each stage. The referral sample method was chosen for three reasons. First, the method insured referral to a Finnish—American meeting sample criteria. Second, it was used to enhance subject acceptance of the interviewer and interest in the project. Third, referral sampling allowed the researcher to follow the diffusion of self-treatment or health maintenance practices that might spread through the sample. Data—Gathering Instrument Choice and Justification A structured interview schedule composed primarily of open-ended questions was chosen as the appropriate instrument to obtain self- treatment data not otherwise available through observation or written response instruments (Talmage and Rasher, 1982). The interview schedule format allowed opportunity to clarify information and ambiguities with probes and follow—up questions in the interview situation. The structured format allowed interview data from many respondents to be aggregated and quantified (Talmage and Rasher, 1982). The use of open—ended questions established a more valid framework for data interpretation, because responses were subject—generated rather than externally imposed (Fabrega, 1974). Instrument Design, Pretestz and Revision An original interview schedule was designed to collect the follow— ing information: 1) data regarding dietary preventive health behaviors Fr l3 (PHB); 2) data regarding dietary self—treatment of certain ailments and conditions; 3) self—care attitude data; and 4) selected demographic data. The term "food" used throughout the interview schedule was defined broadly to include anything taken in by mouth, including foods, food supplements, beverages, herbs and spices, teas, vitamin and mineral supplements, and "non-food" items. The interview schedule was pretested in the field with four subjects meeting sample criteria. Revisions were minor. Confusing or ambiguous questions were refined. The order of sections and specific questions was arranged such that potentially threatening questions were administered last. Final Instrument The revised instrument was reviewed and approved by the primary researcher's Graduate Committee at Michigan State University. In final form, the 81 question instrument contained five sections with a total of 49 major questions asked of each participant and up to 32 subquestions depending on responses (Appendix B). Most questions were open—ended, although forced—choice types were included. The interview schedule required approximately one and a half hours to complete. The specific sections comprising the interview schedule are described below. Section I and Section V of the interview schedule were designed to obtain selected demographic information. Questions in Section I established whether the interviewee met criteria for inclusion in the sample. Section V contained questions eliciting information regarding age, sex, income, employment, and education history for the interviewees 14 and their spouses where applicable. Data about health—care utilization and sources of self—treatment information were obtained also. Section II of the interview schedule focused on current as well as childhood preventive health behaviors, especially regarding health— oriented uses of food. For this study preventive health behavior was operationally defined as any action undertaken by an individual to maintain or promote health and/or reduce the possibility of disease or disability. Section III of the interview schedule asked for specific food uses involved in the treatment of common illnesses. A list of various illnesses and conditions was developed after reviewing the literature on types of ailments commonly self—treated in the home. All respondents were guided through the list of illnesses. Responses were recorded on a separate data sheet for each ailment reported. Self—care attitudes of the sample in relation to medical care were addressed in Section IV. Self—care in this context related to illness detection and treatment (Linn and Lewis, 1979). A nine—item, Likert—scale instrument was adapted from Linn and Lewis' (1979) thirteen—item Self—care Attitude Scale, which was originally developed to measure physicians' self—care attitudes. Nine statements con— sidered to be applicable to lay people as well as physicians were chosen from the thirteen. Seven items were adopted as written by Linn and Lewis, while two were reworded more appopriately for respondents. Each respondent was given the same instructions for completing the form, while the interviewer read aloud from her copy. 15 Data Analysis Demographic data, self—care attitude data, and selected dietary preventive—health—behavior (PHB) data were coded and entered into a Cyber 750 computer at Michigan State University. These data were ana— lyzed using programs in the Statistical Package for the Social Sciences (SPSS) by Nie et a1. (1975). Frequencies and distributions were derived for all variables. Mean, median, and mode were calculated where appropriate. Frequencies and distributions for selected dietary PHB data and data regarding self—treatment of illness were hand—tallied. Chi square and Kolmogorov—Smirnoff tests of significance were applied to selected data (Champion, 1970). The significance level for the chi square test was p S .05. The significance level for the Kolmogorov—Smirnoff One Sample test was p s .01. Because of problems associated with interpreting recall data based on events in one's distant past, data regarding past self—treatment practices were limited to providing a broadly descriptive, qualitative background against which to compare current practices. Only data relating to current dietary self-treatment practices were tested for significance levels. THE RESEARCH SITE The Site The Keweenaw Peninsula was selected as the research site because of the large number of Finnish-Americans concentrated there. It is located in the northwestern portion of Michigan's Upper Peninsula (Figure l) and is a finger—like projection 55 miles into Lake Superior. It is bounded on the north, west and east by the lake, and on the south by the Portage