”4“"! 59* mm w u. , '. I . . '1 ' I .- u l ‘ .F- “ I n .' .H - ' V 5‘ ‘ o".. , I Q N,“ ’ ‘\ ‘ a v.‘ ABSTRACT HEALTH AND ILLNESS 0F MEXICANAMERICAN CHILDREN IN AN UPPER MIDWEST URBAN SETTING By Carol J. Lindstrom The existence and persistence of a well-defined, cohesive folk health care system in the Mexican American culture is well documented in the literature. However, the extent to which Mexican Americans in the midwest participate in the folk system has not been studied. This study focuses on health, illness and health care of young Mexican children in the context of their culture. including the folk'health care system, and in articnxlation with the Anglo or Western scientific health care system. Utilization of preventive care at the Child Health Clinic in Lansing, Michigan is of particular interest. The Child Health Clinic provides well child care, treatment for common childhood illnesses and.referral to other sources for care for children under five in families who do not have access to private well child care. Twenty Mexican American families were selected from the Clinic clientele--ten who attended the Clinic consistently (good users) and ten who attended sporadically (poor users). .Ten Mexican American families.who had access to.the Clinic but had never attended were selected from the community, providing a total of thirty families for the study. Factors which differentiate the three groups were explored. Carol J. Lindstrom An interview schedule was developed to obtain (l) demographic data, (2) mothers' perceptions of health and illness in their children, (3) sources of care for illness and (4) knowledge, belief and practice in the folk health care system. Most of the questions were open-ended, allowing the mother to express her views and the interviewer to pursue selected aspects of the responses. Interviews were conducted in the homes of the respondents. A minimum of two visits was made to each home. In addition, numerous visits were made to three families in each group. There were many similarities in the thirty families. Very few of the parents had finished high school; the fathers had low skill, low income jobs. The mothers stayed home and cared for the children; they were socially isolated. Privacy was highly valued by all of the fam- ilies. All of the parents and the majority of the children spoke Spanish. Skill in English ranged from good to none in parents and children both. Family structure differentiated the good user and poor user groups. All children in the poor user group lived in a nuclear family. Only three families in the good user group were nuclear. The other seven were either headed by a female or composed of the mother, her children by a previous marriage, her husband and children of that union. The mothers in the two latter groups felt highly responsible for their children, since they did not have a man to share in the responsibility for some or all of the children. All but one of the mothers recognized illness in a child by changes in his behavior, not by physical symptoms. They used home .b. Carol J. Lindstrom remedies when a child first got sick and sought help from the doctor if what they did at home was not effective and they thought the child was very sick. Most of the families had a regular source of medical care. Many of them, including those who had a source of care, used the Emer- gency Room at one or more of the local hospitals for illnesses which were not medical emergencies. The majority of the mothers were knowledgeable about the folk diseases, whether they believed in them or not. No mother volunteered information about the folk diseases. They did discuss them freely when the interviewer named the common diseases and asked if their children had ever had any of the diseases. A positive answer to this question constituted belief in the system. In the good user group, five mothers believed and five did not believe in the folk diseases. Eight poor users believed and two did not. In the non-user group, seven believed, one did not and two were not sure if they did or did not believe. The mothers who did believe either knew how to treat the diseases themselves or knew a Mexican American woman who did know how to treat them. Mexi- can diseases were not treated by physicians, because they do not believe in them and do not know how to treat them. The diseases and treatments described by the mothers are consistent with the description in the literature. Only one mother said she knew of a curandera (a Mexican curer). The curandera told the interviewer that she received the gift of curing from God. She does not charge for her services. She has cured many people whom the doctors could not cure. She uses prayers, a number of rituals and a variety of herbs in her treatments. Carol J. Lindstrom Most of the families in this study participate in two insular systems of health care. Mexican folk diseases are treated within the Mexican culture. Non-Mexican diseases are treated by physicians. Families may participate in both systems separately or simultaneously. HEALTH AND ILLNESS OF MEXICAN AMERICAN CHILDREN IN AN UPPER MIDWEST URBAN SETTING By Carol Jffitindstrom A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY College of Social Science 1974 ii Copyright by CAROL J. LINDSTROM l974 to my parents who appreciated my need for this flight "You ane the bows finom which gout chiidhen a4 Living annoum ane bent fionth-~euen as He Cove/5 the Wow (ha/t 6312/5, so He [ave/3 @050 the bow that is Atabte." —-K. 641an ACKNOWLEDGMENTS "Woth it ioue made vibibie." This dissertation is the visible result of the work and love of many people. Those who provided assistance and support throughout the course of my graduate program know how important they are to me. I can express my gratitude here to only some of them. "15 he it indeed wiAe, he duet not bid you enten the houAe 05 hit wi/sdom. but ftCUChQ/L ieadb you to the thneAhotd ofi_youn own wind." To Dr. Charles Hughes-~Chairman of my Guidance Committee, Director of my thesis, teacher, adviser, friend-~who led me to the threshold of my mind. He understood quickly where I wanted to go, encouraged me willingly and consistently and shared the joys and pains of my growth. "Fun the vibion 05 one man iendb not iii winqb to anothen man." To the other members of my Guidance Committee--Dr. Ruth Useem, Dr. Dozier Thornton and Dr. Arthur Kohrman--who helped me to find my vision and fly with my wings. iv "The teacheh . . . qiueA not 06 hit nwidom but nathen 06 hit figith and tovingneAA." To the parents and children in the Mexican families--my teachers and friends--who gave freely and warmly that I might learn. "Voun finiend it youh needA anAwehed." To my friends on the nursing staff of the Ingham County Health Department who answered my needs for information and the sharing of ideas. "And in the tweetneAA ofiyfiniendihip iet thehe be taughtm and the Aha/ling ofi piewswte." To my many friends and my family who helped me to laugh when the road was rough and who shared with me their pleasures and strength. "To moth with tove . . . it to change ait thingé you (cushion with a bneath 06 you own Apihit." To Grace Rutherford, who always knew how I wanted my papers typed--fashioned with a breath of perfection. "It it weti to give when abhed. . . ." To the Division of Nursing, U.S. Public Health Service, for the financial support of a special predoctoral fellowship (No. FO4-NU-27, 183-06) and Dr. Marie Bourgeois for her moral support. (Wondb 06 K. Gibnan thhoughout) TABLE OF CONTENTS Page LIST OF TABLES .......................... x Chapter I. INTRODUCTION AND RATIONALE ................ l The Setting ...................... l The People ....................... 2 Cristo Rey Community Center .............. 5 Child Health Clinic .................. 7 Purpose ........................ l7 II. MEXICAN AMERICANS AS DESCRIBED IN THE LITERATURE ..... 19 Terminology ...................... l9 Multiple Terms ................... l9 Recent Terms .................... 20 Present Interest .................... 23 Descriptions by Anglo Writers ............. 25 Family Relationships ................ 26 Language ...................... 28 Acculturation ................... 28 Social Class .................... 29 Comments by Chicano Writers .............. 30 Mexican Americans in the Midwest ............ 33 Illinois, Wisconsin and Ohio ............ 33 Michigan ...................... 35 Culture or Poverty? .................. 37 Health and Illness ................... 39 . Specific Diseases ................. 42 Curers ....................... 45 Recent Studies ................... 46 Folk—Scientific Articulation ............ 50 Socio-Cultural Factors ............... 52 Poverty and Health ................. 54 Preventive Care .................... 56 Surveys of a Population .............. 56 Surveys of P0pulation of a Source of Care ..... 59 Articulation with the Anglo System ........... 66 vi .L. Chapter Page 111. METHOD .......................... 76 Introduction ...................... 76 Preparation .................... 76 Process ...................... 78 The Questionnaire ................... 79 Development .................... 79 Pre-Test with Migrant Families ........... 8l The Sample ....................... 83 Selection ..................... 83 Interviews ..................... 86 Socioeconomic Status .................. 89 Limitations of the Study ................ 93 IV. MEXICAN AMERICANS AS MIGRANTS .............. 95 The Migrant Project .................. 95 The Migrants as the Outreach Worker Described Them . . . 97 Relationship with the Outreach Worker ....... 97 Relationship within the Group ........... 99 Relationships with Whites ............. 100 Personal Observations and Experiences ....... 102 Data from the Interviews ................ 105 Demographic Data .................. 105 Health and Illness Perceptions and Behavior . . . . 108 V. MEXICAN AMERICANS IN LANSING: SOCIAL AND ECONOMIC DATA . 114 Introduction ...................... ll4 Family Structure .................... ll6 Socioeconomic Status .................. l26 Migration and Mobility ................. l35 Summary ........................ 139 VI. MEXICAN AMERICANS IN LANSING: HOME, FAMILY AND CULTURE . l4] Introduction ...................... 141 Major Informants .................... l42 Families Who Attend the Clinic Consistently . . . . l42 Families Who Attend the Clinic Sporadically . . . . l43 Families Who Have Not Attended the Clinic ..... l44 Home and Family .................... 146 "The Mexican Is Always Remote" ........... l46 "A Clean House, Clean Wife, Clean Children" . . . . l48 "Come Again, Any Time" ............... l50 "I Love My Children" ................ l52 "Families Are Like That" .............. l54 ‘vii Chapter Page "Mexican Women Put Up With A Lot" ......... 157 "Good Food Is Important“ .............. 159 "Five Children--That's Enough" ........... l63 "Mexicans Should Know Spanish" ........... 167 Outside the Home .................... 169 "I Don't Bother Them; They Don't Bother Me" . . . . 169 "Those Other Mexicans Are 'Uppity'" ........ 170 Summary ........................ 172 VII. MEXICAN AMERICANS IN LANSING: HEALTH AND ILLNESS . . . . 173 Introduction ...................... 173 Health Care at Home .................. 174 "I Do Many Things To Keep Them Well" ........ 174 "They Don't Get Sick Much" . . . .......... 176 "I Do the Best I Can" ............... 179 "They're Quiet-~They Don’t Play" .......... 179 "Colds" ...................... 184 "Aspirin" ..................... 188 "When What I Do At Home Doesn't Help" ....... 189 Health Care in the Anglo System ............ 192 Sick Care ..................... 192 Preventive Care .................. 197 Better Health Care ................. 207 Folk Health System ............ . ...... 211 Belief ....................... 211 Source of Care ................... 215 The Curandera ................... 220 A Vi51t with the Curandera ............. 222 Summary ........................ 228 VIII. IMPLICATIONS FOR PRACTICE ................ 230 Introduction ...................... 230 Mexican Culture .................... 231 Language ...................... 232 Dignity of the Individual ............. 234 Home and Family ..... . ............ 236 Mobility ...................... 241 Folk Illnesses and Treatments ........... 242 Health Care In the Anglo System ............ 244 Preventive Care .................. 244 Child Health Clinic ................ 247 Health Care Delivery ................ 250 Summary ........................ 255 viii Chapter IX. Appendix A. on E. REFERENC Page IMPLICATIONS FOR RESEARCH ................ 257 Family Structure .................... 257 Migration and Mobility ................. 259 Sickness ........................ 261 Folk Health Care .................... 263 “Battered Child Syndrome" ............... 265 Child Health Clinic . . ................ 266 Additional Data .................... 268 Comparative Studies .................. 270 DATA FROM MICHIGAN HEALTH SURVEY ............. 272 MENTALLY ILL ADULTS--FOLK BELIEF AND ANGLO CARE ..... 284 QUESTIONNAIRE ...................... 287 CHILD HEALTH CLINIC RECORDS OF FAMILIES WITH SPANISH SURNAME ..... . .................. 298 MIGRANT MOTHERS' RESPONSES TO QUESTIONNAIRE ....... 301 ES ............................ 306 ix Table 10. 11. 12. 13. LIST OF TABLES Child health clinic appointments kept, broken and cancelled by Spanish-surname families in 1972 ....... Relationship betweek kept and broken appointments by location of child health clinic in 1972 ........ Relationship between clinic assignment (North and South) and records closed due to many broken appointments Language spoken at home by members of ten migrant agricultural worker families in Michigan ......... Relationship between having check-ups and giving vitamins stated and practiced as health promotion- illness prevention measures ................ Years of education of mothers by use of Child Health Clinic services ...................... Years of education of fathers by use of Child Health Clinic services ...................... Place of education of mothers by use of Child Health Clinic services ...................... Place of education of fathers by use of Child Health Clinic services ...................... Income of families by use of Child Health Clinic services . Relationship between income and size of good user families . . . . ..................... Relationship between income and size of poor user families Relationship between income and size of non-user families 74- Socioeconomic status scores of families by use of Child Health Clinic services . . ............. Page 11 12 13 107 111 128 129 13D 130 131 Table Page 15. Pattern of migration by use of Child Health Clinic services ........................ 137 16. Length of time in present dwelling by use of Child Health Clinic services ................. 139 17. Other family members in Lansing by use of Child Health Clinic services ................. 154 18. Relationship between number of children and use of contraceptive ........ . ............. 165 19. Language spoken in the home by use of Child Health Clinic services ..................... 168 20. Relationship between mothers' perception of own and children's health by recency of move .......... 178 21. Sources of help for illness by use of Child Health Clinic services ..................... 191 22. Antepartum care by use of Child Health Clinic services . 198 23. Relationship between age on first visit and use of Child Health Clinic services .............. 201 24. Source of referral to Child Health Clinic by use of service ......................... 205 25. Belief in folk diseases by use of Child Health Clinic services . . ...................... 213 A-l. Age distribution of individuals of Mexican descent . . . 273 A-2. Percent of white population by age and area, Lansing- East Lansing ...................... 273 A-3. Education of head of household in families of Mexican descent ......................... 274 A-4. Population 19 years of age and older. Education by area, Lansing-East Lansing ............... 274 A-5. Relationship between age and education of head of household of families of Mexican descent ........ 275 A-6. Yearly income of families of Mexican descent ...... 276 xi Table A-11. A-12. A-13. A-14. A-15. A-16. A-17. Detailed yearly income of families of Mexican descent , . . Relationship between income and education of head of household of families of Mexican descent ....... Relationship between income and size of household of families of Mexican descent ............. . Relationship between income and number of people working in families of Mexican descent ......... Employment status of heads of household of families of Mexican descent ................... Relationship between number of rooms and size of household of families of Mexican descent ...... ,. . . Ownership of dwelling units occupied by families of Mexican descent ................... Length of time at present address by families of Mexican descent ..................... Relationship between home ownership and length of residence at present address by families of Mexican descent ......................... Maintenance of interior of dwelling unit occupied by families of Mexican descent ............... Use of contraceptive measures by women, age 14-60, in families of Mexican descent ............... xii Page 276 277 282 282 282 283 CHAPTER I INTRODUCTION AND RATIONALE The Setting Lansing, the capital of Michigan, is an urban, industrial city with a population of 213,000 (United States Department of Commerce, 1972). The major industries are those involved, directly or indirectly, with the automotive industry. The city is surrounded by good agricul- tural land. Like most urban industrial areas, Lansing has a number of families whose income is low. The Bureau of the Census reports that, in 1970, 7.5 percent of the population had an income below the poverty level (United States Department of Commerce, 1972). Unlike many cities of this size and character, Lansing has traditionally provided very little publicly supported medical care for those families who could not afford or obtain private care. The local Medical Society maintained that care was available for those who need it; there was no need for 'clinics for poor people.‘ Until 1968, there was no resource for preventive care for children in those families which could not afford private care. At the present time (1974), it is difficult for any newcomer to Lansing, including those who can afford private care, to find a source of care. No pediatricians and few general practitioners are taking new patients. Medical care is generally less accessible to families with a low income than to those with a high income. Low availability of medical care in the community serves to further decrease the accessibility to the low income families. Problems in obtaining care will be discussed more fully in a subsequent chapter. The People Much of the agricultural land in the area is devoted to crops which require hand labor, rather than machine labor. For a number of years, much of the labor was done by workers brought in from Mexico for that purpose. When this program was stopped, Mexican Americans from Texas came as migrant laborers every summer to work in agriculture here. Each year, and recently in increasing numbers, Mexican American families left the migrant stream and settled in Lansing or another of the urban industrial areas in southern Michigan. Their numbers increased rapidly in Lansing. The actual size of the Mexican American population in Lansing now (1974) is not known. According to the Bureau of Census Report for 1970, there are 6,307 persons of Spanish language living in Lansing in Census Tracts with 400 or more persons of Spanish language. These figures are based on a sample of the population (United States Depart- ment of Commerce,1972). This is an underestimation of population size. In October, 1970 there were 1,937 children of Spanish surname enrolled in the public -’ ' O o I .. .r u . va- a . O :f . n t ' v0. u- schools of Lansing (J. Brown, 1972). The designation of Spanish language would exclude those families in which English is the principal language. Families living in a Census Tract with fewer than 400 persons of Spanish language would not be counted. Several Mexican American community leaders have said that the 1970 Census estimate would be low. Many families resented the census form because they felt overlooked as an ethnic minority. They do not want to be counted as Anglo (Caucasian), although by law they are clas- sified as Caucasian. They would like a separate and specific classifi- cation. The form itself presented a problem to those who cannot read English. As a result, many families did not return the form (Benavidez, Martinez, personal interview). The leaders estimate the population size at from 12,000 to 15,000 and increasing at about 100 to 150 families a year. The in- crease in the Spanish-surnamed population in Lansing is evident in the “student ethnic count" compiled by child accounting consultant for the Lansing School District.1 Between November 1967 and October 1972, the number of Spanish-surnamed children in the Lansing elementary schools increased from 820 to 1,528 and in the secondary schools from 438 to 879. Both groups doubled in their percentage of the total student body, from 4 percent to 8 percent in the elementary schools and from 3 percent to 6 percent in the secondary (J. Brown, 1972). According to the leaders, the population is characterized by families that are young, large and poor. Average family size is eight. ‘Approximately 95 percent of the Spanish-surnamed population is Mexican American (Benavidez, personal interview). w. o . . . .