. ,_ .1 .' .‘ 5:": ‘ .7 :4 I vx ,J-Jg‘ ‘ éfl-k‘fin ”Li: \‘1 m ‘ flaw »» #1.. . 1 '11 b A 5‘ f ' a . s ' ‘1‘ 1 I ’ *4 4 -,L)‘-" n, ' \ .. -4 $3 a. OVERDUE FINES ' 25¢ per day per ite- RETURNING LIBRARY MATERIALS: _________._.————————- mace in book chum from c 1 7.003 return to remove irculation records INCREASING THE UTILIZATION OF HEALTH CARE SERVICES BY MEXICAN AMERICANS: AN EXPERIMENTAL APPROACH BY Miguela C. Rivera A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1980 Copyright by MI QUELA CARLEEN RIVERA (3 1980 ABSTRACT INCREASING THE UTILIZATION OF HEALTH CARE SERVICES BY MEXICAN AMERICANS: AN EXPERIMENTAL APPROACH BY Miquela C. Rivera The primary purpose of this study was to experimen- tally investigate the problem of caregiver-consumer linkages and the provision of culturally relevant health services to Mexican Americans in Lansing, Michigan. It used an informa- tional outreach component to investigate whether the knowl- edge of the availability of a curandera's (folk medical practitioner's) services in a health center would signifi— cantly affect service utilization rates by Mexican Americans. It also investigated attitudinal, perceptual, belief and socioeconomic correlates of Mexican American health care behavior. Two treatment and one control group comprised the final sample of 101 in this study. One treatment group re- ceived outreach visits at home in which they were informed of contemporary medical services available through a neigh- borhood health program. The second treatment group received the same information as the first treatment group but were also told that the services of a curandera or folk healer were available through the Health Program. The control group received no outreach contacts whatsoever. Four weeks after outreach, all groups were contacted for a follow-up H vi Miguela C. Rivera survey. A primary measure determined the effectiveness of the outreach contacts: receipt of a service through the Health Program. There were no significant differences be- tween treatment groups on receiving a service. Significant differences in service use were found when treatment groups were compared with the control group. ‘The outreach contact itself, not the folk medical dimension, resulted in increased service use. No significant differences were found between treat- ment groups on the follow-up survey scales. When subjects were grouped according to language spoken during the inter- view, significant differences were noted in Health Anxiety and Health Locus of Control Scales. Subjects interviewed in Spanish reported greater Health Anxiety and more external Health Locus of Control than those interviewed in English. When grouped according to educational level, subjects with less than an eighth grade education reported poorer health status, greater health anxiety and worse health histories than those with more education. A significant difference in service use was noted when subjects were grouped according to receipt of government assistance. Recipients of govern- ment assistance used health program services after outreach contact more than those not receiving government aid. Pearson correlations between survey variables general- ly indicated that health status, health histories, health Miquela C. Rivera anxiety and attitudes towards health care delivery were re- lated to economic variables such as monthly income or the ability to afford medical payments. Findings were discussed in terms of differential health care received and socio- economic factors. Implications for health care policy formation, service delivery and future research with Mexican Americans are discussed. ACKNOWLEDGMENTS My thanks to . . . Dr. William 8. Davidson II for his guidance and cooperation throughout my graduate training and research; Dr. Neal Schmitt, Dr. Ralph Levine and Dr. Arthur Seagull for their valuable input into the research plan and final product; Mr. R E Olds Anderson, Ransom Fidelity, Lansing, for the generous funding of this project and the warmth of his friendship; Connie Marin, Coordinator of the Cristo Rey Health Program, for her support, friendship and encouragement throughout all phases of this work; Mr. Tony Benavides, Director of the Cristo Rey Community Center, for allowing the research project to be conducted at the Center; The ten students who helped in the difficult phases of out- reach and for follow-up data collection; and My family and friends, for their continued love and prayers. ii Chapter II TABLE OF CONTENTS INTRODUCTION . . . . . . . Review of the Literature . . . . Scientific Medicine . . . . . Primitive Medicine . . . . Folk Medicine . . Health Beliefs and Attitudes in the United States. . . . . . Health Care Utilization . . . . Mexican American Health Care . . Investigations of Mexican American Health Care Behavior. . . . Mexican American Health Needs and Service Utilization . . . Community Center Health Services for Mexican Americans: Lansing, Michigan. . The Problem of Culturally Relevant Services. . . . . The Problem of Linkage . . . Information Outreach . . . . Outreach Strategies . Attitudinal, Perceptual and Belief Correlates of Health Care . . The Project . . . . . . METHOD. . . . . . . . . Subjects . . . . . . . . Procedure . . . Experimental and Control Conditions Control Group . . . . . In-Person Contact Group: Con- temporary Medical Services Only In-Person Contact Group: Con- temporary and Traditional Medical Services . . . . The Client Card. . . . . Employing A Curandera. . . . iii l3 19 27 28 29 3O 30 32 34 37 37 40 40 40 41 42 42 Chapter II (cont'd.) Page Selection, Training and Super- vision of the Health Program Outreach Representatives. . . . 43 Measurement of Dependent Variable. . 45 Primary Dependent Variables. . . 45 Number of People Receiving Services . . . . 45 Follow-Up Survey Attitudinal Variables . . . . . 47 The Follow-Up Survey . . . . 47 Construction and Use of Scales . . . 48 The Health Locus of Control Scale (HLC) . . . . 49 The Index of Psychological Well- Being (IPWB). . . . . 49 Perceptions Regarding Health Scale (PRHS). . . . . . . 50 Needs Scale . . . . . . 51 Clarity of Outreach Scale. . . . 51 Attitudes Towards Folk Medicine Scale . . . . . . . . 51 Fluency Scale. . . . . . . 52 Demographic Information . . . . 52 Other Areas of Interest . . . . 53 Concluding Operations . . . . . . 53 III RESULTS . . . . . . . . . 54 The Sample. . . . . . . 54 Subject Mortality. . . . . . 54 Effectiveness of Randomization . . . 56 Treatment Effects . . . . . . . 56 Primary Outcome Measure . . . . 56 Other Differences in Primary Out— come Measure and Attitudinal Variables . . . . . . . 58 Correlational Analyses. . . . 62 Relationships Between Attitudinal Variables . . . . . . . 68 Relationships Between Other Survey Variables . . . . . . 69 Reasons Given by Subjects for Response or Non- Response to the Outreach Contact . 71 iv Chapter Page IV DISCUSSION . . . . . . . . . 73 Primary Outcome. . . . . . . . 74 Follow-Up Survey Scales. . . . . . 75 Correlates with Service Use . . . 77 Relationships Between Follow- Up Survey Scales . . . . . . 78 Relationships Between Other Survey Variables . . . . . . 80 Reasons Given by Subjects for Response or Non—Response to the Outreach Contact . 81 Research Issues and Limitations. . . . 84 Research Implications & Future Directions. . . . . . . . . 86 APPENDICES . . . . . . . . . . . 90 A. Historical Overview of Mexican Americans . . . . . . . . . 