Canal which transects it from east to west. On the southern side of the canal lies Houghton, which, with its rural environs, marks the southern boundary of the study area. The research site included all of Keweenaw County to the north and about half of Houghton County to the south. Approximately half of Houghton County's population of 37,872 fell within the study site. Combining Keweenaw County's sparse population of 1,964 inhabitants with half of Houghton County's population yielded a total of approxi— mately 21,00 people for the Keweenaw Peninsula, based on 1980 census data (Ketola, 1981). The population was largely concentrated in the lower half of the Peninsula. The People Current estimates suggested that Finnish—Americans comprised about 25 percent of the Keweenaw Peninsula's total multi—ethnic population (Ketola, 1981; Gregorich, 1981). The Finnish—American respondents were proud of their heritage and generally were well versed in their historical origins and common ancestry. They referred to themselves as "Finns", which applied to anyone who considered himself or was 16 17 SUPERIOR FIGURE 1 Map of Michigan. Darkened area is Keweenaw Peninsula research site. 18 considered by others to be of Finnish background. In this paper, ”Finn' is similarly used to refer to anyone of Finnish ethnicity. Immigration History Finnish immigration into the Keweenaw Peninsula peaked in the early 1900's (Hoglund, 1960; Jalkanen, 1969). Most immigrants were landless subsistence farmers from the rural provinces of Vaasa in western Finland and Oulu in the north (Figure 2). Leaving Finland largely for economic reasons, many immigrants were attracted to the Keweenaw Peninsula by the promise of work in copper mines and an environment similar to their homeland. By 1930, there were some 31,000 foreign-born Finns on the copper mining range of the Keweenaw Peninsula (Murdoch, 1964). Many returned to farming as soon as they were able. Because of their relatively recent arrival in the Peninsula and the resumption of agricultural lifestyles in somewhat closed communities, the acculturation process moved rather slowly, at least among the first generation (Armstrong, 1976). Historical Background and Employment Copper mining provided a stable economic base for the Keweenaw Peninsula through the second decade of this century. Mining companies operated from a base of socially—oriented paternalism providing miners and their families with medical services and economic aid when needed. When copper mining collapsed during the Depression, many mining com— panies sold company—built homes at nominal prices or gave them to employees (Murdoch, 1964). According to respondents, many unemployed Finns owned their own homes during the Depression, had a garden and FIGURE 2 19 F I N L A N D g, . Q 75 150 scale in mi es Map of Finland. Most Finnish immigrants in the Keweenaw Peninsula, Michigan, research site were from the provinces of Vaasa and Oulu, shown in bold outline. Adapted from Hoglund (1960:22). L. 20 family cow, and bartered for goods and services, a lifestyle reminiscent of rural Finland. Since the mining days, population in the Peninsula has continued to decline due to a shortage of jobs. Houghton and Keweenaw counties have lived with double—digit unemployment throughout the 1970's and currently have low per capita incomes compared to the rest of the state and nation (Verway, 1979). Currently, remunerative jobs are found in the tourist industry, federal, state and local governments, lumbering, small farming, other trades and services; however, there is little industry in the area (Verway, 1979). Sisu "Sisu" is a Finnish word meaning ”guts" and described a for— bearance and perseverance through situations stolidly and without ” had become a watchword associated complaint (Lunden, 1970). "Sisu with cultural pride among the Finnish—Americans in the Keweenaw Penin- sula. This outlook was seen to influence the way in which the elderly Finns reacted to illness. Visiting Ritual The visiting ritual among Finnish-Americans has been described elsewhere as providing social cohesion and diversion to this group (Loukinen, 1979; Armstrong, 1976). The elements of this ritual were generally observed in the study population. Multiple visiting relationships with friends, neighbors and kin as well as visits lasting an average of two or more hours were noted. Coffee and baked goods, usually homebaked and often traditional, played an important 21 part in the visiting ritual. The offer and acceptance of these items was expected and considered polite. The Sauna The "sauna”, which describes the Finnish bath and bath process, has maintained a centuries—old position in traditional Finnish culture (Viherjuuri, 1965). Its use was widespread among the Finnish—Americans in the Keweenaw Peninsula, especially among the older Finns, and it was the focus of strongly-held beliefs. The health benefits which "atmosphere" were the sauna provided in terms of cleanliness and expressed by several members of the study population. Typically, the heat of the sauna was reported to be best around 170°F. The heat and steam were also reported as beneficial to health and therapeutic for certain conditions. Religion The sample was predominantly Lutheran representing two distinct branches, the Apostolic Lutheran Church and the Evangelical Lutheran Church. Although the sample was largely Apostolic Lutheran, the Evangelical Lutheran Church had the larger membership among Finnish— Americans in the Keweenaw Peninsula. The Evangelical Lutheran Church was tied historically to the traditional Lutheran Church of Finland. The Apostolic Lutheran Church was an outgrowth of an emotional revi— valism carried to the Keweenaw Peninsula by the Finnish immigrants. The followers of the revivalist movement were excommunicated from the Lutheran Congress held in the Keweenaw Peninsula in 1867 (Nelson, 1975). Since that time, a tension between the two doctrines has 22 existed, being mentioned by a few of the respondents. The Apostolics and Evangelicals were quite different and did not appear to