‘ u ' a V. l ‘n. 0 ‘~ I O 5 w. I 1 A Only about 1 percent of the population is 62 years of age or older. Their impressions are substantiated in several sources of demographic data. The Michigan Health Survey, originally known as Project ECHO (Evidence for Community Health Organization), provided a source for information about the Mexican American population in Lansing. The survey was begun in 1967 in seven urban areas, including Lansing, and six small-town--rural areas in Michigan. The purpose of the study is to provide current information for planning and evaluating health ser- vices. The program, conducted in three phases, provides a continuous appraisal and up-date of environmental, demographic and health data. The first phase consists of a block by block count and appraisal of dwelling units and their surrounding environment. In the second phase, a simple random sample of dwelling units is drawn. The residents in the selected units are interviewed to obtain health and demographic data. The interior condition of the unit is appraised and the blocks in which they are located are reappraised. All data are coded, key- punched and put on magnetic tape for computer retrieval. Phase three consists of an analysis and interpretation of the data to interested people in the local community. For purposes of interpretation and utilization, the city is divided into neighborhoods or areas with a high degree of internal homogeneity and external heterogeneity. The questionnaire was revised several times. The version which was put into use in January 1970 included a question designed to deter- mine ethnic background. "Considering both his parents, what is the national origin or descent of (head of household)?" (Michigan Department of Public Health, 1970b). However, the responses were not coded for a specific category for people of Mexican descent. A hand sort of all Lansing questionnaires for the period from January 1970 through June 1971 yielded thirty-four families of Mexican descent. In general, data from the Michigan Health Survey is consistent with the description of the Mexican American population given by the community leaders (Michigan Department of Public Health, n.d.). Although the 1970 Census (United States Department of Commerce, 1972) underestimates the size of the Mexican American population, the internal data are highly similar to that from the Michigan Health Survey. The population is young, with generally low incomes and low educational levels. (See Appendix A for detailed data.) Cristo Rey Community Center As the Mexican American population increased, the people wanted a church (Catholic) where they could have services in Spanish and English. In 1961, the Diocese of Lansing established Cristo Rey as a church for the Spanish speaking people. In 1965, the church had to relocate. At this time, the community leaders decided that they needed a center which would provide more than religious services. The people needed help with credit, housing, employment and health care and felt that the church was not fulfilling that social role. They requested and were given funds for a building that would serve as a combination of church and community center. Now, the Center is funded mostly by the Catholic Church (Diocese of Lansing), with some help from the Capital Area United Fund. Although the Center was established at the request of the Mexican Americans, the mandate from the bish0p is that they serve anyone who is in need (Lehr, 1974). The Community Center is located in north Lansing in an area characterized by deteriorating or dilapidated housing (Michigan Depart- ment of Public Health, 1970a). Many of the families are Mexican Amer- ican. This is the area in which many of the newcomers first settle; it is the poorest of the several areas in which they live (Choldin and Trout, 1969). There are also many Black families and white families. Michigan Health Survey Area C includes Cristo Rey Community Center and the surrounding area (see Appendix A). The people in Area C are characterized by a relatively high percentage of households headed by a female, high mobility, low level of employment, low income, high infestation by rats, mice and cockroaches, comparatively low level of immunizations, low level of preventive health care and little dental care (Michigan Department of Public Health, n.d.). This constellation of characteristics describes a."poverty" population. (The relationship between poverty and health will be discussed in a subsequent chapter.) Public health nurses have observed that many of the pe0p1e have an inadequate diet, inadequate health care, much illness and little pre- ventive care. The children tend to have medical care primarily for severe, acute illnesses. The families cannot afford private preventive care; neither Medicaid nor the Department of Social Services pays for preventive care. Child Health Clinic When the present Community Center was in the early planning and building stage, the priest told the public health nurse who worked in the area that they would include a clinic room; she could decide how to use it. Since she had not had any experience in developing community services, she asked me for help. At that time, I was on the faculty of the Michigan State University School of Nursing. I was familiar with the area and had had experience in planning and developing community services. I assumed nursing leadership in contacting both professional and non-professional people in the area who might want to be involved in determining the need and deciding what service could be offered. I discussed the alternate plans with the Medical Director of the Ingham County Health Department and wrote the protocol for the implementation of the Child Health Clinic which was established. The Ingham County Child Health Clinic began service to the community in July 1968, in the Cristo Rey Community Center. This Clinic was the first source of preventive health care for children in those families who did not have access to such care from a private physician. Many groups and individuals contributed time, money and effort to initiate and continue the service. It was a community effort; no federal funding was requested (C. Lindstrom, 1970a). When the Clinic began operation at Cristo Rey, it was open twice a month. After eight months, the demand was great enough to necessitate a Clinic session every week. For about the first two years, all sessions were conducted at Cristo Rey. After that, the weekly "u <. we .u 'I ,. .. I n~.‘ I .a "' p. .- . n I! I ‘ o I a ‘V ‘ ”I ”I I.‘ :.:k ’5 V ‘ n P sessions alternated between Cristo Rey and the Health Department. Facilities in the Health Department were more spacious than those at Cristo Rey. The new location made the service more accessible to families in the south part of Lansing. The Clinic provides well child care, treatment for the common childhood illnesses and referral to other sources of care for those problems which cannot be treated at the Clinic. Mothers in the commu- nity had expressed a need for some place where they could take their sick children for care. A traditional well child clinic would not have met the needs of the people in the area. Volunteers provided transpor- tation for those who needed it and looked after the children while the mother was otherwise occupied. The professional staff recognized that lack of transportation and/or a baby sitter were major reasons for broken appointments. Insofar as possible, the mothers and children saw the same doctor and nurse at each clinic visit. The staff hoped that this continuity would help to reduce the number of broken appointments. Nonetheless, there were some mothers who did not keep their appointments. Over time, it became possible for the nurses to look at the appointment book and predict that 'this mother will come because she always comes' and 'this mother will come only if the children are sick.I I worked regularly in the Clinic during the first year and a half of operation. Some mothers brought their children consistently, whenever they had an appointment, whether the child was sick or well. Some mothers brought their children sporadically, usually only when ‘ 9 ..~' 0 u u E b: v V ' we, ‘! .’: ' t. v .n b ' "0p OI'.: -‘ . l it 3.5- :"':.-: :r,‘ '-o o . u- U o . :” ‘Dant: .4" ' . " fl . I P: “‘1‘ U ., - . 5-2" Q" I“. "ra they were sick. This pattern prevailed in all three groups-—white, Black and Mexican American. I became particularly interested in the Mexican American group. The people of Mexican heritage with whom I worked in the Clinic and later in the course of this study referred to themselves simply as "Mexican." They referred to me and other light skinned Caucasians as "white" or occasionally as "American." For this reason, the terms "Mexican“ and "white" will be used in the portions of this work which deal with contact between the writer and the people of Mexican heritage. The problems and issues of ethnic terminology and the differences from the now widely used term "Chicano" will be dealt with more fully in a subsequent chapter. The Mexican mothers did not differ noticeably in pattern of attendance from the white and Black mothers--some attended consistently and some sporadically. Some children were receiving the best care that the Clinic could provide; some were receiving less than the best care. Concern for the children in the latter group prompted me to wonder what differentiated the two groups. The problem of broken appointments and resultant less than good care raises several obvious questions. Who does not keep appointments? Why? It seemed to me that there were two equally salient, but seldom asked questions. Who does keep appointments? Why? All of the mothers who attended the Clinic were part of the "low income" or "poverty" population; they could not afford private preventive care. In addition to low income, the Mexican mothers had no. . l l 4 o. o in. -‘ -. 0h. I. 'v.. o a o ., '\ 10 a cultural background different from the other two groups. The behavior of interest to me might be a function of social class, ethnicity or a combination of both. Since the Cristo Rey area is heavily populated with Mexican Americans, more of these families attended the North Clinic (Cristo Rey) than the South (Health Department). Because Cristo Rey serves as a center for helping the Mexican American families in a variety of ways, and because there are always bilingual people there, I thought it likely that the attendance record would be better (fewer broken appointments) at Cristo Rey than at the Health Department. This was not the case, however. I reviewed attendance records for both clinics, North and South, for 1972. During that time, Spanish-surnamed families were given 154 appointments at the North clinic, with a number of families having more than one. Of these 154, 86 (56%) were kept, 60 (39%) were broken and 8 (5%) were cancelled. In the South clinic, there were 65 appoint- ments, with 42 (63%) kept, 18 (28%) broken and 6 (9%) cancelled. The rate of broken appointments was higher in the North than the South clinic (see Table 1). Further study of the attendance record at the two clinics revealed some interesting information. Eighty-seven families (Spanish- surnamed) had appointments at the two clinics. Of these, forty-six regularly attended the North clinic, twenty-two regularly attended the South clinic and nineteen were new; they had never been to either clinic. These nineteen families account for thirteen broken appointments at the I.. ‘ ‘. , I l l \‘ .| CD I . I .1 'I‘l I b I I .9. I -u M “' '30- . v “‘t a ." .I. ‘ 'rs.. ,~_ I ‘I '“v .. C. ‘ I“ a ‘ 'zo. ’I 11 Table 1. Child health clinic appointments kept, broken and cancelled by Spanish-surname families in 1972 Appointments Kept Broken Cancelled Total Child Health -—-———-—- -——-——-—- -——-———-—- ———-—————- Clinic No. % No. % No. % No. % North clinic 86 56 6O 39 8 5 154 100 South clinic 41 63 18 28 6 9 65 100 Total 127 58 78 36 14 6 219 100 North clinic and seven at the South. (One mother broke an appointment at each clinic.) Eliminating these twenty broken appointments changes the rates somewhat, but the broken appointment rate at the South clinic remains lower (19%) than at the North (33%). Families who never kept an appointment account for twenty-three broken appointments at the North clinic and nine at the South clinic. Eliminating these appointments does not change the rates. It is inter- esting to note, however, that one of these families broke three appoint- ments and one broke five at the North clinic, whereas no family broke more than one at the South clinic (see Table 2). Another interesting chference in attendance pattern appears in Table 2. No family kept nmre than three appointments at the South clinic; three of the four families who kept three appointments account for seven broken ones. In the North clinic, the four families who kept three appointments account for only four of those broken. Also in the North clinic, the 12 four families who kept four or more appointments (a total of 25) account for only six of those broken. The pattern of attendance is different in the two clinics. Table 2. Relationship between kept and broken appoint- ments by location of child health clinic in 1972 Location of Clinic Relationship North South None kept--one broken 1 None kept--three broken None kept--five broken One kept--none broken One kept--one broken 1 One kept—-two broken One kept--three broken Two kept--none broken Two kept--one broken Two kept--two broken Two kept-—three broken Three kept--none broken Three kept--one broken Three kept--two broken Three kept--four broken Four kept--one broken Five kept-~one broken Five kept--two broken Seven kept--one broken dN-amoow—I-a—Imou—aw—Ioo—I—Icn oooo—Id—I—Ioo—I-ho—Jhtoooxo 13 The difference in attendance patterns raised the question of family records closed to clinic service because of many broken appoint— ments. Since the rate of broken appointments was higher in the North clinic, one might expect that a higher percentage of records would be closed. However, more families established a record for good attendance in the North clinic than in the South. On this basis, one might expect that a higher percentage of records would be closed in the South clinic. The latter speculation proved to be correct. A review of Spanish- surnamed records closed to service in 1971 and 1972 revealed that four of the families attended the North clinic and ten the south. Although the active caseload was only available for 1972, I do not think that difference in times has any appreciable effect on the relationship shown in Table 3. There are always more Spanish-surnamed families attending the North clinic. Table 3. Relationship between clinic assignment (North or South) and records closed due to many broken appointments Clinic Assignment Closed Due to Broken Appointments North 46 4 South 22 10 . U ,4»: ' ' ‘ , . - I- ... I' I n a“. ‘ 0 u. I. e ., i I '5 ,‘l .\ e .‘. . .fl. | a. w “a ..‘ ,‘ ‘ '- ‘e I? '1 - . “I _5‘ § ‘- u ‘ C P Q \ ‘ LN I I‘ r- .' \ ‘ I ve‘ h \ .a . ~- .Qu‘a ~2 14 Information from the Clinic records, observations and experience suggested some variables which did not seem to differentiate the two groups. There were mothers who spoke little or no English and mothers who spoke good English in both groups. Mothers who lived within several blocks of Cristo Rey and mothers who lived greater distances away were represented in both groups. There were young mothers with one or two children and older mothers with five, six or more children in both groups. Command of English, proximity to Cristo Rey, age of mother and family size did not seem to differentiate the two groups. Language, the most readily observable cultural difference, did not distinguish those mothers who attended regularly from those who attended sporadically. However, language is only the “tip of the ice- berg" of the cultural differences between whites and Mexicans. There are differences in family relationships, role expectations and child rearing practices. There are differences in orientation to the health- illness spectrum. The existence of a well-defined, cohesive and persistent Mexican folk health-illness system has been well documented. Saunders (1954) describes the cause, symptoms and treatment of the most common folk illnesses and suggests that adherence to the folk system may be one reason why the Anglo system is not used extensively. Rubel (1960) also describes the folk illnesses; he suggests that they persist because they provide a strong cultural bond. Both of these studies were done with populations in the southwest. Relatively few studies have been done of Mexican Americans in the midwest; fewer still have been done of those in Michigan. Those who ‘O . I. n II-O ‘ _. ‘ ‘ 'qvo ' o a: a "1' a u I" . .u'- I I - V i "‘ A I "I. ' u a. I un‘ ; - J‘ a I'- [\p ‘n 'O In, . ‘m . cl.II b l.|.“ . . o l b. ‘”‘.. I “:- '1 Q 15 have settled in Michigan are a self-selected group. Choldin and Trout (1969), in a study of Mexican Americans in five Michigan cities, found that 60 percent of the men had been born in Texas and 11 percent in Mexico. Most of the men left Texas because of the massive poverty; 66 percent gave job related reasons for migration and settlement. In general, the men are better educated and have higher incomes than the men in the areas in Texas which they left. The Mexican Americans in Lansing tend to live near other Mexican Americans; the general geographic areas in which they live can be described. However, there is not one area of any appreciable size peopled almost exclusively by Mexican Americans; no area which would be the equivalent of the “barrio" of cities in the southwest. It seems possible that these families who have left Mexico and/or Texas for bet- ter jobs might be more ready than those who stay to adapt to or accept some facets of Anglo culture. To a greater or lesser degree, all of these families are exposed to Anglo culture. Most of the men have a continuing exposure at their place of employment. The children go to primarily Anglo schools. Many of them have white neighbors. All of the mothers who bring their chil- dren to Child Health Clinic are participating in the Anglo health care system. To a very high degree, these families otherwise live in the Mexican culture. They speak Spanish, eat Mexican foods, play Mexican music, participate in Mexican festivals and return to Texas or Mexico to visit family members. They shop in stores which specialize in 00‘ :~ m - l. .gv'l I .- O \ | .v' I . u- ti o nu. . A u“. ’l 16 Mexican foods and have bilingual staff members. There are a number of Mexican restaurants in north Lansing. To some degree, they live in two cultures. They probably know more about the Anglo culture than Anglos know about the Mexican culture. Public health nurses who work with them in the Clinic and/or at home are aware of some of the cultural differences--language, if nothing else. However, the public health nurses probably do not know much about Mexican culture in general, or the folk health-illness system in partic- ular. They see the mothers and children only in a contact with and in the context of the Anglo culture and system. However, the Mexican mothers live in both systems and may participate in both systems of health care. The degree of participa- tion and the relationship that the mothers see between the two systems are not known. Goldkind (1959) compared folk health beliefs and practices of, Ladino women in Saginaw, Michigan, and Denver, Colorado. He hypoth- esized that there would be more belief and practice in the group in Denver, because they live in the midst of the traditional Mexican- American culture. He administered a questionnaire to 36 women attend- ing the General Medical Clinic of Denver General Hospital and 40 women attending the Guadalupe Health Center in Saginaw. The women in Saginaw were older and less well educated than those in Denver. He found no significant difference between the two groups in use of and belief in the effectiveness of curanderas, personal experience with witchcraft and use of a group of 21 folk medicines. He found less adherence in .' '3; D. ’ . l «a " . I I . j. I | 1 I "we I ‘uo .