90 B. Curanderismo: Mexican American Folk Medicine . . . . . . . . 100 C. Client Card . . . . . . . . 104 D. Consent Form . . . . . . . . 106 E. The Follow-Up Questionnaire. . . . . 107 F. Follow-Up Questionnaire Frequencies. . . 123 REFERENCES . . . . . . . . . . . 141 Back Informational Outreach Pamphlet Cover LIST OF TABLES Project Outline . . . . . . Final Sample Composition: Subject Mortality by Condition and Project Phase. . . . . . . . . REceiving a Service by Type of Contact Attitudinal Variables According to Language of Interview. . . . . Receiving a Service by Receipt of Government Assistance. . . . . Attitudinal Variables by Educational Level. . . . . . . . . Pearson Correlations . . . . . vi Page 46 55 57 59 60 61 63 CHAPTER I INTRODUCTION Projections by the United States Bureau of the Census predict that the Hispanic* population will be the largest ethnic group nationally by the turn of the century. Mexican Americans comprise the largest Hispanic subgroup in the United States. Researchers, administrators and health care providers must plan and implement health services to meet the needs of Hispanics based upon reliable data from various segments of the population. Most of the early research on Mexican American health care behavior were conducted with very low income Mexican Americans in rural areas of the Southwest. Anthropological in nature, these studies were frequently compared to find- ings of research based on middle—class white populations. As a result, Mexican Americans were viewed as having "primi- tive, unscientific" attitudes towards health and illness and firm beliefs in traditional Mexican American folk medicine (Curanderismo). Researchers explained these differences in health care behavior in terms of cultural differences. Two *Hispanics: People whose ancestry stems from Mexico, Puerto Rico, Cuba, Spain, Central and South America (excluding Brazil). 1 rub «a .nv ‘¥:‘ UL“ I .01. o u .c flea H. '1 “Q! I ‘ch‘ 2 decades of research and service delivery were subsequently based on these early studies. The urban Chicano has largely been the focus of Mexican American health care research in the last decade. Researchers critical of the early work in the field note that previous studies promote ethnocentric stereotyping and do not consider health system variables that pose barriers to Mexican Americans attempting to use existing services. The role of attitudinal, socioeconomic and health system variables in Chicano health care behavior have been investi- gated in recent studies through survey research methods. No studies to date have experimentally investigated cultural, attitudinal and socioeconomic variables in Mexican American health care. This research was designed to experimentally investigate the problem of caregiver-consumer linkage and the provision of culturally relevant health services to Mexican Americans in Lansing, Michigan. It uses an informational outreach component to investigate whether knowledge of the availability of a curandera's (folk medical practitioner's) services in a health center will significantly affect service utilization rates by Mexican Americans. It also investigates attitudinal, per- ceptual, belief and socioeconomic correlates of Mexican American health care behavior. The background for the conceptual framework of this research is discussed in this chapter. First, literature 3 on health care beliefs and attitudes in the general popula- tion are reviewed. Factors affecting health care utiliza- tion rates by Mexican Americans are then detailed. Third, the problem of linkage between health services and commun- ity members is reviewed. Finally, a brief description of this experimental research is presented. Detailed research methodology is presented in Chapter II, and findings of the project are reported in Chapter III. Conclusions and impli- cations for service delivery and future research are made in the final chapter. REVIEW OF THE LITERATURE Beliefs, attitudes and values are "ordering mecha- nisms" which provide continuity and structure for a person's psychological world. They are cognitive organizations of a person's knowledge and perceptions of previous experience. "Beliefs tell us how things are related to each other, atti- tudes tell us how we relate to them, while values tell us how to choose from among objects and events." (King, 1962, p. 53.) Beliefs are the pattern or meaning of things or events. They are comprised of knowledge, opinions and faith about life experiences. Attitudes add an affective component to beliefs, resulting in a readiness to act. Attitudes frequently are seen as either positive or negative, depending upon the emotion attached to the belief. Values are principles by which people establish priorities among to\ «u. . \li. 4 needs, desires and goals. Beliefs, attitudes and values thus help an individual find meaning in events and answers to various life situations. They assist a person in achiev- ing various goals. Beliefs and attitudes can be clear and explicit or vague and indistinct. Some may be interwoven in a belief or attitudinal system, while others may be distinct and sepa- rate. Beliefs and attitudes that are central to the individ- ual's personality structure are generalized, well organized and based on that person's need for identification with people and groups. Cultural and social backgrounds are important factors in the development of an individual's beliefs, attitudes and values. Margaret Mead (1953) defined culture as those learned behaviors and traditions in arts, sciences, tech- nologies, religions and philOSOphies, foods, daily living practices and political systems passed from one group to their children or other immigrant groups that become members of the society. Culture thus serves as a systematic device for perceiving the world (Paul, 1955). As cultures vary, so do world views. Cultural groups will thus vary in the extent to which they perceive circumstances as illness or health, normalcy or abnormalcy, needing remedy or not. Social class membership is another factor in the in- dividual's development of beliefs, attitudes and values. Level of education, occupation, income, prestige, place of residence and social interactions are frequently used as ‘A by "\ an» “V. b .5 ac 1. . a: n y. ‘P. G» c.- B.. YV 5 1h! u f Q C LU s‘ ‘ +5 5 indices of social class. Social class groupings provide frameworks for common values, leisure activities, customs, aspirations and child-rearing practices. They influence one's perception of a situation, including those pertaining to health care. Ethnic group membership is determined by a common background in language, customs, habits and traditions of racial or national origin. Racial consciousness and pride are of central importance, too. Family structure, marriage patterns, and daily life practices are influenced by ethnicity. Health attitudes, beliefs and values also vary accordingly. The definitions of health and illness, pre- ventive and treatment measures, and expectations of inter- vention differ between ethnic groups. One's perception of the world is a dynamic process in which cultural, social class and ethnic factors contrib- ute and interact. Since these perceptions are dynamic, the importance of each factor will vary from situation to situ- ation. Health, illness and death are biological and social phenomena. They influence the individual's physical well- being