intermingle much. Historically the Apostolics placed emphasis on sober rural living in accord with the Bible (Karni et al., 1975). Conversations with Apostolic respondents indicated that Church teachings still encouraged sober and plain lifestyles and a reliance on the basics while staying close to nature. The Evangelicals also valued plainness, following the doctrines of traditional Lutheranism. Among both the Apostolics and Evangelicals, the Church held a place of central importance as a social and spiritual nexus, especially among the elderly. Self—Reliance and Health The self-reliant attitude within this population, which was apparent in matters relating to health, had its roots in Finnish history. Because doctors were uncommon in pre—twentieth century rural Finland, immigrants arrived in the Keweenaw Peninsula with traditional home remedies, a history of self—relaince, and an attitude that illness should not be encouraged (Armstrong, 1976). Many respondents also reported a reliance during their childhood on specific laypeople with particular medical skills. "Bonesetters” were Finnish laymen skilled in the setting of bones, sometimes learned from a doctor, and were utilized by some respondents while growing up in the Keweenaw Peninsula. Lay midwives also were commonly utilized in those days, often working in conjunction with doctors. Finnish masseurs and masseuses trained in Swedish massage were utilized also 23 for their particular skills during that time. Respondents reported that the reliance on laypeople skilled in health matters had largely died out by the Second World War. Currently, there were no bonesetters or lay midwives in the Peninsula, but two masseuses, now elderly, still maintained a clientele. Berry-Picking Berry—picking had a traditional place of social importance among the Finnish-Americans of the Keweenaw Peninsula (Armstrong, 1976). Because of their age, only a few respondents continued to gather the wild blueberries, blackberries, and thimbleberries available in the Keweenaw Peninsula. However, many described berry—picking as a regular event when they were younger, which provided families with healthful exercise. Some respondents sought wild blackberries and blueberries because their medicinal properties were superior to the domesticated berries. Health Care Services Because of the paternalistic mining companies, respondents reported more doctors and health care facilities serving the Keweenaw Peninsula when they were growing up than currently. Today, health care services are concentrated in Houghton County with no doctor, hospital, or nursing home located in Keweenaw County (Ketola, 1981). Twenty-seven licensed physicians and two hospitals service the combined counties (Tieter, 1981), which results in a potential patient load of 1500 people per doctor. The percentage of the population 65 years of age and older in these counties has been increasing yearly become a serious problem for the elderly. RESULTS AND DISCUSSION Results of field research are presented in this section. Field methods are described. Results obtained from the structured interview schedule are also discussed. Data presented include demographic information and information on dietary preventive health behavior, dietary self-treatment of illness, and self-care attitudes of the Finnish—American sample population in Michigan's Keweenaw Peninsula. FIELD METHODS Pre-Data—Collection Phase Upon arrival in the study area, the researcher notified the appro- priate civil authorities of her presence, purpose and length of stay. The Board of Commissioners for both counties in the study area were contacted, as were police and sheriff's departments at various locations in the Peninsula. Two long—term Finnish-American residents known to the researcher functioned throughout the study as key informants. They suggested specific people or institutions in the peninsula which were generally well—regarded by the local Finns. As a result of these conversations, the researcher contacted the Cooperative Extension Service Home Economist, a respected pharmacist, a Finnish—American County Commis- sioner, a Lutheran minister, and a retired doctor who had treated many of the older Finns. This group served as a bridge into the subject population by offering support and suggesting specific people to participate in the study. Participant observation was accomplished in a number of ways. The researcher informally attended various Finnish-American social and 25 26 Church-related functions, for example, a Cooperative Extension Service meeting, polka dances popular among the older Finns, and various Lutheran church services. Informal conversations with local Finns occurred regularly over coffee in Finnish—American cafes or in homes around the peninsula. The local newspapers and radio talk shows provided information about some of the day—to—day concerns. Obser- vations at the two food cooperatives and several pharmacies used by area Finnish-Americans provided insights about the position these places had in their self-treatment network. This process was on—going during the study period. Establishing Referral Chains Five subjects meeting sample criteria were initially identified through community contacts and key informants before data collection began. Each of the five suggested the names of Others qualifying for inclusion in the sample. These individuals in turn suggested others to be interviewed. Thus five referral chains were established initially and were followed simultaneously (Figure 3). Individuals were inter- viewed as they became available until four pretests and 30 interviews were collected. All individuals gave permission to have their names mentioned when their referrals were contacted. All referrals were reached initially by telephone and asked to participate. In all, five indi- viduals declined to participate. Four individuals declined when initially contacted, and one individual failed to keep an interview appointment. It never became necessary to start a new referral chain, 27 .cmwflLOfiz .mHSmCHcom smcomsmx .mcmofiumfi