-A. . in " uh. 'h-.. . r ‘--:l .“‘ “.- .. -' I“ g V. ‘5 b; t: F I ‘ . ‘M V! . . _ .U .J‘ {AF "vi 1. .7 t, \. 17 the Saginaw group to having babies at home, admitting knowledge of cases of witchcraft and knowledge of a group of 21 folk medicines. He suggests that the aspects of folk medicine which seem to have been weakened by residence in Saginaw pertain to belief or knowledge rather than actual practice. Purpose Relatively little is known about the Mexican American population in Lansing. They are a self selected group; their life situation and circumstances are different from what they left. For these reasons, it does not seem reasonable to generalize to this group from studies done with those who live in the southwest, particularly Texas. It might be expected that there will be some culture change, some lessening of the traditionalism described by Saunders (1954), Rubel (1960, 1966), and others. However, what culture traits are changing and how rapidly is not known. More specifically, change in knowledge, belief and practice in the folk health-illness system is not known. The purpose of this study is to explore, with a selected group (If Mexican mothers, the extent of their knowledge of, belief in and partficipation in the folk health-illness system specifically as this relates to their children under five. The study will include their perceptions and behaviors in relation to their children under five, i.e., what they do to keep the children well, how they recognize ill- ness, what they do and where they go for help once illness has been recognized. Participation in the Anglo system for both prevention and . .4. o w... a - D .. I. D o 1.; ‘D .....- . I ”r I 5.; D .y, '~l. ,’ ‘Il' W“ ‘ 18 treatment will also be explored. Health perceptions and behavior will be viewed in the context of significant aspects of the Mexican culture. The mothers who bring their children to the Clinic will provide a group who have some articulation with the Anglo system. Some mothers attend sporadically; some attend consistently. The relationship between attendance pattern and participation in the folk system is not known. There are also many mothers in the community who have access to the Clinic, but have never attended. It seems safe to assume that these children have had no preventive care, with the possible exception of immunizations. An exploratory study of these three groups may point out some factors which differentiate them from each other. Increased understanding of the Mexicans may help health professionals provide better health care. CHAPTER II MEXICAN AMERICANS AS DESCRIBED IN THE LITERATURE Terminology Multiple Terms A discussion of ethnic terminology is necessary prior to a review of the literature. Ramirez (1973) says, "The Census Bureau tabulates 9 million Spanish Americans in the United States. Of these, 57 percent are of Mexican origin; 17 percent Puerto Rican; 7 percent Cuban; 6 percent Central and South American and 13 percent 'other Spanish origin'" (p. 2). "Mexican-American," with or without the hyphen, is used frequently; it is descriptive and not likely to be confusing to the reader. "Spanish American," "Spanish speaking," "Spanish surname," "Latin," and "Latin American" are also used to refer to those of Mexican origin. Any one of these terms may also be used to describe any of the five groups above. Some authors do not define the specific group about which they write. "Hispanic American" and "Hispano" may also be used to describe those of Mexican origin or the descendants of those early Spanish settlers who had no Mexican heritage. 19 .II I . _’.., l .e O - r . I . .. 'u'. 'U .. .1 . M a - u . I ‘ U '4 ‘A ‘\ a ‘0 ..' l ‘ I I C I *b C‘.‘ 0‘. ‘4 s I \ v ‘d ‘ l .u. Np L I C a“. .' -: ‘ .‘l -.‘ . I, I' l ‘. F- 4 H. \- . I ‘d .- .u 20 Burma (1970b) recognizes the lack of concensus in terminology. He provides a broad guide to current usage. In Texas, "Latin" or “Latin American" is preferred. In other areas these terms generally refer to people of Central or South American heritage. Mexican usually means a citizen of Mexico. In New Mexico and Colorado, Spanish American or Hispano refers to those of Spanish origin dating back some three hundred years. Elsewhere, these terms may be used to designate middle class Mexican Americans. In general, however, Mexican American is the preferred term (pp. xiii-xiv). Recent Terms Two terms, "La Raza" and "Chicano," have come into wide usage recently. Moore (1970) says "the idea of 'La Raza' permeates the Mexican American population. 'La Raza' does not refer to 'race' at all, but to a vague sense of ethnic identity, a compelling feeling of belonging--but to what is left relatively unconceptualized" (pp. 158- 159). La Raza apparently encompasses all Mexican Americans. Steiner's (1970) La Raza is sub-titled The Mexican Americans. Samora's (1966) La_ Razg_is sub-titled Forgotten Americans. Both writers are concerned with Mexican Americans as a minority group. "Chicano," used more frequently than La Raza, is still in the process of change in definition and usage. Simmen (1972) says that the origin of the word is unknown. Two plausible theories exist. One theory "ascribes the word to Nahuatl origin, suggesting that Indians pronounce Mexicano as 'Me-shi-ca-noh' . . ." (p. 54). The first . ..o I. III, . . O I " . I ' I t h | r . _‘ ., 7, . ‘ ~ 'u' . I 'q I ... I h .V)‘ ' I - r V I- . - . . _ I. § 0 . . ". i h '\ I'. e . ' - \ . .‘ .- 'I “I. . I " P 21 afllable was drOpped, the “sh" was changed to "ch” and the term was (med for ethnic identification. The other theory "asserts that the vmrd was conventionally formed by suffixing afl9_to ghigg_(young boy) exactly as one would form, for example, Mexicano from Mexico" (p. 54). Simmen (l972) recognizes that a minority of Mexican Americans would like to use the term "Chicano" to replace all other labels presently used. Most Americans today would define Chicano as follows: "A dissatisfied American of Mexican descent whose ideas regarding his position in the social or economic order are, in general, considered to be liberal or radical and whose statements and actions are often extreme and often violent" (p. 55). However, he thinks that, in time, the word will mean "an American of Mexican descent who attempts through peaceful, reasonable, and responsible means to correct the image of the Mexican-American and to improve the position of this minority in the American social structure" (p. 56). There is a curious blend of all three usages in the literature. Simmen (l972), on the back cover of his book, uses "Chicano” and "Mexican American" synonymously. Delgado (1971) writes about the Chicano movement, a movement by the young, particularly students, as a "refusal to acculturate or be absorbed, or assimilated into the dominant or larger society . . ." (p. 1). He Speaks as a militant to provoke action. Carranza (1969) seems to see the Chicano as militant and/or intellectual who is actively engaged in a "cultural revolution" of self-determination for all Mexican Americans, with the Chicano as the agent of change (p. 8). He speaks as an intellectual, to arouse feeling r" .. . ' ~ya \ . . I . ‘ ‘ D ’O '- - . . .f . - Du ' 9 K. o J. V ‘ .l I . ‘L- a . . o : u *‘a- i n . 1 ‘ o ' O n .I‘ ' I \v . g Q.. '- - 2"- u, I I‘ w u 3‘ I. .. I; ' y 22 and provoke thought. Other books with "Chicano” in the title use the term to refer to all Mexican Americans (Simmen, l972; Simmen, l97l; Ludwig and Santibafiez, l97l; Wagner and Haug, l97l; Vasquez, l970). The bibliography compiled by Grebler, Moore and Guzman (1970) provides an interesting perspective on terminology. This bibliography contains about l,500 entries and covers a Span of more than fifty years. Most of the entries prior to the mid-forties use the term "Mexican" to refer to those of Mexican heritage. Beginning with the late forties and to the present, "Latin" is used frequently for studies done in Texas, "Mexican American" or some Spanish designation for those in other states. This change may reflect a change in Census Bureau terminology. In 1940, the Bureau dropped the Mexican classification and "used prin- cipal language other than English,“ using the classification Spanish speaking (Samora, 1966, p. xiii). It may also reflect a change in attitude toward the Mexican American. Servin (1969), in a brief description of the literature, says that during the twenties and thirties, most of the studies concluded that the plight of the Mexican American was the "result of his inherent lack of ambition, his innate violence, his racial make-up, or his religious beliefs" (p. vi). Following the Second World War, this attitude changed. "American writers began viewing the unhappy plight of the Mexican-American from a sociological viewpoint that exonerated him and attributed the cause of his downtrodden position to various aspects of American society" (p. vii). The bibliography (Grebler, Moore and Guzman, l970) also attests to the recency of the terms La Raza and Chicano--each term is repre- sented by only one title in the entire collection. .1v“ . .I " _..n I . ,....- . ...- ' a N... - .y,. 7‘".- u x ‘ fl 3" 23 In reviewing the literature, I will use the terminology used by the particular author. In some instances, I can only make an educated guess as to whether he refers to Mexican Americans or some other Spanish-speaking group. Present Interest National interest in and concern for the Mexican Americans is a fairly recent phenomenon. Grebler, Moore and Guzman (1970) state that they were first recognized in a national political campaign by John F. Kennedy in 1960. A decade of change began in the larger society, demonstrated in civil rights legislation, anti-poverty pro- grams and Supreme Court decisions against discrimination in many spheres of life. At about the same time, the Mexican Americans began to recognize themselves as a "national minority" largely ignored, but perhaps capable of bringing about change in their situation (p. 4). A spate of literature in the 19605 and on into the '705 attests to their having been ignored by the larger society. The writers, the majority of them Mexican American, refer to the group as "Forgotten Americans" (Samora, 1966), "An Awakening Minority" (Servin, 1969), "An Awakening People" (Haddox, 1970), "A Forgotten American" (Hernandez, 1969), and "Emerging Faces" (Cabrera, 1971). Concomitant with having been ignored by the larger society are statements of having been ignored in the literature. Cabrera (1971) says, "We are in an era of ethnic cultural awareness today, and there is a demand for publications about Mexican-Americans. Not much is 24 available" (p. vii). Burma (l970b) says "until the last five years it was very difficult to secure information on this important ethnic group" (p. xi). Moore (l970) points out that Mexican Americans "have had almost no press whatsoever." Although they are the nation's second largest disadvantaged minority, lime magazine in 1968 “has yet no idea that Mexicans are a substantial part of the nation's poor" (p. 157). Heller (1966) says, "The meager literature about the Mexican Americans both reflects and contributes to their being unremembered and little known" (p. 4). Grebler, Moore and Guzman (1970) disagree, however. Contrary to widespread impressions, a great deal has been written about Mexican-Americans by social scientists. (Our bibliography lists about 1,500 items ranging from books to magazine articles and government publications.) Much of the scholarly work is valuable. However, most of it is so local in scope that its impact on even the scholarly community has been limited. Moreover, many studies have focused on the rural Mexican American, or they were conducted in remote areas and urban ghettos where isolation allowed traditional culture traits to be preserved. These studies unwittingly helped to overempha- size the notion of a highly distinctive population. Many users of such research carelessly extended the notion of cultural uniqueness to the entire Mexican-American popu- lation regardless of differences in the social setting. Policy makers embraced this notion when it would help "explain" why American institutions failed to reach the population [pp. 6-7]. Their bibliography is indeed lengthy and comprehensive. The vast majority of the literature concerns Mexican Americans in the five southwestern states with large numbers of this population-~Texas, Arizona, New Mexico, Colorado, and California. Little has been written about those who settled in the midwest. Education and language are consistently the topics of major interest. 25 The health-illness spectrum, with all of its ramifications, receives little attention. I counted seven books, two chapters in compilations, 29 journal articles, 11 unpublished dissertations and 15 other unpublished materials. In the meager total of 64, one--a Master's thesis--concerns Mexican Americans in the midwest. Health and illness as a topic and the midwest as an area have received relatively little attention in the literature. Descriptionskby Anglo Writers There is a very high degree of similarity in the anthropological studies of the Mexican Americans. To all intents and purposes, Saunders (1954), Clark (1955), Madsen (1964) and Rubel (1966) say the same thing. Heller (1966) is concerned specifically with teen-aged boys. However, all five books present essentially the same picture of the culture of the Mexican Americans. Knowledge, belief and practice related to health and illness can only be understood within the context of the culture of the group. Books written about health and medical care of the Mexican Americans include a study of the culture (Clark, 1959; Saunders, 1954); books written about the culture include chapters on health and illness (Rubel, 1966; Madsen, 1964). Clark (1959) points out the relationships between health/illness systems and the culture in which they are found. Since medical systems are integral parts of the cultures in which they occur, they cannot be understood simply in terms of curing practices, medical practitioners, hospi- tal services, and the like. Medical systems are affected by most major categories of culture: economics, religion, 26 social relationships, education, family structure, language. Only a partial understanding of a medical system can be gained unless other parts of culture can be studied and related to it [p. 1]. Some aspects of the culture and social position of the Mexican Americans have particular salience for public health nurses, both in themselves and as they interact with the health-illness system. These will be reviewed prior to a review of the folk health care system. Family Relationships, "One cultural trait of the Spanish-speaking pe0p1e that is constantly underevaluated by Anglo medical professionals in both rural and urban areas is the strong family relationship and the extent to which family affairs take precedence over matters that Anglos consider more important" (Saunders, 1954, p. 210). The strength of family ties, both nuclear and extended, is emphasized in everything I read. Madsen (1964) describes the family as "the main focus of social identification in all classes of Mexican- American society." It is "a sanctuary in a hostile world" (p. 44). He states that a person is a member of a family first and an individual second. Children are valued and loved. Kinship ties extend to both sides of the family and over three generations. Kinship is further extended through the institution known as compadrazgo, or caparenthood. The coparents are sponsors, as in baptism, who assume carefully defined roles in establishing a ritual kinship. Sex roles are clearly defined and children learn them early in life. The father is the head of the household, to be honored, respected 27 and obeyed. The mother is submissive.to her husband; her responsibility is to her husband and children. The mother tends to be isolated in the home; visiting with other than real or ritual kin is discouraged. Madsen (1964) concludes with the observation that the tradi- tional strong family is best preserved in the lower classes and weak- ening as families rise in socioeconomic level and become more anglicized. However, the ties of the Mexican-American family are stronger than those of the Anglo family, regardless of degree of anglicization (p. 46). Rubel (1966) likewise stresses the importance of the home and family. "The strength with which a person is bound to his family . . . overshadows all other bonds in importance . . ." (p. 55). Sex roles and interpersonal relationships are well defined. "The older order the younger and the men the women" (p. 100). The family is extended bi- laterally and further extended through ritual kin. The nuclear family is isolated socially, if not spatially, from non-kin (p. 100). Tuck (1946), a number of years prior to the previous writers, recognized the changes which were occurring in the Mexican-American home. When it comes to the matter of family life, one's subject matter becomes at once less concrete and more unmanageable. The most common experience in talking with informants was to be given a description of "the Mexican home," drawn in bold, substantial, unequivocal outline, consistent in every detail. Just as I was feeling solid ground under my feet, the speaker would add, "But, of course, we don't do a lot of those things in our home. . . ." By the time I had gone through a dozen such interviews, that nice, neat structure labeled, "the Mexican home" had been partially torn down, remod- eled, repartitioned, and even redecorated. . . . Still, through the mass of detail, outlines could be glimpsed which corresponded to that "Mexican home" which had originally been defined for me [p. 119]. .I‘. “u o I .- . . .A u .v .v I 0' ~ I - .‘ -. ‘Iog. , '~ ~u- 28 Language Tuck (l946) says, "There are three areas in which culture survival seems to be strongest: language, food habits, and family life. Even here, nothing is static“ (p. l18). The Spanish language persists in the homes, but by the second generation it has become rather Anglicized. Few of the children can write good Spanish. Twenty-two years later, Heller (1966) found that the prin- cipal language used by first, second and third generation Mexican Imprican youths, particularly in interpersonal relationships, was a fiwm of Anglicized Spanish. Saunders (1954), in commenting on the [mrsistence of the Spanish language, says "language difference is both acmuse and an effect of isolation, and as such exerts a strong influ- emce in the perpetuation of other cultural traits . . ." (p. 111). Acculturation All writers agree that the Mexican Americans, as a group, are "assimilating" into the larger society very slowly. Today, the Mexican-Americans are undergoing acculturation in the American melting pot, but many seem to be well- insulated against the melting process. They cherish much of their Mexican cultural heritage as too precious and universally valid to be abandoned. . . . There is no general agreement on what mechanisms can best be uti- lized to hasten the remaking of the Mexican-American into a plain American. Many sincere individuals working with this problem are distressed that the Mexican- American fails to recognize the "inherent superiority" of the all-American way of life [Madsen, 1964, p. l]. Heller (1966) says, "Both in the rate and degree of accultura- tion and assimilation Mexican Americans are among the least "American- ized" of all ethnic groups in the United States." She goes on to say, 29 "they display a marked lack of internal differentiation, whether in terms of schooling, occupation or income" (p. 4). Social Class All writers likewise agree that the vast majority of the Mexican American population falls in the low income or disadvantaged or poverty group. Glick (1966) says, "Two ethnic or racial groups in the United States are currently distinguished by their inferior economic status as compared with the nation as a whole" (p. 95). Barrett (1966) says, "The Spanish-Speaking population in the five southwestern states has remained a socially and economically underprivileged group during the 117 years since the treaty of Guadalupe-Hidalgo" (p. 195).1 Rubel (1966) de- scribes the differences in life on the two sides of the tracks--the north or "Mexican town" side and the south or "American town." He says the differences in the two are due, in part, to the traditional cultures which guide the lives of the two groups and, in part, to the low income characteristics of those in Mexican Town (p. 23). Cabrera (1971) summarizes the picture of Mexican-Americans presented by the Anglo writers. Historically, the Mexican-Americans inherit similarities which identify them as a group. The Spanish language unifies them, not only as a means of communication, but also as a symbol of their culture. Religion serves as a bond. The extended 1There is a relatively small group of upper middle class Spanish Speaking people, many of whom are descendants of the original Spanish land-grant'famdlies. They live apart from the majority of the Spanish speaking people whose background is Mexican (Madsen, 1964). , .a , I a 4 .u' a". . u ‘v . ,v .10 ' I ,. .ur , u i. I \ -I- I a on a a n 'I 0‘. 