and affect roles and social relationships. Beliefs and attitudes toward health and illness are important in understanding how a group will perceive and react towards illness. The meaning, definition, classification, preven- tion and treatment of health and illness may all be 6 influenced by beliefs and attitudes as well as culture, social class and ethnicity (King, 1972). Three general considerations should be recognized in reviewing health belief and attitude systems. Primarily, health beliefs and attitudes will be integrated with other belief and practice systems, such as familial networks, religious beliefs and political and social control. Second, the perception and treatment of health and illness will vary from group to group. Third, the group will hold firm in their assurance of the adequacy of their health belief system. King (1962) places health attitudes and beliefs into three major categories: scientific medicine, primitive medicine, and folk medicine. Considerable variation occurs within each, yet each type has distinguishing characteris- tics. An individual or group can ascribe to more than one belief system. One system exists within each individual or group, but an alternative system may be called upon under severe, unpredictable or threatening health situations. Scientific Medicine The rational explanation of health and illness in terms of cause and effect is the basic feature of scientific medicine. Cause is viewed as naturally occurring, not supernatural. Facts are determined in this belief system through the scientific method of observation, description and classification. Hypotheses are derived through 1."... Lc‘v‘. IA‘- Inv‘. h“. 4“ 7 inductive reasoning and predictions tested through experi- mentation. In turn, findings are compared to basic princi- ples, with the latter being changed as necessary. Primitive Medicine Primitive medicine is based on magic. Causal rela- tionships in primitive medicine are viewed as supernatural, not natural. The supernatural laws are unchangeable, so experimentation is not necessary. Tradition is an important support for the powers of the supernatural. "Primitive" medicine is so named because it was the first health system in existence, is unsophisticated, and found most frequently today among pre-literate, unscientific societies. Though unsophisticated, primitive medicine may be detailed and complex. Magic may be used in all life areas such as work, war and in family relationships. Objects are tied together through magic, and rituals become mechanistic. Efficiency in health is thus determined by a magical element. Disease may be caused by a number of factors: sorcery, breach of taboo, disease object intrusion, soul loss and spirit intrusion. Folk Medicine Traditional nonprofessional beliefs about health care are the key to folk medicine. Folk medical beliefs gain much credence from experience of elders, and case or natural 8 empirical evidence. Cause and effect are noted in folk medicine, but the mechanism producing illness is not under- stood scientifically. Since folk medicine is empirical rather than experimental, it is rather disorganized and fraught with contradictions. These deficits, however, are minimized by the adherence to tradition. Folk medicine is typically characterized by the use of home remedies. Its roots lie in agrarian social prac- tices, involving the group rather than selected profession- als. Since the beliefs are shared by everyone and passed through generations, there may be resistance to change as societies develop. It exists in some societies alongside primitive or scientific medicine with little conflict. The role of folk medical beliefs in the health care behavior of Mexicans and Mexican Americans will be elaborated in another section of this chapter. Prevalent throughout many folk medical belief systems is the idea that health is maintained through the balance of hot and cold forces in the body. When one is overexposed to one or the other, disease results. Foods, liquids, body states, illnesses and the environment are considered inher- ently hot or cold regardless of their actual thermal quality. The hot-cold dimension of folk medicine is notable in folk medicine of India, Spanish-speaking countries, and Greece or groups influenced by Greek thought. 62‘ 2?», “4H‘ 9 Body fluids are often the center of certain folk medical beliefs that have little or no substantiation in scientific medicine. Blood and semen are seen as central agents of strength and resistance to illness. If semen or blood is lost, resistance decreases. In the United States, for example, folk medical beliefs state that blood "thick- ens" in the winter and must be "thinned" or purified with sulfur and molasses in the Spring. Health Beliefs and Attitudes in the United States Talcott Parsons (1979) described health attitudes and values in the United States in terms of the nation's general value system and social structure. He viewed Americans as achievement oriented and concerned primarily with role-performance. Parsons considered education and health the basic essential components for achievement. The maintenance of health itself thus becomes an important value among Americans. Any disturbance in a person's ability to fulfill a role is most likely viewed as illness. Health services provide protection and restoration of the person's capacity for achievement. Instead of passive acceptance of illness, American society promotes the person's mastery over illness and complete cooperation with the health care provider. A person thus works to achieve recovery, as he works to achieve other valued goals. Illness is viewed as an undesirable condition to be recovered from as quickly as SEC .3 2. ya u Yv‘ 10 possible. When medical science sanctions that a person "can't help" his illness, it is generally accepted by society. Where scientific evidence is not readily avail- able, American health attitudes reflect that the person probably could help or avoid the illness. Plans for "free" health care are frequently viewed with suspicion by some because of the readiness of people to claim illness whenever possible. In a Regionville, New York study by Koos (1967) health care attitudes and behavior were found to vary according to social class. Cost and age were also significant factors, with the former being a deterrent to health care and the latter a promoter. Psychogenic needs, social role, symptom occurrence and class values all affected the perception of health and illness in the sample. A National Opinion Research Center study sponsored by the Health Information Foundation (King, 1962) surveyed a cross-section of the American public on their health be— liefs and attitudes. Data were analyzed in terms of socio- logical and demographic variable breakdowns. Positive or preventive health were concepts familiar only among the upper socioeconomic classes. The low income viewed illness as an inevitable part of life. The lower social class also had poorer nutrition and used health services less than those of higher income. Low income re— spondents displayed much less knowledge about scientific up; otlvku ll medicine, particularly contagion. While inadequate knowl- edge does not necessarily mean that the person will not use scientific medicine, he may be less inclined to do so if aspects of the health care system pose barriers to the patient. Wary of the doctor and medically naive, some still