'u , l i 30 family, with its strong ties, provides security. Internal qualities are valued over material success. Frequently, Mexicans are described as having a present-time orientation. There are many ideologic con- trasts between the concepts of the Mexican-American and the Anglo. The result is discrimination and prejudice. He concludes by stating that this "standard story or explanation of the Mexican American . . ." is likely to be accepted without question. "How much of this is true or how great are the contemporary variants are basic questions for exacting studies. . . . Today what passes as understanding the Mexican-American is at times distorted, polarized and absurd" (Cabrera, 1971, p. 4). Comments by_Chicano Writers Other Chicano writers are not as kind as Cabrera in their evaluation of the Anglo social science literature about Mexican Americans. Chicano writers point out that the Anglo authors present a stereotyped view of the Mexican Americans as a pe0ple without a history, passive, non-changing and all alike. Romano (1971) writes a detailed critique of a number of the books mentioned above and con- cludes that "contemporary social science views of Mexican Americans are precisely those held by people during the days of the American frontier. In short, there has not been any Significant change in views toward Mexican Americans for the past l00 years" (p. 37). He goes on to say that the social scientists are perpetuating opinions that are "pernicious, viscious, misleading, degrading and brainwashing in that they obliterate history and then re-write it in such a way as to eliminate the historical significance of Mexican Americans" (p. 37). 31 Rios (1971) comments as follows on Romano's article: The question now arises as to what steps follows Romano's lethal thrust at the erroneous and prejudicial, but widely accepted concepts concerning the Mexican American advanced in the name of social science. Obviously the Mexican American must write his own perspective. Need- less to say, this perspective must not be the half- digested excrement that current social scientists offer as intellectual nutrient [pp. 7-8]. Wagner and Haug (l97l), in the preface to their book of readings, refer to Madsen's (1964) book as "stereotypic, supercilious, and unfor- tunately very influential . . ." (p. xi). Morales (1971), in an Intro- duction to the same book, points out that there are some Chicano writers who "echo Anglo-Saxon stereotypes of Mexican Americans." There are also non-Chicano writers who "have adopted a subordinate-group, i.e., a Chicano perspective" (p. xviii). Galarza (1970) uses the continued stereotype of the extended family as an example of a hazard in language and in research. He says that sociologists still talk about the "extended family" when they describe the Mexican culture in the southwest. It may indeed still exist in isolated rural areas, but is no longer useful in the urban areas and most of this population now lives in urban areas. This leads to "dysfunctional research" as universities still send graduate students out to study the extended family. They might better put their efforts into defining and studying the areas of change in the Mexican family and community (p. 4). One of the major points made by these Chicano writers (Romano, Rios, Galarza) is that the Anglo writers (Tuck, Meller, Madsen, Saunders) say, implicitly or explicitly, that the problems of the Mexican American 04-, fl. - o4 :9. . ud- . "I“hn .4 ‘H‘n. u, ' a" b ’I v . t. ,I‘h . ', s l ' l . . ,- § n. . p ' I 32 are a result of his culture. The Chicano writers suggest that much of the problem lies in the social structure of the larger society. Galarza (1970) talks about the deviancy of American social institutions in relation to the Mexican--they are not geared to meet the needs of the Mexican as he sees the needs. Grebler, Moore and Guzman (1970) deal with the theme and vari- ation of a cultural distinctiveness in the social science literature. The study which they report is recent and comprehensive; their approach to treatment in the literature is less emotional than some of the Chicano writers (see quote on page 24). The purpose of their study was to "depict factually and analytically the present realities of life for Mexican Americans in our society. These realities depend largely on the minority's interaction with the dominant society." The study focuses on urban Mexican Americans interacting with the larger society in the south- west, primarily Texas and California. The study emphasizes change and diversity within the group, not the lack of change and high degree of similarity reported elsewhere. The Spanish language does persist strongly; other than that, the authors report change and diversity in the commonly mentioned cultural traits.1 1A number of Chicano authors attest to the persistence of Spanish by using Spanish words, phrases and sentences in their writing. In the instances in which an English translation is not provided, the point the author is making is obscured. 33 Mexican Americans in the Midwest Illinois, Wisconsin and Ohio Samora and Lamanna (1967) report a study done in East Chicago as part of the Mexican American Study Project mentioned above. For the most part, the findings are the same as reported in other studies. They find little difference between those in East Chicago and those in the southwest, within the parameters discussed by Grebler, Moore and Guzman. Those in East Chicago are likewise "disadvantaged" by any yardstick. Moving to the industrial north apparently did not help them to improve their socioeconomic status. The population is young, with large families. The family continues to be a bulwark of tradition; the Spanish language persists; assimilation is largely limited to a few individuals who have moved out of the isolated areas in which most of the Mexican Americans live. In fact, this report sounded to me more like those of Madsen (1964) and Rubel (1966) than like Grebler, Moore and Guzman. Shannon (1966) reports on a longitudinal study done in Racine, Wisconsin. He studied three low-income, immigrant groups--Anglo, Black and Mexican-American. Here, as in the other studies, the Mexican- Americans are part of the poorly educated, low-income group with poor housing and low-status occupations. The group is young with large families. Use of Spanish continues, with most of the children bilingual. However, many of the Mexican-Americans see their ethnic practices declin- ing, although this is not what they want. Most of them feel that they have bettered their situation by moving from the Southwest (largely Q]. i .q. .u 1. ;-, up; .- D! «'0 . .tu: . w I .' an ‘ ‘ " ”I I! I ‘ 3. w ‘ u. ‘ . o 'lI‘ ', .v Q" . C h ‘ 7‘- : 2.? n l . " I . D; - . A. o I. ‘- s h I p. . Da- -‘\ .‘ 5 ' u x I ~ 0 '- ~ ‘~‘. \.'. S .- . .g‘ u ‘- n C. k , 34 lexas). This does notwmean that they are satisfied to remain in the low-income group. Upward mobility is a slow process, however. Edu- cational attainment does not function for the Mexican-American as it does for the Anglo in improving Opportunity and status. One conclusion which they draw is that “variables completely beyond the immigrantS' control have probably had more to do with what has happened to them than the individual or group characteristics that have so often been hypothesized to be the determinants of absorption and integration into the larger society" (p. 428). In a follow-up study ten years later, very few of the Mexican-Americans had improved their socioeconomic position (Shannon and Shannon, 1973). Macklin (1963) studied the Mexican-American community in Toledo, Ohio. The people lived in three contiguous communities, all near the central city. Although the areas were not exclusively Mexican- American, there was almost no socialization between Mexican-Americans and non-Mexican neighbors. Almost all interaction took place between real, affinal and ritual kin; the women were socially isolated in the home. Family ties remain strong. Families are large, with an average of five children. Most of the men have low-skill, low-income jobs; the families live with "poor whites in a culture of poverty" (p. 42). Macklin suggests that the slow rate of acculturation is the result of some aspects of the Mexican-American culture, some factors in the dominant community and the fact that Anglo culture is mediated to the Mexican-Americans through Anglos in the lower socioeconomic classes. 35 Michigan Goldkind (1963) studied factors in the acculturation of Mexican Americans in Lansing. He found the p0pu1ation, generally, to be young with low educational levels, employed in low Skill occupations and having low incomes. He considered four dimensions of acculturation-- position in the occupational structure, membership in organizations, contacts with Anglos and ethnic cultural traits. Those who were more acculturated had greater fluency in English, longer residence in the north, less experience in the migrant stream and higher education. He used knowledge of folk medicine as one of the ethnic cultural traits. He found recognition of Mexican folk medicine related significantly to "longer Mexico residence, older age, longer agricultural work experi- ence, lower grade of school completed, less English fluency, and less pre-Lansing contact with Anglos. Also, a higher index of Mexican appearance is significantly related to a greater recognition of folk medicine" (p. 120). However, he did not consider belief or practice in the folk system, nor articulation with the Anglo system. Choldin and Trout's (1969) study of Mexican Americans in Michigan (excluding Detroit) is similar to the Grebler, Moore, Guzman study in that it stresses change and interaction with the dominant society. They are struck by the diversity within the group, as were those involved in the former study. Much of the demographic data is the same as in any other study. The p0pu1ation is young, with large families. They are disproportionately represented in the low-income segment of the total population of Michigan. Their educational level 36 is low, by Anglo standards, but higher than the level achieved by those who live in Texas. They suggest that the "role of cultural variables in the migration, resettlement, employment, education and mobility of Mexican-Americans must be considered in the varying situational contexts into which migrants move and within which they and their children live" (p. 11). Verway (1973) presents a profile of "Spanish Michigan" using data from the 1970 census. The census term "persons of Spanish language'I includes all peOple in families where at least one parent gives Spanish as the native language. This designation encompasses Mexican, Cuban, Puerto Rican, Central and South American.) His findings are essentially the same as Choldin and Trout's (1969) and Shannon's (1966). The popu- lation is young with large families. (All comparisons are made with total population of Michigan.) For the most part, they have settled together in certain areas of the state and in specific areas in cities. They are over-represented in low skill, low paying jobs. Unemployment is higher for both sexes and in nearly every age group. Women are under-represented in the labor force. In most occupations, the Spanish speaking earn less than their "other white" counterparts. However, they "are relatively better off than their national counterparts in both an absolute and a relative sense" (p. 7). “Are «0' I «not .~-..' u c l b P‘I .: ' ~ u. I ‘; . ‘0. 'l. él‘II: C u ‘\ .: "A s u .-I «II 37 Culture or Poverty? All writers agree that the Mexican Americans are a "disadvantaged minority" or part of the poverty population. Early writers, for the most part, suggest that their culture is responsible for their low social status. Later writers suggest that the poor Mexican American has much in common with all other poor people and much of his behavior is a func- tion of poverty. Shannon (1966) and Choldin and Trout (1969) view the social situation as a crucial variable. Several Chicano writers point out that many of the attributes of the Mexican American are really attributes of most poverty groups. Sotomayor (1971) attempts "to Show how a Significant number of weaknesses that had been attributed to the internal dynamics of the Mexican-American family can now, by the systems approach, be ascribed to the limitations placed upon the Mexican Americans by external systems . also . . . to point out how these limitations affect the internal integration of the family unity" (p. 320). Casavantes (1971) presents a comprehensive discussion of eight qualities "invalidly attributed to Mexican Americans as part of their ethnicity" (p. 46). Briefly stated, the characteristics are (1) ethno- centricity, (2) non-participation in voluntary associations, (3) pref- erence for the old and familiar, (4) anti-intellectual attitude, (5) male demonstration of manliness, (6) use of physical force to settle arguments or punish children, (7) inability to postpone gratification and (8) a fatalistic view of the world. He relates these to poverty, a context in which they do have validity, and concludes that these eight ,QOI. 1 I\ v‘ a up. “W: In 38 qualities are "basically the qualities or attributes of people from the culture of poverty, not the culture of Mexico“ (p. 49). He sees the essence of the Mexican American in the Spanish language and Mexican- Spanish ancestry. Most are Catholic and most have dark skins, although these qualities are not essential. He sees poverty as the major factor in the "impossible situation" of the Mexican American in this country today. Burma (1970a) uses many of the above mentioned qualities in comparing the Mexican American subculture with Lewis' culture of poverty model. His comparison differs from Casavantes in that Burma recognizes both similarities and differences whereas Casavantes sees only similar- ities. For example, he says the existence of the "ideal" Mexican family, with a loving mother and a providing father who bring up their children to be respectful and courteous provides for a major family difference in the Mexican American subculture and the general subculture of poverty. Mexican Americans demonstrate more personal pride than the rest of the poverty population. He states that there is a qualitative difference in social interaction in the Mexican American subculture, with greater stress on courtesy and pleasantness. The Mexican American is not as materialistic in his goals and desires as the Anglo. Communication problems exist between those in the subculture of poverty and the dom- inant culture even when both have English as their native language; these problems are compounded for those who have Spanish as their first language. In working with the Mexican families in Child Health Clinic, I had recognized that some of their behavior might well be a function of 39 poverty. I had also observed some differences between the poor Mexicans and the poor whites which might be attributed to cultural differences. Experience bade me accept the idea of diversity within the group, rather than lack of internal differentiation. Observation told me that they had large families and little money. No experience in the Clinic, howr ever, told me anything about the existence of or adherence to a folk health care system. Did these mothers participate in the folk system? If they did, they did not mention it in the Clinic. Do the folk dis- eases and folk cures persist in the midwest? This will be the major focus of this dissertation. Health and Illness The existence of a well-defined, cohesive folk health care system within the Mexican American culture is amply described in the literature. Foster's article (1953), tracing much of the folk medicine of Mexico and other Central and South American countries to medieval Spain, is widely quoted.1 In addition to this source, Saunders (1954) 1Foster describes the "hot-cold" theory of disease as one aspect of folk medicine brought by the Spanish. Harwood (1971) describes the theory as part of the belief system of many Puerto Ricans in New York City. "The hot-cold system stems from Hippocratic humoral theories of disease . . ." in which the body humors are thought to be "hot" or "cold." Illness results from an imbalance and is treated by foods or herbs which are "hot" or "cold" to restore the balance (p. 1153). "Hot" and "cold" are inherent prOperties not related to temperature. The "hot-cold theory" is not included in this study for several reasons. Very few of the writers refer to the theory in their descrip- tion of the Mexican American folk system. Rubel mentions it briefly in his early re ort (1960), but not in the later publication (1966). Madsen (1964 states that some curanderos and recent migrants from Mexico subscribe to the theory. Clarkll959) found that very few of her informants knew which foods were inherently "hot" or "cold." Al- though they retained many of the dietary habits and treatments of the DI. ' - o‘v .Il l g l n" . ‘5 u ' Ia _, ., :4 Nu '- ol ~ .. u- I ,- . ‘_ 40 says that the medical knowledge of the Spanish speaking people comes from one or more American Indian tribes, Anglo folk medicine and "scientific" medicine. Saunders describes folk medicine as common knowledge within the group. The practices and beliefs are rooted in tradition; they are taken for granted as part of daily living. Folk medicine is integrated with and reinforced by other elements of the culture. It is accepted uncritically. Folk medicine "is rooted in belief, not knowledge, and it requires only occasional success to maintain its vigor" (Saunders, 1954, p. 146). Health and illness are integral parts of social life in the Mexican American culture. Illness may be caused by disturbed inter- personal relationships within the kinship group, or outside it; it may be a punishment from God; it may be caused by forces over which the individual has no control, be they witches or bacteria. Madsen (1964), Clark (1959) and Rubel (1960) give essentially the same description of the folk health-illness system, the causes, symptoms and treatments of folk diseases and the integration of system, foods were considered "hot" or "cold" according to temperature. Kay (1972) does not mention the theory in her comprehensive classifica- tion of the health-illness systemof abarrio (Mexican American enclave) in Tucson. She does give examples of specific relationships between diet and health-illness conditions. Apparently the behavior persists; tne underlying theory may be lost as part of the process of culture c ange. None of my informants mentioned the theory as such, although they did allude to some of the behaviors. ("It is not good to drink something cold when you are all hot and sweaty.") The theory is not relevant to the four folk diseases in which I was particularly interested. 41 health-illness with the rest of the culture. All include examples of the various diseases as they were manifested, caused, diagnosed and treated in instances known to their informants. Since my interest in this study is directed to children under five, I selected the four folk illnesses which commonly affect children (caida de mollera, mal de ojo, empacho and EEEIQ)- Do Mexican children in Lansing get these diseases? If they do, how and where are they treated? Does belief in these diseases result in delay of medical treatment? Do mothers who believe in these diseases tend not to have preventive care for their children? These four diseases "have remained firmly embedded in the socio- cultural framework, despite the introduction of an alternate system of belief and competing healing ways" (Rubel, 1960, p. 318). They are diseases that only people of Mexican heritage get and they are not amenable to treatment by scientifically trained physicians because they do not understand or believe in them. Rubel concludes that these four diseases will continue to be important to the traditionally oriented Mexican Americans because they "function to sustain some of the dominant values of the Mexican American culture" (Rubel, 1960, p. 813). Macklin (1963) arrived at the same conclusion in her study of the Mexican-Americans in Toledo. She reports that most mothers know how to treat the common Mexican-American diseases; more serious problems are usually taken to a medical doctor. The Mexican-Americans feel that edu- cated physicians are "adequate as far as their knowledge goes . . ." but laugh at or scoff at folk illness, therefore they are not equipped to 42 take care of them (p. 219). Many of the people visit a curandera who lives more than one hundred miles from Toledo. Macklin feels that the presence of this curandera serves to stabilize the social structure and inhibit culture change, since she "nearly always interprets illness in terms of deviation from approved Mexican-American behavior" (p. 222). Specific Diseases The following descriptions of the four diseases are condensed from Rubel (1960), Clark (1959) and Madsen (1964). Caida de mollera(fallen fontanelle).--This is the only one of the diseases which afflicts only children, usually under six months of age. It is believed that the area of the head, directly beneath the anterior fontanelle and the hard palate balance each other. Anything which disturbs either the fontanelle or the palate can cause the fontanelle to fall, a condition which can be felt with the finger. Thus, a blow to the head or a fall can result in the fontanelle falling. Vigorously pulling the nipple from the baby's mouth while he is sucking can also cause the fontanelle to fall. In addition to the depression in the skull, a "little ball" can be felt in the palate. Symptoms include vomiting, diarrhea, fretfulness, inability to suck well and, usually, fever. There are four methods of treating fallen fontanelle, all designed to restore the balance between the fontanelle and palate. (1) The palate may be pushed up hard with the thumb in an effort to make the fontanelle "pop" back into place. (2) The curer may place her lips around the fontanelle and suck gently to bring the fontanelle back up. (3) The fontanelle may be covered with a thick soap suds or a solution 43 of egg white and water. This may be left to dry and pull the fontanelle up or the curer may cup her hand over the fontanelle and the solution, create a vacuum and pull upward. (4) The child may be held upside down by the ankles with the top of his head in a pan of warm water. Then he may be shaken gently, twirled, or the bottom of his feet may be slapped gently three times. Mal de ojo (evil eye).--This disease may afflict anyone, although women and children are more susceptible, Since they are weaker than men. It is believed that some people have "strong eyes“ and can gain control over a weaker person. If a person with "strong eyes" admires or makes a fuss over a child, perhaps with envy, the child can get mal de ojo. There is no intent of evil on the part of the person causing it, and the spell will be broken if the person touches the child's head. If a mother suspects mal de ojo, She tries to determine wmo might have caused it and gets that person to touch the child. If this is not possible, other treatment is necessary. The illness has a sudden onset with intensive crying, trembling, insomnia and, usually, fever. Diagnosis is made by rubbing an unbroken egg over the body of the ill child, then breaking the egg into a glass of water. If a spot appears on the yolk, the diagnosis of mal de ojo is made. Treatment consists of rubbing an egg over the entire body in the shape of the cross while reciting prayers. The egg is then broken into a bowl of water, three small crosses are made on it with Holy Palm leaves (or broom straws) and the bowl is placed under the bed. In the morning, the child will be well. If the egg appears cooked, the fever has gone out of the child into the egg. «a 0 a ,7: 44 Empacho (a form of indigestion).--In this disease, a ball of undigested food gets stuck on the wall of the stomach or intestine. It causes pain, swelling, and loss of appetite; the hard ball may be felt. It may be caused by eating a food which disagrees with one, or by eating too much. Rice, bananas and soft white bread are particularly likely to cause emgacho. It may also be caused by eating food one does not like or want to eat, or at a time when one does not want to eat. For example, if a guest eats food he does not want out of courtesy to the hostess, he may get empacho as a result. Treatment consists of rubbing the back and abdomen, pulling up the skin along the spine and letting it "snap" back, administering various herbal teas which have a laxative effect and maybe giving a dose of castor oil. (An Anglicized informant told Rubel (1966) that empacho is nothing but constipation and a good dose of epsom salts was all that was necessary.) Susto (fright Sickness).--This illness is caused by an expe- rience which frightens the individual. Rubel (1960, 1966) says it occurs when the individual is in a situation in which he perceives himself to be helpless, frequently an inability or failure to meet social role expectations. The symptoms include fatigue, restlessness, loss of appetite and irregular pulse. There are many ways of treating sgstg, Most treatments utilize prayers, rituals using the Sign of the cross, sweeping the body, and ingestion of herbal teas. They may extend over three or nine days. If not treated immediately, sgstg_can be a serious and dangerous disease. Madsen (1964), Clark (1959), Rubel (1960, 1966) and Saunders (1954) all stress the importance of interpersonal relationships as a ‘r‘ v ' \ . Q 45 factor in the cause of disease and as a major factor in treatment of disease. Much of the success of treatment, they feel, derives from the concern, love and attention directed toward the patient. If the treatment is done by someone other than the mother, the family is consulted and participates in the rituals. sees. Rubel (1966) reports four levels of healers from whom the Mexican-Americans seek help when ill. The least specialized are housewives, who care for members of their own families. Next are neighborhood healers who usually are older women with experience in treating illness (sefioras). "The most highly revered of all categories of healers, the curandero, is unlike any other" (p. 200). He or She cures by virtue of a gift from God. Finally, there are the certified physicians "whose technical skills and knowledge are accorded consider- able respect by Chicanos" (p. 200). Weaver (1970) describes the same categories of healers. He inesented hypothetical illness situations to individual rural tradi- ‘fional Spanish Americans and to a group of acculturated urban Spanish IMericans. All participants "were asked a series of direct questions about the symptoms, diagnosis, treatment, beliefs, and action associated ifith the particular ailment . . ." (p. 141). (Although Weaver's infor- mmns are Spanish American, their responses and behavior are the same as the Mexican Americans in other studies.) He describes four phases hithe illness referral system. The first is the kinship phase, which imfludes consulting with members of the nuclear family and bilateral kin. 46 The second phase is the community phase, in which influenctial, knowledgeable and experienced pepple are consulted. The folk specialist phase, the third, includes culturally defined healers. The urban pro- fessional phase consisting of scientifically trained practitioners is fourth. The typical rural traditional patient goes from kinship to community to folk specialist to urban professional. The typical urban acculturated patient goes from kinship directly to urban professional, but may go to the folk Specialist after the professional (p. 142). There is concensus about these categories of healers. The traditionally oriented, unacculturated Mexican Americans are apt to have more contact with the folk healers and less with the physicians than are the acculturated. To a greater or lesser degree, some belief in the practice of folk medicine persists in both groups, on a continuum. It is not unusual to find people participating simultaneously in both systems in their search for a cure. Folk illnesseS--those which only Mexicans get--are treated within the folk system. If a cure does not result, then perhaps it was not a folk illness, but something which a physician could treat. Conversely, if the physician does not cure the lutient, then perhaps the problem should have been treated in the folk system in the first place. Recent Studies E It is apparent from the foregoing discussion that the folk health care system has been studied within the context of the Mexican American culture. However, as stated earlier, the broad Spectrum of health and illness has not been of major interest to those who have ‘r- O r... n c .. . U. 0'- . b ,. . v I .-.: I. \p ..- . (1‘ II. p o".- I v-.,.,, u ‘ n c ‘ O . '}‘ ' n - §. _ . "‘ II. | ‘ I (I H u. :- ""Fn ' w I r . ,, ‘s . \.. 47 studied this population.1 The Mexican-American Study Project (Grebler, Moore and Guzman, 1970) produced an Advance Report related to health. Since the Study did not produce any original data, the Report is com- posed of existing materials, with some Special tabulations (Moustafa and Weiss, 1968). Shannon's (1966) study in Racine, Wisconsin, was initiated by a request from the State of Wisconsin Board of Health. They recognized a problem situation in the community peopled largely by Mexican-American immigrants. "Foremost among the problems were the poor physical health of the residents and their economic dependence or instability. Communi- cable disease rates were high and illnesses common. The children of the community were said to be ill-fed, ill-housed and ill-clothed by middle class standards" (p. 2). There were also problems of sanitation--no running water or sewers in the community. Professional people "expe- rienced great difficulty in their attempts to reach this segment of the (mmmunity and became aware of the fact that normal approaches were inadequate to deal with what they defined as an extremely desperate situation" (p. 2). The Department of Public Welfare and the Governor's (bmmission on Human Rights joined the discussions. It was decided that "research was urgently needed on processes of value assimilation and lmhavioral change among culturally separate immigrants to Midwestern k 1Locating what has been done recently in research into this area posed problems. Neither Med-Line nor Index Medicus has a category for Mmdcan Americans by any designation. Psychological Abstracts has no smmect entry for Mexican Americans. Sociological'Abstracts has an enhy'"Mexico (an) (ans)." Abstracts in Anthropology indexes by the terminology used by the author. 48 communities" (p. 2). However, the study did not include any_questions related to health or illness. In the portion of the study dealing with respondents' perceptions of institutions in the community, the respondents were Anglo and Black, no Mexican-Americans, and no health institution was included. The nursing literature offered little about the Mexican Americans. Baca (1969) presents a brief description of some of the concepts of health and illness held by the Spanish-speaking. She feels that it is important for nurses to know not only that these concepts exist, but that they persist. If the scientific measures and treatments which the nurses teach conflict with the folk system, the people "are apt to reject that which is foreign and contrary to their own tradition" (p. 2172). More recently, Prattes (1973) provides a more comprehensive description of folk beliefs and practices. She, too, points out that they persist and will probably continue to persist because of the social isolation of the poor Mexican-Americans and the continuing in-migration from Mexico. She recognizes the frustration the nurse must feel "at their failure to see the benefits of scientific health care practices . ." (p. 136). She points out that "scientific medical care is often rmt available to these people in a form that is meaningful to them, and many have seen little evidence of the benefits of modern medicine and nursing" (p. 137) . The persistence of the folk health care system is stressed also m/ethnographers of the Mexican-Americans. They suggest that belief and “o n "I On p '1 l s." m, I "An u, l u. . ,. ‘2.» "A ' 1,5 l . ‘:- .. l‘ ' -I "in U 5“ ., .I‘ r i. .__ i s‘:.‘ ~| "I J" ‘ I"‘ u . u, I I“ V. f": o P ‘l '.. 'u_ a II . or “p u 49 practice exist on a continuum, being strongest in the least acculturated and weaker in the more acculturated. However, they do not provide data on how many of any given group adhere to the beliefs and practices. Martinez and Martin (1966) report on an exploratory study "to determine the extent of knowledge about these (folk) concepts among Mexican- American women in a large Southwestern city; to obtain a detailed account of beliefs about etiology, symptomatology and modes of treatment . . ." (p. 161). They interviewed 75 Mexican-American women who lived in a public housing project. They found that "more than 97 percent of the women interviewed knew about each of the five diseases" (p. 162). The five diseases were mal ojo (evil eye), caida de mollera (fallen fontanelle), empacho (surfeit), susto (fright) and Mal puesto (hex). The causes and treatments reported by these women were essentially the same as those reported by others. "All but 5 percent of the women reported one or more instances of these illnesses in themselves, a family member, or in acquaintances" (p. 163). The respondents iden- tified eight sefioras and one curandera in the neighborhood. More than half reported having been treated by a sefigrg, but only 20 percent had sought the services of a curandera. However, adherence to the folk system did not preclude visits to a physician. The authors conclude that "many Mexican—Americans participate in two insular systems of health beliefs and health care" (p. 164). Folk diseases are treated inthin the folk system because physicians do not believe in or under- stand these diseases . Creson, McKinley and Evans (1969) report a study which, they state "replicated the work of Martinez and Martin" (p. 266). However, .A.. «a (I '1 J . - o” :- ' i n ‘ . ‘h- A. I * ' 4.. '53, : .‘w- i W a o a I '3 50 their sample was smaller and was selected from a different group. "Twenty-five consecutive patients with Spanish surnames were interviewed in the Pediatric and Psychiatric Outpatient Clinics of a teaching hospi- tal" (p. 264). Twenty of those interviewed were female, five were male. Shme the care of the sick is culturally vested in the female, their findings may reflect lack of knowledge on the part of the males. They felt that twenty of the subjects had "a good knowledge of the tenets offolk medicine. This was defined as knowledge of at least four of the five syndromes . . . with some knowledge of symptoms and treatment lnocedures" (p. 265). Many of the subjects mentioned using folk remedies at home, particularly herbal preparations. Someone in twelve of the families had used the services of a curandera. The authors conclude that "the concept of folk illness was deeply entrenched and resistant to the influence of the Anglo culture and its scientific nedicine" (p. 265). Folk-Scientific Articulation The relationship between adherence to the folk health-illness system and seeking and using care in the Anglo system has received little attention in the literature. Most of the studies relate to adults who have a mental illness which was diagnosed and treated in the Anglo system. Since this study is concerned with physical illness in children, the above body of literature has little relevance. (See Appendix B for a review.) A recently reported study purports to examine the relationship between folk medical beliefs and health care of Mexican Americans in Nebraska . 51 A sample of Mexican Americans was interviewed to ascertain their attitudes toward medical care and doctors and to determine what kinds of medical care they are receiving. Social characteristics of the respondents are examined to explain differences in "folk" medical beliefs. Beliefs are most strongly related to the size of the Mexican-American community the respondent lives in, but are not highly correlated with any characteristic [Welch, Comer, and Steinman, 1973, p. 205]. Nowhere in the article do the authors state that they asked any questions pertaining to the folk health system. Apparently they infer belief in the system from responses that seemed to indicate closeness to Mexican society and culture (use of Spanish, length of residence in the United States, birth place of respondent's parents and size of Mexican-American community). They conclude that "there seemed to be relatively little evidence of a prevailing 'folk' medical culture" (p. 212). In general, they found that social variables (income, age, sex, education) explained differences in health care to a much higher degree than did attachment to the Mexican culture. Their findings are similar to Suchman's (1965a and b, 1966) which are reviewed below. Nall and Spielberg (1967) recognize that Mexican-Americans' conceptions of disease differ from Anglos, but do not accept the impli- cation that "the presence of such folkways represents a causal dimension of the frequent rejection of modern medical practices by Mexican- Americans . . ." (p. 300). Acceptance or rejection of treatment for tuberculosis is the focus of their study. They inferred that commitment to the folk health system was not related to rejection of treatment for tuberculosis. Commitment to the folk system was defined as experiencing the illness or describing its occurrence in the family or in a close 52 friend. They did find that strong integration into the ethnic subcommunity favored rejection of treatment, and vice versa. They conclude that "the findings imply that the gflljgg_of the Mexican- American sub-community is "unfavorable" to the . . . techniques embodied in the medical regime for tuberculosis treatment" (p. 306). Socio-Cultural Factors Nell and Spielberg's (1967) milieu is highly Similar to the ethnocentrism described in several reports by Suchman (1964, 1965a, b, 1966), concerned with social patterns of medical care. He summarizes the findings as follows: 1. The lower socioeconomic and minority groups are significantly more socially isolated, parochial, or ethnocentric. 2. Ethnocentrism is, in turn, highly related to less knowledge about disease, unfavorable attitudes towards medical care and dependency upon group support during illness. 3. The lower socioeconomic and minority groups hold these "negative" health orientations to a signif- icantly greater degree than the upper socioeconomic groups. The individual's degree of ethnocentrism strengthens or weakens his conformity to the overall medical orientation of his group [1966, p. 667]. Suchman (1964) found that the Puerto Ricans in his study were highly ethnocentric with families strongly oriented to tradition and authority and having a non-scientific or "popular" orientation to health and medical care. However, he did not ask any questions about Specific folk illnesses. Since the Puerto Ricans, like the Mexican Americans, have a Spanish background, it is safe to assume that at least some of their folk beliefs would be Similar (Foster, 1953). l _,... A” an! n ..‘~s.v.l _ . .v- u u «y n- D- ' ‘I .1 u” i l. ‘ "‘I O '59- .u . ' I I a... . “‘r ., , _ I l“. .' .P v ‘1‘. ' V I :o ‘ \ s.‘ I r-‘ a . ~ I F i ,l l .o, - I l-“ I ‘- ow. | 53 Reeder and Berkanovic (1973) report on a "partial replication" of Suchman's study. They replicated Suchman's questions related to medical orientation. They were not able to replicate his questions pertaining to community orientation. However, they feel that their items "connote a theoretical dimension similar to Suchman's . . ." (p. 136). Their argument of theoretical similarity seems to be weakest in the dimension of traditionalism. Suchman's items refer to family hadition and authority; Reeder and Berkanovic's do not. Since 15 percent of their sample was Mexican American, a group with strong fmm1y orientation and authority, the similarity may not be as great astme authors believe. Their findings did not support Suchman's. hifact, they state that their evidence "directly contradicts Suchman's ijndings . . ." (p. 142) with respect to the relationship between ethno- (entrism and medical orientation. They suggest a number of reasons for 'Um differences. They conclude, however, that the "relationship between mefical orientations and health behavior remains to be established . . 