rely to some extent on folk medicine. Overall, results of the NORC-HIF survey indicated that most respondents utilized existing health services and had faith in medical personnel. Scientific medicine domi- nates nationally, with folk medicine occasionally being practiced as an added or alternative approach. Health Care Utilization In the past two decades much literature has dealt with differences in the use of mainstream medical facili- ties. Despite the extent of the literature, McKinlay (1972) concluded that the literature were more substantial than the findings, results were inconsistent, and little had been done to account for the disparities. A number of variables related to health care use have been delineated, however, and investigated in subsequent studies. McKinlay defined six sets of factors evident in health care utilization. Economic aspects of health care were examined. While cost was a factor, its removal did not significantly affect the rate at which health care services were used. Socio- demographic variables (age, sex, religion, socioeconomic 12 status, education, race) are related to health care usage, but explain little in terms of causal relationships. Geo- graphic location of services was also considered an impor- tant determinant of health care usage. Little evidence exists to show proximity of services to consumers as a sig- nificant variable. Social psychological variables such as knowledge of cure, recognition of need, and alienation from health care services have also been studied, but findings remain unclear. Sociocultural variables have been studied as factors in health service usage because groups dictate health beliefs and practices. Cultural differences in health care patterns have been studied by Koos (1967), Denton (1978) and Zola (1966). Organizational variables comprise the sixth set of factors delineated by McKinlay as important to health service utilization. The discrepancies between beliefs and practices of health care providers and those of consumers have been noted as deterrents to service use. Mexican American Health Care Accurate demographic data on the Mexican American pOpulation nationally have been scarce because government sources traditionally have not regarded "Mexican American" as a distinct ethnic classification in census information. The U. S. Bureau of the Census estimated that the Hispanic or "Spanish origin" population nationally numbered over 9 9 1'9. ‘o- ' a: 4: .— u nu A.» Q.» L» .m 0 "3 Lu u ., 7. *~ .r it...e 13 million in 1971 (USBC, 1971). Of these, approximately five million persons were of Mexican descent (Forbes, 1970). Available census information and population growth trends have currently placed Mexican Americans as the second larg- est and fastest growing minority in the United States. An historical overview of Mexican Americans nationally and in the Midwest specifically is elaborated in Appendix A. Investigations of Mexican American Health Care Behavior Weaver (1976) noted three historical phases in re- search and analyses of Mexican American health care behavior. He repeatedly noted the theme that Mexican American health behavior was a consequence of and reinforcement for a com- munity-wide subculture (Weaver, 1978). Lyle Saunders, the first noted investigator, is noted for his impact upon subsequent analyses of Mexican American health care behavior. In the late 1940's, Saunders (1954) used anthropological and ethnographic investigations in attempting to formulate a cultural perspective of health care behavior. He used Latin American investigations as a background for describing six families in New Mexico. Saunders proposed that four basic sources of health care existed and were utilized by Mexican Americans: (1) folk medical beliefs originating in Spain and modified in Mexico, (2) Native American tribal practices, (3) Anglo folk medi- cine and (4) scientifically-based contemporary medicine. Faun UJJ“ ‘IA t n‘u 5. .3 '1” “11. Q A :‘fi .6 o by V‘- FA}: “$4.. ..6 L. fl~.v‘ C .. v-~ .1...- a ‘ \ l4 Saunders considered folk medicine the central core of the Mexican American health care system. He also noted that the Hispanic's health beliefs, knowledge and practices were influenced by the person's age and extent of participation in the Anglo culture. Saunders made no regional or social class distinctions among Mexican American groups. Instead, comparisons are made between general Mexican American and Anglo American health belief models (Weaver, 1976). A detailed description of basic beliefs in Curanderismo, Mexican American folk medicine, may be seen in Appendix B. Saunders noted that Mexican American folk culture looked upon health as a matter of chance, with the individ- ual having little control in prevention of disease. Many illnesses occurred because of supernatural forces. Many diseases could be treated by the afflicted person, an attending family member or a physician. A curandero(a) or folk healer may be seen if the disorder is thought to result from supernatural forces. Saunders noted that because of the family-centered social organization and social inter- action aspects of the culture, Mexican Americans avoid hospitalization as much as possible. Their poor (if any) conceptualization of time also results in nonadherence to time schedules or return visits. The second phase of Mexican American health care studies occurred during the middle and late 1950's. Three of the main investigators during this period developed tie“ in t1- F Oct V 55, L- Par" ca ‘1-‘1. “vi CO A 15 detailed ethnographies of working class rural and village populations. Like Saunders's work, they focused upon folk medicine and cultural interpretations of behavior. Margaret Clark (1959) investigated a small popula- tion of Mexican Americans in Sal si Puedes ("Escape if you can") near San Jose, California. Clark obtained informa- tion from fourteen (14) families in the barrio. Clark used Saunders's research as a framework; her findings confirm his health subculture hypothesis. Patients used self-treatment, assistance by family or friends, or consultation with a curandero(a) for medical assistance. Etiologies were similar to those in Saunders's study. Some of the most detailed descriptive works on Mexican American health behavior were done by Rubel (1966) and Madsen (1964). Rubel's intensive research focused upon the detailed lifestyles of key informants in a small village in the Rio Grande Valley of South Texas. Madsen, alterna- tively, attempted to draw an overall cultural picture. Both investigators used participant observation, biographies of key informants and familiarization with many aspects of community life in their studies. Rubel (1966) investigated natural and magical diseases, healing through the use of natural herbs, fatalistic atti- tudes toward illness, and reliance upon alternate support systems such as family or folk healers for medical care. Rubel noted that not the cost of health care but the fee 1‘ . q .. 1 .. A..:. Cn‘ .v- 1 4 r a (D I (n (I) In .56 X A I C) ' h '71 Eeyt rate R VON“. lg.