3' (p.143). Anderson (1971) reports on a comparative study of socio-cultural wnjations in response to illness. The study group consisted of 270 families--some Anglo-Americans and some Spanish-Americans--living in a rural area in southern New Mexico. He never mentions how many of the families were Anglo-American and how many Spanish-American. His SDanish-Americans were probably Mexican-Americans, since Spanish- ‘Unemicans are more apt to live in northern New Mexico. The literature 'tO vflfich he refers all pertains to Mexican-Americans. He says that rs. 54 Grebler, Moore and Guzman (1970) "have estimated that the 1970 U.S. Census will reveal about 5.6 million Spanish-Americans living within the United States" (p. l). The work to which he refers is entitled The Mexican American Pe0ple. In comparison with the Anglo-Americans, the Spanish-Americans were younger, had larger families, were more poorly educated and had more low status jobs. He says that the two groups "are somewhat comparable in socioeconomic conditions" (p. 16). They found that the Anglo-Americans resorted to self-treatment for illness as frequently as did the Spanish-Americans. However, "the utilization of existing health services by Spanish-Americans was found to be lower than that of Anglo-Americans" (p. 15). The Spanish- Americans had considerably more children born somewhere other than a hospital and delivered by someone other than a physician. Spanish- Americans had a higher level of anxiety about their health and tended to rate their health as fair or poor more often than did the Anglo- Americans, yet no differences in health were detected in the multiphasic screening. The author reports that preventive care is low, based on immunization levels. Poverty and Health The relationship between low socioeconomic status (poverty), poor health and inadequate health care has been well documented. James (1965), Commissioner of Health for New York City, compared the mortal- ity rates for five of the ten leading causes of death in a middle class wfifite area and a lower class, poor white, Black and Puerto Rican area. 55 If the poor area had had the same rates as the middle class area, there would have been 13,000 fewer deaths in the poor area. He concludes that "poverty is the third leading cause of death" (p. 1764). Hochstim, AthanaSOpoulos and Larkin (1968), in a study in Oakland, found that pe0p1e who lived in a poverty area, had low incomes and were members of a minority group had more health problems and less health care than high income whites in a non-poverty area. Hurley (1971) presents an excellent review of the current literature related to poverty, illness and inadequate medical care. The poor are crowded into deteriorating or dilapidated housing in a [mysical environment inimical to good health. Little preventive health (are is available to them. They have more illness and more serious ill- ness than the non-poor. Mortality rates for a number of conditions are lfigher for the poor than for the nation as a whole. By any index, the [mor need more health care than the non-poor, and have less. Bice, Eichhorn and Fox (1972) review the literature related to socioeconomic status and the use of physician services. They conclude that "relationships between income and use have diminished considerably cwer the past four decades. Race and education remain consistently related to use" (p. 269). They found little evidence that socio- Psychological variables accounted for a difference in use among socioeconomic groups. They suggest that "Medicare and Medicaid have Probably played a major role in increasing access to physician services among the poor" (p. 269). 7.. 1r 56 Olendzki, Grann and Goodrich (1972) studied the effect of Medicaid on the use of private care by the urban poor. Those who considered a private physician their major source of care increased from 1 percent prior to Medicaid to 10 percent after. The majority continued to use publicly supported clinics, some because they pre- ferred them and some because there were too many barriers to private care. The relationship between cultural-Social-psychological factors,“ demographic variables and utilization of health care services remains (floudy. However, the advent of Medicaid would have no effect on the utilization of preventive care, since Medicaid does not pay for pre- ventive services. Preventive Care Literature pertaining to preventive health care for Mexican lherican children in low-income families is limited indeed. However, Here is a body of literature related to utilization of health care services, both preventive and curative, for children in low-income families. It can be divided into two broad categorieS--random sample unweys of a particular population and surveys of the population of a Particular source of care. Meys of a Population Mindlin and Densen (1969, 1971) conducted a survey on a random Sample of new-borns in two areas of New York City. One area was an 1"ter-racial slum with Negroes, whites and Spanish. (In New York City, 57 Spanish are Puerto Rican). The other area was composed largely of middle-class white families. They were interested in the illness and medical experiences of the babies during their first year of life. They reported separately on continuity of care (1969) and health supervision (1971). The authors "have devised a numerical index which combines visits and immunizations to give a rating of the amount of health supervision an infant receives" (1971, p. 687). They object to immunization status alone because it ignores other aspects of care. They found that infants in the middle class have markedly more care than infants in the lower class. Low education of the mother and low family income are associated with less care; however, ethnicity and residence have a higher influence. Infants in a single-parent family or a large family were apt to have poor care. They define continuity of care as "having a single source of medical care during the year, or getting to subsequent sources only by referral from earlier ones . . ." (1969, p. 1295). They state that "continuity is considered an attribute of good medical care" (1969, p. 1294). Their findings were much the same as in the above study. There was generally less continuity for children in the lower socio- economic group. There was less continuity for Negro and Spanish babies than for white at the same education and income level in the same com- munity. All infants with continuity of care scored better on the Health Supervision Index. Schonfield, Schmidt and Sternfeld (1962) report a study con- ducted by the local health department in Cambridge for the purpose of 58 providing a community setting for health studies and health training for a variety of disciplines and to gather data for program development and improved health services. They selected a random sample of birth certificates and studied 163 mothers and infants (6.6% of annual births). They found poor health supervision related to low educational level of the mother, lower social class, large family, clinic care and late antepartum care. Gallagher (1967) studied 10 percent of the infants born during a ten month period in a three county urban area in the midwest. His objective was to get some basic facts about community health needs and behavior. The sample of 279 infants represented all social classes-— he makes no mention of race of the infants. No preventive health care for the infant was heavily concen- trated in the lower clases, and correlated highly with no antepartum care. Reason for not seeking care were lack of knowledge of the value of health supervision, transportation problems, baby-sitting problems and expense. Free clinics were available, but some mothers preferred private care and sought care only for illness. The author points out that, although inadequate care was concentrated in the lower classes, this was not the norm for that group. Most of these infants had adequate care. Smiley, Eyres, and Roberts (1972) studied a group of 403 mothers and infants who lived in high risk areas in Detroit--thqse areas with the highest maternal and infant mortality rates in the city. They wanted to learn if there were characteristics which would predict which I. ... 59 babies were most at risk of illness and death in a nominally high risk population. The babies who had at least one episode of sickness during the first three months of life tended to have unhappy mothers who lived in a socially isolated, non-supportive environment. The mother and baby had probably moved during the three-month period. The mothers had medical care either late in pregnancy or not at all. The mothers' use of prenatal care was also predictive of her use of well-child care for the baby. Mothers who had prenatal care early tended to have well-child care for the infant. Those who had prenatal care late or never tended not to have well-child care for the baby. The latter group also tended to be older, unmarried, mobile, poorly educated mothers who had a low income and large family. Surveys of Regulation of a Source of Care Studies of families who utilize a particular source of care address themselves, for the most part, to differentiating between those families who make good use of the service and those who do not. Stine et a1. (1968) were interested in determining character- istics which might help to explain the frequency of broken appointments among the lower social class patients. They felt that "prediction of the likelihood of appointment breaking in a given family in the future . . would provide a rationale for efforts to change parental informa- tion, attitudes or habits" (p. 333). The study population consisted of the 203 low-income Negro families who received comprehensive child health care in the Maternal and Child Health Clinic of Johns Hopkins University School of Hygiene 60 and Public Health. There was no charge for the care which was provided in an attractive setting by a friendly staff. They concluded that, with multiple factors considered, comple- tion of high school by the mother explained the greatest proportion of variation between mothers in appointment keeping. Urban origin of the mother and poor marital relationships were associated with poor appoint- ment keeping. "The concept of social disintegration of poorly educated urban families gave more meaning to these findings than the concept of social class" (p. 339). Alpert et a1. (1970) were interested in evaluating the effec- tiveness of a comprehensive health care program for children in low- income families. The study group was comprised of 250 low-income families receiving comprehensive care and a control group of 250 families receiving traditional fragmented care at Boston Children's Hospital Medical Center. Both groups of families were interviewed initially. The experimental group was interviewed at six-month inter- vals for three years. The control group was interviewed again at the end of three years. Mothers' attitudes toward preventive practices, physicians and the relative importance of health showed no change over the three years. The mothers in the comprehensive group showed greater satisfaction with the care received, more use of the telephone in seeking help and a greater preference for a primary physician. They made more visits for health supervision. Medicaid was initiated during the time period of the study. However, the authors state that "it is clear . . . that provision of 61 comprehensive services has a much greater impact than provision of a payment mechanism alone" (p. 505). Nolan, Schwartz and Simonian (1967) report a study of utilization of pediatric services in the Kaiser Foundation Health Plan in Oakland. They wanted to determine whether social, ethnic and educational characteristics seem to influence the use of pre-paid med- ical services. The study group included all children who were seen in the Appointment Clinic (339), the Drop-In Clinic (367) and the Emergency Room (22) during a four day period. Families in the upper social classes made Significantly more visits for health supervision; those in the lower social classes made more visits to the Drop-In Clinic for acute care. With social class controlled, whites made more visits for health supervision than did Negroes. Whites were apt to have more continuity of physician care. Negroes made more evening and Saturday visits. Belkin et a1. (1964) interviewed a representative sample of 247 mothers who used the Child Health Stations in New York City. Their purpose was to determine what the mothers thought and felt about the clinics. All mothers were in the lower social classes; 55 percent were Negro, 23 percent Puerto Rican and 22 percent white. Younger, better educated and higher income mothers viewed the care at the Clinic less favorably than did the older, less educated and lower income group. Gold, Stone and Rich (1969) report on a study of the Maternal and Infant Care Program in New York City. About 1,000 "super high-risk" pregnant women are selected each year and offered comprehensive care; 62 well-child care is offered for the infant. The Clinic population is overwhelmingly Negro and Puerto Rican. In reviewing broken appointments during the first 19 months of operation, they found the rate to be 19 percent for antepartum appointments and 36 percent for well-child appointments. Home visits by public health nurses are said to be a major aspect of follow-up of broken appointments. However, the information given indicates home visits for this purpose only to maternity patients. They offer no explanation for the broken appointments (1968). In the later report, two time periods are used with comparisons between the first thirteen months of operation and the next eighteen months. The broken appointment rate for antepartum visits remained stable at 19 percent. The rate for well-child care increased from 38 percent to 43 percent. The authors conclude that the patients "exemplify their traditional attunement to seek care for illness or catastrophe . . . they are, however, not so well attuned to seek pre- ventive medical services . . ." (1969, p. 1853). They suggest a need for socio-cultural and motivational studies to determine the reasons for this disparity in motivation for care. Morris, Hatch and Chipman made two reports (1966a, 1966b) of a study of 246 lower social class infants referred at birth for well- child care at the North Carolina Memorial Hospital Well-Baby Clinic. Over 75 percent of the families were Negro. The purpose of the study was to learn more about the factors which acted as deterrents to well- child care as a first step in decreasing broken appointments. 63 They found that whites made more visits than Negroes. Less preventive care was associated with lower educational level of both mother and father, low status occupation, big families, distance from the Clinic, little knowledge of purposes of well-child care and alienation (1966, p. l). The second report deals specifically with alienation as a deterrent to well-child care. Social isolation predicted care-seeking behavior in whites in low status occupations. Powerlessness predicted care-seeking behavior in whites in the lowest educational group. Alienation did not predict care-seeking in the Negro families. With race and occupational status controlled, there was no significant relationship between agreement on the purpose of well-child care and care seeking behavior. It cannot be assumed that people act according to what they know (1966, p. 2). Triplett (1969, 1970) studied perceptions of well-child clinic services held by 40 white women in a midwestern city. Twenty of the women were good users of the service, twenty were poor users as defined by public health nurses. Her purpose was to discover if there were demographic or personal characteristics which differentiated the two groups. Her particular concern was with threat and disparity perceived by the women in inter-relationships with health professionals. She found no relationship between use and age, social class or education. Poor users were more apt to he heads of households, receiving welfare and have more children. Good users tended to have lower self-esteem, be more socially isolated, express feeling lonely, and feel more threat (1969). 64 In another report of the same study, she hypothesizes that the poor users have built up strong defenses for their inadequacies and tend to avoid failure. The good users attend clinic, despite threat, because they get some positive support and it provides them with some socialization (1970). Brinton (1972) and LaFargue (1972) report separate but related studies done in the Maternal and Infant Care Pediatric Clinic in Seattle. More than 60 percent of the mothers failed to keep their appointments for follow-up health care for their infants. The studies "were under- taken to determine factors which might be limiting the program's effectiveness" (Brinton, p. 46). Brinton studied differences in values pertaining to health and health care between public health nurses and low income families. The study group consisted of ten black mothers, five of whom kept their appointments and five who failed to keep their appointments; ten white mothers, six of whom kept their appointments but four who failed to keep their appointments; and 23 public health nurses. All infants were "recognized as having certain high-risk conditions, medical or social" (p. 48). All the nurses were white, well educated, middle class and young. Questionnaires designed to determine the degree of importance attached to health concerns, value priorities and value orientation were administered to the mothers and the nurses. In addition, the nurses were asked to respond as they thought the mothers would. The nurses and the mothers gave Similar replies to the importance of health, 65 except for the importance of home remedies and luck, which more mothers saw as important. However, the nurses perceived the mothers as having quite different values from theirs in regard to health. Of the mothers who kept appointments, 82 percent felt that it was important to take a child to the doctor when he was sick. Of those who failed appointments, only 44 percent felt it was important. The author devised a "preventive care score" for the mothers, based on when the mother began prenatal care, whether she had a post- partum check, and immunization status of the infant and other children, if any (Brinton, page 49). Of those who kept appointments, 91 percent were oriented to preventive care. Of those who failed appointments, 45 percent had a preventive care orientation; they had obtained pre- ventive care from a source(s) other than the Clinic. The 55 percent who failed appointments were not oriented to preventive care and had not received preventive care from an alternative source. LaFargue (1972) studied the same 23 nurses and the ten black mothers in an effort to determine whether prejudice prevents black mothers from seeking health care. Racial prejudice among the nurses (all white) was relatively low. All of the families felt that they had been discriminated against, at some time, because of their color. All five who failed appointments and three of those who kept them felt that there was discrimination in the health care field. The families felt that they had been treated unfairly by doctors, clinic nurses, social workers and hospital clerks. The only study I found which specifically includes Mexican American children (Wingert, Friedman and Larsen, 1968) is concerned 66 with illness care, not preventive care. The authors interviewed the parent(s) of 3,058 children who were brought to the Pediatric Emergency Room of the Los Angeles General Hospital. They reported on three ethnic groups--Caucasian, Negro and Mexican-American. Mexican-Americans com- prise 8.5 percent of the population of Los Angeles County; however, they accounted for 29.6 percent of the visits to the Emergency Room. Mexican- American families were the largest and the most intact. The fathers had the highest employment rate and the mothers the lowest of the three groups. The families were characterized by low income, low educational level, low status occupation and poor or no relationship with private physicians. Immunization levels were rather low in all three groups, with no appreciable difference between groups. Articulation with the Anglo System It is apparent that Mexican Americans have some contact with the Anglo health care system, and that the amount of contact is increas- ing. However, according to a number of authors, much of the contact results in negative experiences which serve to discourage further con- tact. Although Rubel (1966) says that the "technical skills and knowl- edge . . . [of physicians] are accorded considerable respect by Chicanos" (p. 200), he does not give any examples of a positive relationship or experience. Rubel (1966) does give some examples of negative experiences and points out a number of reasons why the Mexican-Americans do not use the health care available to them. One reason is the tremendous 67 social distance between the poor, poorly educated Mexican-Americans and the upper-class, well educated physicians with their professional culture and vocabulary. The communication gap is increased when the patient has a poor command of English; very few physicians speak Spanish. The Mexican-Americans object to the fee for service, which is not part of their traditional curing system. They feel that doctors are only interested in getting paid and do not care about the person. Physicians are ignorant of the health concepts of the Mexican-Americans and do not listen to their complaints. The physicians who provide medical care to the Mexican-Americans with whom Rubel (1966) worked see their role as both health care pro- viders and as teachers. They recognize changes in the traditional patterns of health behavior of the Mexican-Americans, but are dismayed and puzzled because the people do not accept the whole complex of sci- entific treatment and prevention. The physicians feel that treatment by the traditional curers delays the beginning of medical care to the detriment of the patient. Saunders (1954) provides examples of negative experiences of Spanish speaking people in contact with the Anglo health care system. He, too, suggests a number of reasons for the limited use of Anglo medical care. The most important differences between Spanish-American folk medicine and Anglo scientific medicine that influ- ences the choice of one or the other are these: Anglo scientific medicine involves largely impersonal relations, procedures unfamiliar to laymen, a passive role for family members, hospital care, considerable control of the situ- ation by professional healers, and high costs; by contrast the folk medicine of Spanish-American villagers is largely 68 a matter of personal relations, familiar procedures, active family participation, home care, a large degree of control of the situation by the patient or his family, and relatively low costs. Given these dif- ferences, it is easy to understand why a considerable motivation would be necessary for a Spanish-American to have any strong preference for Anglo medicine over that which is not only more familiar and possibly psychologically more rewarding--or at least less punishing--but also less expensive [p. 168]. Madsen (1964) likewise relates negative experiences. A bustling, efficient public health nurse was unwelcome in the homes because she had "strong eyes" and spread sickness (mal de ojo) among the children. The people could not believe her statements that She understood sickness and wanted to help them because she did not even know enough to touch (prevent mal de ojo) the children she admired. One of Madsen's infor- mants comments on the differences between being treated by a curandero and a physician. "A curer cures because he cares. The doctor cures because he likes money and power. . . . A curer admits there are things he cannot cure and helps you find someone to treat it. Have you ever had a doctor send you to a curer because your sickness was susto?" (p. 91). Clark (1959) describes several situations in which the Anglo physician displayed sympathy and understanding which resulted in a positive experience. These experiences are the exception rather than the rule, however. Physicians are generally viewed as cold, impersonal and efficient, more interested in money than in people. They are authoritarian; curers have no authority in the Mexican-American culture. Nurses may be criticized more harshly than physicians, perhaps because they come to the home and work directly with the family, much as the curandera does. 69 Cabrera (1971) discusses the poor health and poor health care suffered by the poor, many of whom are Mexican American. In an agri- cultural area, one physician reported that 100 to 200 farm workers suffered each year from pesticide poisoning. He objected to the lack of enforcement of safety regulations regarding pesticides. Another doctor in the same community "expressed a pride in the effectiveness of the hospitals. He believed the hospitals, as well as the doctors' offices, were open to all regardless of economic means" (p. 22). The prevailing sentiment in the community was that the gringos "do not understand the embarrassment Mexicans feel when they are unable to pay their bills" (p. 22). Lack of money makes Anglo health resources unavailable to many Mexican Americans. Folk treatment is better than no treatment at all. Moore (1970) suggests a different reason for the lack of use of Anglo health agencies by Mexican Americans. "Officials in public agencies almost always comment on the passive 'hard-to-reach' character of the Mexican approach to public agencies. . . . Mexicans are not responsive; they withdraw; they are uninterested; they lack aggressive- ness" (p. 94). Cultural explanations are advanced; however, Moore considers it equally logical that the Mexicans are SUSpicious and do not trust the government. In studies done by health agencies, the conclusion reached is that Mexican Americans avoid using the services because of cultural conflicts. "But some of the studies also note, sometimes almost in passing, that the public health worker is greeted in the Mexican American home just as is any other government worker, as somebody coming to cause trouble" (Moore, 1971, p. 95). 70 As mentioned in an earlier discussion of Shannon's (1966) study in Racine, he did not gather any information about health status, health practices, or contact with any health professionals. He studied eco- nomic absorption and cultural integration and approaches the area of health from this frame of reference. "The fact that public health nurses found it difficult to establish rapport with immigrant workers or their families suggests that they were not defined as part of the overall change which the Mexican-Americans and Negroes sought as a consequence of their moves from the South and Southwest" (pp. 441—2). He suggests that the Mexican Americans could not communicate with the public health nurse because they could not identify with an English speaking, uniformed, middle class Anglo. The formal, bureaucratic structure of any social agency serves to impede its utilization by the immigrant groups. It is apparent that there are many factors involved in the relationship between Mexican Americans and the health professionals and institutions of the Anglo health care system. There is misunder- standing and lack of understanding of concepts, practices, methods and goals on the part of both groups. Problems of communication are com- pounded when the person who is seeking care does not have a good command of English. A recent article in the Journal of the American Medical Associ- gfljgg exemplifies many of the problems. A local pediatrician who knows oflmy interest in the Mexican American folk health care system asked me if I had read the article in JAMA which told about treating a baby by 71 holding his head in boiling water. At that time, I had the reference (Guarnaschelli, Lee and Pitts, 1972) but had not read the article. I proceeded forthwith to read it. A Mexican-American baby, two months old, was admitted to the Pediatric Unit of the hospital. "The patient exhibited areflexia, paleness, and lack of Spontaneous respirations. Althoggh no external sighs of trauma were noted, the anterior fonta- nelle was full and moderately tense . . ." (p. 1545, italics mine). The initial history obtained from the parents indicated a normal birth and uneventful development. Two days before admission, the baby became irritable, listless, and vomited forcefully. Diagnostic studies included a retrograde femoral angio- gram demonstrating bilateral, large subdural mantles. Deliberate Questioning then revealed that the infant had had a sunREh fontanelle. In order to reverse the effects of the fallen fontanelle, or caida de mollera, his grandmother subjected the infant to a series of therapeutic maneuvers. The last of these consisted of holding the infant upside down by his ankles with his head partjally_immersed in boiling water, shaking him vigorously three times while slapping the soles of his feet [p. 1545, italics mine]. The authors comment on the persistence and importance of folk concepts of disease to Mexican-Americans. They describe the cause and treatment of caida de mollera, giving Foster (1953) and Clark (1970) as references. (Clark's book, originally published in 1959, was reissued, unchanged, in 1970.) Four maneuvers in treating caida de mollera are described by the authors. I was familiar with the first three, but not the fourth "the child is held by his ankles, with the crown of his head dipped into a pan of boiling water. After two to three minutes, the curandera pounds or slaps the soles of the infant's feet while the child is still in an inverted position" (p. 1545). They do not cite a direct Quote for the treatment. 72 The authors state that it is difficult to determine the frequency of folk treatment of caida de mollera in southern California. They refer to the survey done by Martinez and Martin (1966) in which 97 percent of the mothers interviewed knew of the sickness caida de mollera, but "only 33 percent would admit knowledge of its treatment. This trend is consistent with the extreme reluctance on the part of our patient's family in relating the grandmother's role as curandero" (p. 1546). They cite examples of subdural hematoma occurring without visible signs of head injury, as in whiplash injuries and in "severe rotational acceleration/deceleration injuries produced in monkeys" (p. 1546). They conclude that "it is conceivable that the folk treat- ment of caida de mollera served as a whiplash injury, resulting in a rotational/acceleration mechanism for this infant's subdural hematoma" (p. 1546). I was familiar with the literature on folk treatment of ggjga_ de mollera; nowhere had I seen boiling water mentioned. Further, I was familiar with how the Mexicans felt and behaved toward their children; it was inconceivable to me that any Mexican would subject a child to anything as painful as boiling water. Completely apart from any knowledge of Mexican American folk concepts, it did not seem possible to me that a baby could have his head boiled, yet have no external signs 0f trauma two days later. I checked Foster and Clark for treatment of caida de mollera, Foster (1953) does not mention water at all in the treatment of this 73 condition. Clark (1970) says that the infant “may be held up by the ankles, head down, with the crown of the head dipped into a pan of tepid water" (p. 171). I wrote a letter to the editor of'gAMA_in which I quoted the treatment directly from the references given by Guarnaschelli, Lee and Pitts (C. Lindstrom, 1973). The negative bias of the authors is apparent in their transla- tion of curandero as "quack" (p. 1545). It is also apparent in their acceptance of the "boiling water treatment," in view of the fact that the baby had no evidence of burns. The authors misinterpret the findings of Martinez and Martin (1966). Martinez and Martin did find that more than 97 percent of the women knew about the diseases, caida de mollera included. However "85 percent of the women reported therapeutic measures for all the males except for mal puesto, but only one-third could or would admit knowledge about its treatment" (p. 162). Males are sicknesses; mal,puesto is a hex--a sickness or evil "put on someone willfully by another. This putting of an evil or hex can be done either by a curandera or brng_ (witch) upon request, or by any person knowing the intricacies of witchcraft" (Martinez and Martin, 1966, p. 163). Thus, 85 percent of the women knew about the treatment for caida de mollera. Guarnaschelli, Lee and Pitts do not say "could or would admit knowledge," only "would admit knowledge“ with the implication of "extreme reluctance" which they noted in the baby's family. Guarnaschelli, Lee and Pitts consider the folk treatment for 2219a de mollera to be a variant of the battered child syndrome. If one defines the battered child syndrome as any injury done by an adult 74 to a child, then perhaps this situation is a variant. An expert in the field of child abuse does not think it is, however (Helfer, personal interview). Caffey, a pioneer in the field of child abuse, says, "Many cerebrovascular injuries attributed to prenatal infection or congenital malformation may actually have been caused by undetected whiplash shakings during the first weeks or months of life" (Caffey, 1973, p. 151). Cerebrovascular injuries of infants and young children as a result of rough handling, including shaking, are being studied by pediatricians in this country and Great Britain. Subdural hematoma is the same injury, whether caused by shaking or treatment of caida de mollera. However, the mechanics of the injury are different, requiring different approaches for prevention or recurrence. I cannot explain why Guarnaschelli, Lee and Pitts believed the Infiling water treatment. I can offer an explanation of why they were told boiling water was used in the treatment. The authors do not nemtion how much command of English the family had; neither do they mention using an interpreter. It seems probable that the parents of the baby had some knowledge of English, but not a great deal. They knew that their baby was very sick; their anxiety level must have been high indeed. With this stress, their ability in English would decrease. The "deliberate questioning" which elicited "with great reluctance" the information about the folk treatment was probably done by an angry Anglo sPeaking rapidly. Under these circumstances, the frightened, anxious Parents may have translated aqua caliente (warm water) as boiling water (399a herviendo) instead of warm water. On the basis of my experience 75 with Mexicans whose English is not very good, this explanation is reasonable and highly probable. After I had read the article, I talked with the pediatrician who had mentioned it to me. I asked him if he believed the part about the boiling water. He said yes, he did. When I pointed out that the baby did not have a burned scalp, he agreed that the boiling water was unlikely. He said he scanned the article, which is what most pedia- tricians would do. Since this man, who has more interest in and knowledge of Mexicans than most pediatricians, believed it, I expect that any physician who read it would believe that the baby's head had been held in boiling water. Articles like Guarneschelli's, with its strong negative bias, lack of understanding of Mexicans and Spanish and misrepresentation of some of the pertinent literature, can only serve to widen the gap between the Anglo health professional and the Mexican people who need health care. CHAPTER III METHOD Introduction Preparation A celebrated malariologist who worked on the Panama Canal project made a remark which lingers in the memory of his public health disciples. "If you wish to control mosquitoes," he said, "you must learn to think like a mosquito." The cogency of this advice is evident. It applies, however, not only to mosquito populations one seeks to damage, but also to human p0pu1ations one h0pes to benefit. If you wish to help a community improve its health, you must learn to think like the pe0ple of that community. Before asking a group of pe0p1e to assume new health habits, it is wise to ascertain the existing habits, how these habits are linked to one another, what functions they perform and what they mean to those who practice them [Paul, 1955, p. l]. I learned, in the first course I took in public health nursing, that I was supposed to be able to 'think like a mosquito' in order to practice public health nursing successfully. AS long as I worked only vfith English-speaking pe0ple, I could 'think' in English. When I began working with Spanish-Speaking people, I was frustrated, initially and overwhelmingly, by my inability to communicate With them. At Cristo Rey, there was usually someone available to inter- Pret for the professional and the mother. I was never completely satis- fied with this, however, because I did not know if the translator's bilingual vocabulary was adequate for the task. Some knowledge of 76 77 Spanish would have enabled me to use the interpreter's help to better advantage. A knowledge of Spanish was also necessary for some under- standing of how the Mexicans with whom I work gg_think. We think primarily in words--language--the same words we use to communicate our thoughts, ideas, feelings and to describe our experiences and the world within which we live. However, language does more than provide us with the symbolic tools which we use to describe experience. The Sapir-Whorf hypothesis suggests that "language functions, not simply as a device for reporting experience, but also, and more Significantly, as a way of defining experience for its speakers" (Hoijer, 1954, p. 93). In an intensive course in Spanish, I learned the structure of the language and developed some verbal skill. This proved invaluable in my contacts with the families during the data collection process. In addition to knowing the language, I needed a good background in the culture of the Mexican Americans. I needed to know something of their family life and child rearing practices; something of their values and attitudes, particularly in relation to health and illness; something of their reactions to Anglo health professionals. With this knowledge, I would be able to relate to them in a manner acceptable and meaningful to them. Ethnographies about the Mexican Americans provided me with a picture of their life style, their values and how health and illness fit into their perception of life and living (Clark, 1959; Madsen, 1964; Saunders, 1954; Macklin, 1963; Rubel, 1966). Kiev (1968) provided 78 particular insight into the relationship between interpersonal relationships, expected behavior, mental illness and folk curing methods. When I was ready to begin interviewing, I knew something about acceptable and unacceptable behavior in Mexican homes. I knew the Spanish names for diseases, something of their causes, symptoms and cures. I knew what Specific aspects of family life, values and behavior I wanted to observe and learn more about. finesse-LS. As a public health nurse, I was accustomed to interviewing, observing and recording. However, my objectives as a public health nurse were different from my objectives as a social scientist. With some reading and guided practice, I learned to observe, interview and record like an anthrOpologist (Wax, 1960; Whyte, 1960). With some modifications, I followed the traditional anthro- pological method of participant observation and interviewing key infbrmants in the community. I had frequent and continuing contact with the Mexican American families from November 1972 through,August 1973. However, I did not live in the Mexican American community. Observations included maintenance of housing (interior and exterior) and yard and characteristics of the neighborhood as described in the Michigan Health Survey (Michigan Department of Public Health, l970a) and in Appendix A. While I was in the homes, I made a number of observations related to homemaking practices. I also observed family members interacting with each other and with people other than immediate family members, both at home and in other settings. 79 Conversations covered a wide range of topics not included in the interview. Informants talked about their relationships with their parents and siblings, their husbands, in-laws, children and neighbors. They described experiences and.aspects of life in Texas and in the migrant stream. My open-ended questions usually elicited a lengthy response. To facilitate ease and completeness of recall, I seldom had contact with more than two families in one day. I made copious notes both on the questionnaire form and in a notebook. Following a visit with a family, I wrote detailed field notes. When the field work was completed, I had about 150 pages of notes, excluding those on the questionnaire forms. The notes provided the data for the following chapters. The Questionnaire Development Since no one has studied the perceptions and behaviors of Mexican mothers regarding health and illness in their preschool children in relation to their utilization of preventive care in the Anglo system, it was necessary for me to develop a tool Specifically for use in this study. I gained ideas for the design of the questionnaire from a number of sources. During the time that I worked as a public health nursing consultant for the Michigan Health Survey, we revised the questionnaire several times. The revisions were the result of long and at times 80 heated discussions among those who conducted the interviews, program directors from the health departments involved, the nursing consultants, the director at the state level and the consultant in questionnaire design. During the process, I learned a great deal about designing a health information questionnaire, particularly in the areas of the order and wording of the questions. Other ideas for the questionnaire came from two major sources. The study done by Smiley, Eyres and Roberts (1972) in Detroit resulted in information about utilization of preventive care for infants in low- income families. Although the families involved were not Mexican, they were low-income; lack of money presents a common barrier to utilization of health care. Smiley is a public health nurse; we have many interests in common. We spent an afternoon discussing my pr0posed study, her study, methodology and some of the problems she had encountered and I might anticipate. Smiley Shared with me a c0py of Steckert's paper reporting a study of the medical beliefs and behaviors of southern mountain women living in Detroit. This paper was published later (Steckert, 1971). It was of particular interest to me for several reasons. The southern mountain people have migrated to Detroit from a poverty stricken rural area and come from "a culture alien to that of our large urban centers" (p. 95). They bring with them folk health beliefs and practices which persist and are glorified--"the way things were done back home in the past was far superior to the present" (p. 103). Medical knowledge and treatment are culturally the role of the women. Steckert used a loosely 81 structured questionnaire with open-ended questions and had repeated contact with a small number of women. Her study resulted in descriptive data similar to that which I wanted to gather.1 Using the above sources for ideas, my knowledge of the culture and folk health system of the Mexicans and my knowledge as a public health nurse, I developed the first draft of the Questionnaire. I discussed the questions and format with the nursing supervisor responsible for the Child Health Clinic, my adviser and a Chicano friend who is bilingual and bicultural. After some changes, the questionnaire was ready for pre-testing. A copy of the questionnaire is in Appendix B. Pre-Test with Migrant Families The questionnaire was pre-tested with Mexican American migrant agricultural workers for several reasons. More than half of the male heads-of—household of the stable or settled Mexican American population in Michigan come from a migrant agricultural worker background. Twenty- five percent were born in Mexico and 60 percent were born in Texas (Choldin and Trout, 1969). Some contact with those presently in the migrant stream would give me a basis of comparison for the stable population and some background information about the life which those who "settled out'l had left. The reactions and responses of the mothers would provide valuable information both about the migrant families and the acceptability and adequacy of the questionnaire. 