“ 16 system itself was a barrier to Mexican Americans receiving medical care. Folk healers are paid through gratuities, so some Mexican Americans may view physicians requiring payment as advancing themselves at the expense of the patients instead of serving the common good. Madsen (1964) stated that reliance upon traditional folk health beliefs varies inversely with social class. Lower social class members may rely heavily upon folk heal- ing techniques in alleviating disorders; middle class indi- viduals would have more contemporary orientations while maintaining some traditional beliefs. Madsen noted that many Mexican Americans may struggle between contemporary medicine and traditional folk beliefs and health practices. He hypothesized that many contemporary Chicanos may actually use folk healing practices while not admitting to it openly. While Madsen contended that adherence to folk beliefs varied according to education, occupation, and social class, he viewed the Mexican American community (excluding the elite) as traditional. On a different scale, E. Gartly Jaco (1959) conducted a statewide study on the incidence of mental illness among Mexican Americans in Texas. Jaco's data were from records of psychotic patients admitted for the first time to Texas mental institutions during 1951-1952. First-time admission rates for Mexican Americans were 42 per 100,000 population compared to 80 for Anglos and 55 for nonwhites. The Mexican ‘ ”ID,“ 'A ‘1 ~un~$u -. 115~ . Oil U-~ tian c ‘ Q Ana-.. 4 fitvuu’ «.gz. 1' V. t ‘ . 45‘!" - ‘ v44-» my.” a: Li (D 17 American admissions rate to public institutions was about three times greater than their admission rate to private treatment facilities. Jaco recognized but minimized cul- tural differences in Mexican American health beliefs. He concluded that Mexican Americans have lower psychotic ad- mission rates simply because they are afflicted less often than other groups. A review of admission rates in Colorado about a decade later (Colorado Commission on Spanish-surnamed Citizens, 1967) found a slightly higher admissions rate for Mexican Americans across all classes of illnesses, not simply psychoses. Psychiatric admission rates alone were lower and alcoholism admission rates higher than those in the general Anglo population. Moustafa and Weiss (1968) found that admissions for Mexican Americans in New Mexico were 41.8 per 100,000 population compared with 53.6 for Anglos. Both studies support Jaco's findings in Texas. Overall, during the second phase of Mexican American health care behavior research Chicanos were viewed as a fairly homogeneous group who relied upon folk medicine, reflected fatalistic attitudes toward illness and manifested a complex system of health beliefs and practices. The research on Mexican American health care con- ducted during and since the 1960's has had more methodo- logical diversity and varied scepe than works done in earlier phases. Survey and ethnographic studies on large and St rural , . Cn“~2* .55 v1.41. l8 and small populations of varied socioeconomic strata in rural and urban settings were conducted. Politically, chicanismo or the Chicano movement for respect and recog— nition witnessed an upsurge in research across disciplines. This diversity resulted in new, though frequently contra- dictory, literature. In general, however, high morbidity, mortality and health service underutilization rates by Mexican Americans were reported. 'Bachrach (1972) noted that the occurrence of mental illness among Mexican Americans varies inversely with age, with younger Chicanos showing higher incidence rates (Bachrach, 1972). Cultural and assimilation stresses and conflicts are possible explanations for such a pattern (Castro, 1977; Karno & Edgerton, 1969). Younger Chicanos may experience these difficulties more than those older be- cause the latter may be more sheltered within the family structure. Ari Kiev (1964; 1968) developed and presented a psy- chodynamic explanation of Mexican American culture in several works on folk psychiatry. Kiev explained stereo- typic Mexican American traits such as male recklessness and machismo and female masochism in terms of Oedipal conflicts, unmet dependency needs and other psychodynamic concepts. He concludes that the basic Mexican American cultural traits of traditionalism, personal dignity (dignidad) and world view orientations were dysfunctional to an individual's sense of 1' wer: “5‘ H 1; MS, ”A ..v‘ l9 well-being. Kiev's implication is that intervention by a curandero(a) sensitive to the Mexican American cultural framework deters a more widespread psychoses or other dis- ruptive behavior in the Chicano population. Curanderos(as) treat individuals with symptoms of psychopathology. The third phase of Mexican American health behavior research included investigations of social, structural and cultural components of service delivery. These differed from the patterns of study followed in the earlier two research phases. Their general findings are reviewed further. Mexican American Health Needs and Service Utilization In a Colorado study (Moustafa & Weiss, 1968) infant mortality was three times the rate for Mexican Americans (13.6%) than among Anglos (4.3%). The average age of Mexi- can Americans at death was 56.7 years as compared to 67.5 for Anglos. Similar patterns were noted in a San Antonio, Texas study. While morbidity and mortality are high among Chicanos, they also underutilize existing health facilities. Among California hospitalization rates, Chicanos ranked lowest per 1,000 persons with 76 compared to 82 for Blacks and 95 for Anglos. Rates of visits to physicians by Mexican Americans were also comparatively low; Chicano enrollment in health insurance plans followed the same pattern. Researchers attribute low health facility utilization rates among Mexican Americans to: (1) folk medical beliefs 20 and practices in prevention and treatment (2) negative atti- tudes toward Anglo American medical treatment, prevention and programs and (3) beliefs toward causation and prevention of illness. Reluctance of some Mexican Americans to seek help or give information to government or other agency in- vestigators or practitioners may cast a different light on research findings (Clark, 1959; Humphrey, 1941; McWilliams, 1933). The role of the family in health behaviors of Mexican Americans has been considered by some researchers. Some have found the family to be a source of strength and support for Chicanos experiencing mental stress (Woods, 1958), but others have argued that the family is more disruptive than supportive for many Mexican Americans (Heller, 1966; Nall & Spielberg, 1967). The latter contend that the Mexican American family stresses values which hinder mobility and are not conducive to an industrial society. Family ties, honor and present time orientation are antithetical to those values of achievement, independence and delayed gratifica- tion essential to success in the majority culture. This psy- chopathological View of the family has been termed the "Social Science Myth of the Mexican American Family." (Montiel, 1978, p. 56.) A culturally—based explanation for health service underutilization by Mexican Americans emerges and gains support with Kiev's suggestion that Chicanos rely upon folk that at :« Fla .rn .C C~ '- b. L” 1v- A“ t b a: Tu ECG? Y Q 5‘ 1.1.8 - h ~ 21 rather than contemporary medicine, the hypothesis that the family is the major support system, and Jaco's conclusion that illness is not as widespread in the population. Alter- nate health beliefs, sensitivity or reluctance to share problems with outsiders and fear of health authorities are also factors which could influence rates of health service use by Chicanos. These have been tested by investigators in the