1Both Smiley and Steckert provided me with a copy of the questionnaire used in their respective studies. u M‘ ‘I 82 The opportunity for contact with the migrant population was offered to me fortuitously. I met a Chicano graduate student, an education major, who wanted to do some independent study in sociology during the summer. Since he spent the summer as an outreach worker with the migrant families, he wanted to do something related to this group. He was interested in pretesting my questionnaire and in pro- viding me with some contact with the migrant families. He felt that gaining some knowledge about the health and health problems of the migrant families would give him an additional dimension of understanding. Originally, we planned to pre-test with thirty families, the same number I planned to interview in Lansing. The only criterion I set was that the family have at least one child under five years of age. AS things turned out, he was able to interview only ten families. The summer of 1972, when the interviewing was done, was a bad summer for the migrants and the growers. There were many days of rain, followed by many days when the fields were too wet to work. Many families left early, either for another agricultural area in Michigan or to return to Texas because there was no work in the Lansing area. On the days when they could not work, the family might leave the camp. If they did not leave, the father was at home and the mother would not talk with the outreach worker. He said that the pe0ple, especially the men, get very suspicious when they see papers being filled out. He could not even interview on Friday nights, when the men usually went to town to drink beer. This year, they could not afford their night out. As an example of how bad things were, one woman told me that they had been on the farm for five weeks and only worked eight days. 83 With seven of them working, they only made about $20.00 a day, sometimes less; ordinarily, they made about $40.00 a day. One grower said he had replanted this year, the first time he had done that in twenty years of growing pickles. Another said that the first check he got from the buyer was about half of what he usually gets. Although the number of interviews was small, the information obtained was valuable. I made some changes in the questionnaire as a result of the pre-test and conferences with the Chicano worker. Spe- cific findings will be presented in a subsequent chapter. The Sample Selection The sample was composed of ten families who attended Child Health Clinic consistently, ten who attended sporadically and ten who had never attended. A sample size of ten in each group was large enough to provide some clues to factors which might differentiate the three groups. A total of thirty families provided a data base large enough for some generalizations in those factors which were common to the entire group. It was possible for me to interview thirty families and obtain the kind of in-depth information I wanted. Although the sample was not large enough for any tests of statistical significance, it was large enough for the purposes of this study. Before selecting the sample I talked with Mrs. Ellyn Preas, Nursing Director and Mrs. Marilyn Lee, Nursing Supervisor in the Ingham County Health Department. They were both aware of my interest in the 84 Mexican families who attended the Child Health Clinic. I explained the purpose and plan of my study; they gave me permission to review the records of Spanish surname families. Thereafter, most of my contact was with Mrs. Lee, since she was responsible for the Clinic. I told her that I would visit ten mothers who attended consistently and ten who attended sporadically; I would provide her with the names of the families I was seeing. Since I planned to introduce myself as a public health nurse, I fully expected that I wduld provide some nursing service to the fam- ilies. I could not, in good conscience, refuse if there was a need which I could help the family meet. In addition, service involvement with the families would provide me with information which I would not get through the interview itself. I planned to have at least two con- tacts with each family and to work intensively with a few families in each group. Mrs. Lee concurred with these plans. I would keep the staff nurses who had agency responsibility for the families informed of prob- lems and actions taken; the staff nurses would continue to provide ser- vice when it was no longer feasible for me to do so. It was agreed that I Would function as an "ex-officio" staff nurse while working with the families. Since I had worked in the Child Health Clinic for about a year and a half, I was familiar with the information which would be contained in the records. I developed a form on which to record the pertinent information. A copy of the form is in Appendix C. 85 I reviewed the record of every Spanish surname family receiving health care in the Clinic. Records which indicated that the family was not Mexican or that the mother was not Mexican were rejected as not meeting the criteria for my study. Information from the remaining records was noted on the form in preparation for selecting the families which I would visit. The records were divided into three groups--those families who attended consistently, those who attended sporadically and those who had not been attending long enough to establish a pattern. The families who attended consistently met the following cri- teria: (1) There was at least one child under five years of age. (2) The mother had made at least five visits to the Clinic. (3) There was no more than one broken appointment. (4) At least one visit other than the initial one was a well-child visit--that is, a visit in which the mother stated that the child did not have a health problem. The families who attended sporadically met the following cri- teria: (1) There was at least one child under five years of age. (2) The mother had made at least two visits to the Clinic. (3) The mother had failed to keep at least two appointments. Some of the families in this group were no longer attending the Clinic. According to Health Department policy, records of families with a history of broken appoint- ments are made inactive--no more appointments are given to the child. The families who had never attended the Clinic met the following criteria: (1) There was at least one child under five years of age. (2) The mother had not attended the Child Health Clinic. (3) The child/ children under five did not receive well-child care. (4) The mother had 86 access to the Clinic, either by living within walking distance or having transportation available. I did not have any specific method for selecting the families in this third group. I had considered two possibilities. I was reasonably certain that some of the public health nurses would be visiting families who met the criteria. I also thought that the mothers whom I visited might give me the names of mothers who did not go to the Clinic. I had not considered that I might locate some fam- ilies by accident--a method which provided me with four of the ten families in the third group. In addition, two families were referred by the public health nurse, two were relatives and two were friends of mothers who attended the Clinic. Interviews Before I began interviewing the mothers, I talked with two of the leaders in the Mexican community: the Executive Director of the Cristo Rey Community Center and one of the leaders in Quinto $01, a Mexican organization. I wanted both men (Benavidez and Martinez, personal interviews) to know and approve what I planned to do. I did not anticipate any objections from them, nor from pe0p1e in the com- munity. However, if anyone did question or object to what I was doing, one or both men would hear about it. Both expressed interest in and approval of the study. They offered to help in any way they could, including locating families for me to interview. Both felt that I would be accepted into the homes readily because pe0ple respect public health nurses. I appreciated 87 their interest and willingness to help. However, if possible, I wanted to find all of the families myself. If I could do it, then it was possible for another public health nurse to do so, too. I conducted all of the interviews myself in the homes of the families. I did not make any contact with the families to make an appointment for the first visit. Experience had taught me that I was more likely to receive a positive response from the mother if the first contact was face to face. I introduced myself by name as a public health nurse and asked whoever answered the door if this was the family I expected to find. I know that poor people move frequently. This was the "accidental" means by which I met some of the families who met the criteria for the third group. With this introduction, I was invited to come in, whether or not this was the family I had named. I then explained to the mother that I was doing a special study because I was particularly interested in Mexican families; I knew that they had some ways 0f thinking about and doing things that were different from the ways of white people and that public health nurses needed more information and better understand- ing of Mexican families in order to work well with them. I asked the mother if she would be willing to talk with me and answer some questions about herself and her children. Every mother whom I contacted agreed to participate. If the time of my first visit was inconvenient for the mother, we agreed on time when she would have time to talk with me. I kept every appointment and always found the mother ready for me when I came. 88 With the exception of one family, I had at least two contacts with each family. This enabled me to conduct the interview at a leisurely pace, follow clues for further information, make some per- tinent observations in the home and of the mother's interactions with the children. I had repeated contacts over a period of months with three families in each of the three groups. All of the mothers talked to me willingly and freely. The interviews were conducted informally, frequently at the kitchen table. The fact that I was writing things down did not seem to bother them. I never had the feeling that they were telling me what they thought I wanted to hear rather than what they thought or felt or did. They had the option of refusing the interview, or of refusing to answer any of the questions; none did. I assumed, as was assumed in the Michigan Health Survey, that if the mother agreed to participate, she would answer the questions truthfully. A number of mothers volunteered information of a highly personal nature which I had not requested; to me, this was an indication that they trusted me. Their comments will be discussed fully with the findings from the interviews. I met the father in 17 of the families. Twelve of them par- ticipated actively in the interview, expressed interest in what I was doing and in some instances displayed more knowledge of the folk cures than the mother did. The families were delighted that I spoke some Spanish and were impressed with my accent. We frequently used a mixture of Spanish and English. I could conduct the interview in Spanish, but my vocabulary 89 was not always adequate for the answers. My Spanish-English dictionary helped immensely. In the situations in which neither parent spoke any English, we did use an interpreter, always provided by the family. I was very pleased with the strongly positive response of the families. I think that there are a number of factors involved in their acceptance of me and what I was doing. Mexicans are a courteous people; consideration for others is an aspect of their culture which has been retained. I could carry on a conversation in Spanish; very few white health professionals can do so. I was asking them to help me learn about them; I was interested in what they believed and did. I was not telling them what to do. More specifically, I was encouraging mothers to tell me about their children; this is a favorite topic of conversa- tion for mothers. I like and relate easily to children; I frequently had a child on my lap when I was in a home. Knowledge of their culture enabled me to do many things their way rather than mine. Their experi- ences with the public health nurses in Lansing had been positive; I was probably accepted and respected initially because I am a public health nurse. All of these things probably contributed to the fact that every mother thanked me for coming and invited me to come back any time I wanted to. Socioeconomic Status At the time I began this study, I knew that the families with whom I would have contact were part of the poor or low-income segment of the population. Anything that I read about Mexican Americans told me that they were poorly educated and largely employed in very low skill, 90 low-pay occupations. Few of the women are employed outside the home, with the result that most families rely on one income. The families are large, which increases the dependency ratio. My experience with the families in the Child Health Clinic supported what I read. The most widely used measure of socioeconomic status is the two-factor index of social position developed by Hollingshead (1957), which consists of occupation and education of the male head of house- hold. I did not want to use the Hollingshead index for several reasons. It was over ten years old and had not been updated to keep pace with changes in status symbols and the deletion and addition of occupations. It had not been standardized to preventive health behavior. Education of the father is one of the factors. Education of the mother has been demonstrated to be a more sensitive index of health care and decisions (Mindlin and Densen, 1969, 1971; Peters and Chase, 1967; Schonfield, Schmidt and Sternfeld, 1962; Stine et al., 1968). These studies were all reported after the Hollingshead index was developed. A relationship between ethnicity and health care behavior is pointed out in the literature; Blacks, Mexican Americans and Puerto Ricans generally have less care and less adequate care than whites in the lower social classes.(Mindlin and Densen, 1969, 1971; Hochstim, 1968; Morris, Hatch and Chipman, 1966; Nolan, 1967; Peters and Chase, 1967; Wingert, Friedman and Larsen, 1968). The Hollingshead Index does not allow for ethnic differences. Green (1970) developed a method for scoring socioeconomic status which is well suited to public health programs and planning. He gathered 91 data from over 1,500 families with at least one child under five years of age, using nine items of preventive health behavior as the dependent variable. He presents a three-factor index of occupation, income and education of the mother, also a two-factor index of income and education of the mother. The scoring is standardized to preventive health behavior. He found that the relationship between income, education of the mother and preventive health behavior was different for whites and non- whites. Education of the mother was the predominant variable in the white majority; however, in the non-white population, income was "more important than education in accounting for the variations in the pre- ventive health behavior . . ." (Green, 1970, p. 826). His scoring system allows for the difference through the use of different weights assigned to the two variables for the two population groups. Using Green's system, a family will fall somewhere on a scale ranging from O to 55. He does not define a discrete set of social classes as Hollingshead does. He states that the "only essential feature of any index of socioeconomic status is that it places indi- viduals, families or neighborhoods on a hierarchy according to their social status relative to others in the same community" (Green, 1970, p. 816). Green has established scores for coding education, income and occupation. The range for education of females is from 28 for no education to 73 for five or more years of college. Income scores for the North-Central region range from 25 for an income of less than $1,000 to 81 for an income of $50,000 or more. The scores are weighted 92 differently for white and non-whites. .SES is determined as follows, using the two-factor index: SES (non-white) = (0.5 x education) + (0,5 x income); SES (white) = (0.7 x education) + (0.4 x income) (p. 826). For example, a Mexican family (here considered non-white) in which the mother has six years of education and the family income is $6,000 would obtain an SES score as shown: 0.5 x 34 (education) = 17.0 0.6 x 44 (income) = 26.4 SES score = 43.4 The weighted scores will fall on a scale between 30 and 85. Subtracting thirty from each score permits scoring from 0 to 55 and does not affect the statistical properties of the scale. The above family would have an SES score of 13.4 or 13. I used Green's two-factor index for non-whites to score socio- economic status for all families in this study. I had specific data on income and education of the mother, but not on occupation. I chose to use the scoring for non-white Since poor Mexican Americans more closely resemble poor Blacks than poor whites (Shannon, 1966; Wingert, 1968). For the purposes of this study alone, either index for either P0pulation would have given essentially the same information. The choice I made seems to provide more precision for purposes of comparison with other studies . 93 Limitations of the Study The most obvious limitation, of course, is the Size of the sample. The sample size of ten in each group makes the drawing of conclusions or generalizations rather risky. The total of thirty is probably adequate for generalization in those things which are common to the entire group. The good and poor users were selected from those families which met the criteria. The ten good users selected were the first ten whom I could locate. A different group of ten families might have resulted in different information. The pool of poor users was considerably smaller than good users. However, these families, too, were the first ten I was able to locate. There was no selection process in finding the non-users. As mentioned earlier, I found many of them by accident. A defined method of identifying the non-users might have produced different families and different results. I began data collection with two mothers whom I had known when I worked in the Clinic. Since I was not entirely sure of a positive reception, it seemed wise to begin with the known and move to the unknown. Had there been glaring errors in the questionnaire, from the point of view of the Mexican mother, these two women would have told me about them and helped me to correct them. The fact that I had known some of the women previously might have resulted in some bias in those interviews. I made every effort to iavoid differentiating between those mothers and the ones whom I had not l