Southwest. Karno and Edgerton (1969) found differences between East Los Angeles Mexican Americans and Anglo Americans in the perceptions of mental illness. When Chicanos were shown a situation of a person experiencing mental illness, they recommended a visit to a physician more often than Anglos did. Mexican Americans expressed greater confidence in the psychiatrist's ability to help patients and were more opti- mistic about the individual's recovery or the "curability" of the mental illness. Karno and Edgerton (1969) found proportionate underrep- resentation of Mexican Americans in psychiatric treatment in California. Chicanos comprised 9 to 10 percent of the popu- lation statewide but represented on 3.3% of the psychiatric resident population. On the bases of attitudinal data and utilization rates, the authors concluded that a complex of social and cultural factors, not simply traditional folk be- liefs, are barriers to Mexican American health service use. 22 Linguistic differences, accessibility, and bureau- cratic procedures are among the primary factors influencing mental health service use by Latinos (Padilla, Ruiz, and Alvarez, 1975). There are not enough mental health services sensitive and in proximity to the Latino community. Bureau- cratic procedures at some mental health facilities may be frustrating and discouraging to people seeking assistance. Extensive personal information requested, checking-in pro- cedures, long waiting periods and scheduled appointments appear intimidating, needlessly inquisitive, insensitive or rude to the Latino seeking help (Padilla, Ruiz & Alvarez, 1975). Fees may pose another barrier. Personnel variables and treatment modalities in the mental health system also influence service utilization by Hispanics. The effects of therapist ethnicity and language have been noted with Latinos (Edgerton & Karno, 1971; Karno & Edgerton, 1969). Relevant service delivery to minorities is not merely one of matching provider and client ethnicity. Cultural sensitivity, understanding and acceptance of the Latino in his personal and social situation by the health provider is essential (Abad, Ramos & Boyce, 1977; Padilla, Ruiz & Alvarez, 1976; Yamamoto, James & Palley, 1968). The provider must also be aware of his own biases towards minor- ities (Jones & Seagull, 1976) since they may affect the working relationship. 23 Social class differences in attitudes, values, goals and lifestyles between lower and middle or upper classes are important in service delivery since therapists work most comfortably and successfully with clients of their same social class (Lorion, 1973). Treatment orientations are frequently develOped on Anglo assumptions, too. The insight therapies which rely upon client verbalization have not proven to be very useful with minority groups. Perhaps the discrepancy between an individual's anticipation of treatment and the actual treatment received results in disillusionment, dissatisfaction or alienation of the individual from the system of providers. The individual can then either choose to return for treatment, go without any treatment whatsoever, or seek out alternative sources of support. Clergy, family members, friends, physicians and curanderos(as) serve as general or mental health care providers for many Mexican Americans. These sources are perceived as sensititve, under- standing, accessible and fairly inexpensive (except phy- sicians, in some cases). Some attempts have been made to make health facili- ties more accessible and relevant to Hispanics. La Frontera Mental Health Center in Tucson, Arizona (Burruel & Chavez, 1975) is centrally located in the Mexican American community. Its bilingual bicultural staff provides services in an in- formal way with minimal bureaucratic procedures. Phillipus (1971) also reported successful and unsuccessful approaches 24 in delivering mental health services to urban Hispanics. A Denver General Hospital Mental Health Team was located in and served Hispanics in westside Denver. The Team was originally located in an old home, intake procedures were simple and scheduling hours flexible. When they later moved into new neighborhood health center facilities and used more bureaucratic procedures, the number of Hispanic clients dropped by over 50 percent within six months. While the overall number of clients increased, Hispanics represented only 35 percent of the total. Changes were introduced again and the number of Spanish-speaking clients increased. The author suggested that accessibility, the use of a bilingual receptionist (the client's first contact with the Center), a crisis orientation in treatment, bilingual staff members, drop-in facilities for clients, community involvement and active relationships with general medical services are im- portant in providing relevant services to Hispanics. Vivian Garrison (Fields, 1976) investigated the over— lap between folk and contemporary psychiatry in order to promote understanding, collaboration, better planning and delivery of mental health services to Puerto Ricans in the South Bronx. Garrison began by investigating natural help- ing networks or organizational structures in the Puerto Rican community. She lived in the home of an espiritista (folk healer, somewhat similar to Mexican and Mexican American curanderos(as)) who operated her own centro or .o-- 4.. C . Cu «G A: A,» 25 healing center. Garrison also located other centros in the area frequently visited by community members. A centro is similar to a neighborhood crisis center, sometimes located in storefront buildings. PeOple spend time visiting in a reception area while waiting to see the espiritista. No appointments are scheduled. While a detailed account of services provided will not be covered here, Garrison stated important implications for service delivery. Primarily, interventions by doctors might be more acceptable if they resembled spiritist practices in certain aspects. Walk-in services with short-term treatment orientations might best meet the expectations of the Hispanic client. Home visits, combinations of individual, group and family treatment mod- alities, role playing rather than didactic techniques, structured problem solving rather than long-term personality change, and use of paraprofessionals are some of her recom- mendations for relevant services for Hispanics. In summary, research on the health behavior of Mexi— can Americans has largely been based upon rural villages, subsistence farmers, or urbanized low income barrios. Weaver (1976) noted that methodological and conceptual limits of mental health studies with Mexican Americans make conclusions difficult to draw, and tenuous at best. Results are frequently contradictory to those in which variables vary slightly. These differences in population and systemic variables have not been experimentally manipulated or other- 26 wise empirically tested in order to determine their signif- icance in health care. Many studies during the third phase of research in Mexican American health care behavior offered some support for the contention that the emphasis upon tra- ditional folk beliefs was overdrawn. These conclusions, however, were typically drawn from educated, employed, middle class urban Mexican Americans. A systematic investigation of cultural and non-cultural client and health system vari- ables and service use by Chicanos has not been conducted. Weaver (1976) calls for further research in health attitudes, beliefs and practices of Mexican Americans nationally. He notes that "while there are numerous studies of rural and lower-class southwestern and western Mexican Americans, no research has been conducted that incorporates a cross-sectional sample of the population or encompasses Mexican Americans living in Ohio, Illinois or Michigan" (Weaver, 1976, p. 66). The roles of systemic and cultural variables in the underutilization of health services by Mexican Americans must also be studied. Third, he addresses the need to study the effects of Spanish-speaking personnel in health delivery and the role of active citizen participa- tion in health planning efforts. This study attempted to investigate some of the ques- tions set forth by Weaver and other investigators of Mexican American health care behavior. Unlike other studies detail- ed in the literature, this project combined an experimental 27 outreach information component with a traditional folk medical and attitudinal component in studying health service utilization among a group of Midwestern Mexican Americans. Community Center Health Services for Mexican Americans: Lansing, Michigan The Mexican American population in Lansing today is estimated at 10,000 (Garza, 1979). While Chicanos reside throughout the city, they are largely concentrated in the northern section of Lansing. Many are native residents of Michigan; others still have close ties with Texas or Mexico. Haney (1978) considered the Mexican American population in Lansing to be fairly "traditional" in orientation. Many Mexican Americans in north Lansing are of low income, fre- quently employed as unskilled or semi—skilled workers. Work is not always consistent, however, so many individuals are not only faced with low income problems of poor health, limited education and substandard housing, but also with un- predictable means for dealing with daily needs or crises which may arise. With urgent needs of food, shelter, util- ities and clothing, health may be low priority. A person in this situation may exercise various options in dealing with health needs: (1) take no treatment or preventive measure whatsoever (2) call upon family members, friends, or clergy for assistance (3) use available public health clinics of which the person has knowledge or (4) consult with a local curandero(a) for assistance. 28 Cristo Rey Community Center in North Lansing provides many programs and services to the community. These include employment referrals and placements, recreation, counseling and guidance, senior citizens nutrition and miscellaneous activities, substance abuse intervention, direct assistance (emergency food, clothing and shelter), legal assistance and health education and treatment. Cristo Rey is located with- in walking distance of many north Lansing residents. The staff is predominantly bilingual and bicultural; many are from the area and are familiar with the lifestyles and op- portunities the community provides. The Cristo Rey Health Program provides information and referral, and preventive services of education and con- sultation. Treatment services by a physician and attending nurses are available through adult and pediatric clinics. The Cristo Rey Health Program is open to all community members regardless of race, income or residence. The Problem of Culturally Relevant Services While the Cristo Rey Health Program services are available, their use by community members has been low. Some of the factors noted earlier in this review which con- tribute to underutilization of health facilities nationally by Mexican Americans may also be operating with the Chicano population in Lansing. Language barriers (some physicians typically only speak English though an interpreter is avail- able), social class and other variables causing distance in 29 the doctor-patient relationship and requirements of fees for service (based on a sliding scale) may affect an indi- vidual's propensity to use the health service. Three other factors may also be instrumental in the decision of service use or non-use: (1) knowledge of services available (2) a sense of personalized treatment and (3) the maintenance of folk medical beliefs. The Problem of Linkage Many Chicanos in north Lansing may not be receiving the services which they need, though services are available in their area. One reason might be a lack of information about available services. Another factor might be perceived costs which may be involved and the concern that one might not be able to meet those costs. Accessibility to services is important, too. The person of low income may experience a sense of social isolation which sets them so apart from the mainstream of life that even seeking available known services might be difficult. Many Mexican Americans also face a language barrier. These factors may result in an individual seeking health care only when crises arise. The Cristo Rey Health Program attempts to overcome many of the barriers typically experienced by Chicanos when they approach public agencies. The bridging of community members with the Health Program is important in reaching and serving the target group. This bond between the client and appropriate services is one of the main objectives of 30 the Cristo Rey Health Program. The means to facilitate that initial linkage is needed. Information Outreach The Cristo Rey Health Program provides services in order to link clients with appropriate services within or outside the Center. The problem with information and re- ferral services, however, is that the individual must initi- ate the request for assistance (Brumfield, Fox & Goldman, 1968). The factors that keep people from contacting health care providers initially also keep them from contacting the Information and Referral Service. The hypothesized factors which complement those in the Mexican American health care literature include: client unaware of services, denial of a problem's existence, avoidance of outsiders and other con- tact, general apathy towards service (Gaitz, 1974), misinfor- mation about services and eligibility, or resistance to receiving public assistance. One difficulty, then, is getting community members to the Center in the first place. The notion of "outreach," a plan by which the information about services is given to clients directly is an attempt at removing some of these obstacles to service use (Kushler, 1977). Outreach Strategies Very little, if any, literature exists concerning effective ways of providing information and referral services 31 to Mexican Americans. In a study with outreach to the elderly, Klippel and Sweeney (1974) found that senior citizens use informal sources of information in decision- making and that product sampling was important in its sale to this group of consumers. It might be best to use peers or other familiar individuals in giving outreach information to Mexican Americans while trying to insure further positive contact with the Center's personnel. Information in per- suasive messages should also be specific (Katz & Lazarsfeld, 1955). These findings are important in formulating an out- reach contact. Bergner and Yerby (1968) noted that mass media does not effectively render health service information to low income people. Rush and Kent (1974) noted that mass media instead most frequently reaches young, white middle class individuals who are well educated and socially active. It's probably safe to say that mass media is not the most effec— tive way of reaching low income Mexican Americans, either. In an experimental study investigating alternative outreach modes to low income elderly, Kushler (1977) found that in-person contacts were most effective in getting peOple to register for services, place their names on agency newsletter mailing lists or receive a service from the Center. Lower cost mail and telephone contacts were some- what successful but were surpassed by the personal contact mode. Bergner and Yerby (1968) also advocate personal 32 contact in reaching low income groups most effectively. Attitudinal, Perceptual and Belief Correlates of Health Care Minimal research has been conducted on the role of Mexican American health care—attitudes, perceptions of health, and medical beliefs in their use of health facili- ties. Most of the literature originally focused upon the role of traditional medicine in health care; more recent literature has looked at systemic variables as factors in- fluencing utilization rates. Findings about beliefs in folk medicine and utilization rates are inconsistent, with some Mexican Americans very traditional and others very con- temporary in their orientation and practice. Welch, Comer and Steinman (1973) hypothesized that Mexican American social factors and attitudes towards modern medicine would affect their use of health services. They also hypothesized that while negative attitudes toward modern medicine may lead to the avoidance of treatment, social class factors affect the availability of services, the knowledge people have about them, and their attitudes towards health care. The authors found little evidence of folk medical beliefs in their Mexican American sample in Nebraska. Utilization was also related more to social characteristics than health care attitudes. The use of health care facilities by Mexican Americans may be influenced by the extent to which they believe they ca ' up. u! (19 \| A «G v- «.2 3: Li «a 33 can actively influence their own health status. Rotter's (1954) Locus of Control concept theorized that a person's experience builds up expectancies about a situation and affects future behavior in that situation. Wallston and Wallston (1975) developed a health locus of control scale on the assumption that the scale would predict the relation- ship between health behaviors and the extent to which a person feels he has control over his health (internal con- trol). Mexican Americans have frequently been viewed as fatalistic or externally controlled. One would expect, then, that their health locus of control would be related to and influence their health behavior. An individuale mental health status frequently re- lates positively to his general physical health (Berkman, 1971). The literature on Mexican American health care be- havior has noted that Chicanos use general and alternate sources of health care for mental and physical problems, with clergy, curanderos(as) or general physicians serving as advisors, counselors or other sources of support. An individual's mental health status may thus affect the rate at which that person uses existing health facilities of which he has knowledge. Another factor which may play an important role in whether or not an individual chooses to use available health services is that individual's perceptions of his or her current health status. Perceptions of prior health status, 34 future outlook concerning health matters, and perceptions of susceptibility and tolerance of illness may influence a person's need for health care and subsequent decisions in the type he seeks. The Project This project was designed to address the problems of linkage and the provision of culturally relevant health services to Mexican Americans in the north Lansing area. It investigated whether knowledge of the availability of a curandera's services in a health center would significantly affect service utilization rates by Mexican Americans. It also investigated attitudinal, perceptual and belief corre- lates of Mexican American health care behavior. The results of research investigating the influence of folk medical beliefs upon health service utilization by Mexican Americans are contradictory. Beliefs in and prac- tice of traditional medicine by Mexican Americans vary regionally and according to the rural or urban setting of the population. Chicanos in East Los Angeles seldom uti- lize curanderos(as) in meeting health needs (Edgerton, Karno & Fernandez, 1970), while rural Mexican Americans in the Rio Grande Valley of Texas actively pursue and practice traditional folk medicine as an integral part of overall health care (Rubel, 1966). Many Chicanos in Lansing are originally from or have close ties with South Texas yet currently reside in an urbanized area. This population was 35 of particular interest in further investigating the influ- ence of folk medical beliefs upon health care among Mexican Americans. To investigate if the availability of tradi- tional folk medical Care affects utilization rates, a curandera was available for consultation through the Cristo Rey Health Program. The Health Program thus provided both traditional and contemporary medical care and consultation, aiming to meet the needs of the Mexican American community by responding to possible alternate health beliefs. Various methods of community outreach have been em- ployed by agencies to bring information about social or health care service to the public. Personal or home visit contacts alone or in combination with telephone outreach have shown to be most effective in reaching target popula- tions (Bergner & Yerby, 1968; Goodrow, 1975; Kushler, 1977). The personal contact-home visit outreach mode was used in this study to experimentally examine whether the avail- ability of traditional folk health care services would affect Mexican American service use. This outreach mode was appropriate in this study because of the subject popu- lation. The low income Spanish-speaking individual may feel a sense of isolation and alienation from a predominantly middle class, English-speaking society. This person may not be aware of available health services or may be hesitant to seek health care even if their availability is known. A personal contact-home visit may decrease social isolation 36 and the sense of depersonalization frequently faced with agency services while encouraging the individual to use the services of the Health Program. Information about the availability of the folk medical dimension was included in one of the outreach formats. A variety of questions relating to Mexican American health care behavior were investigated in this study. Pri- marily, it combined an experimental outreach component with a folk medical dimension to investigate whether knowledge of the availability of traditional folk medical services would significantly increase health service utilization among Mexican Americans. It also examined the effectiveness of the in-person outreach contact mode in increasing their health service use. This study was also exploratory; it attempted to identify major determinants and correlates of health care among Mexican Americans. Relationships between health perceptions, health locus of control, attitudes to- ward traditional and contemporary medicine, mental health status, socioeconomic variables and demographics were examined in order to determine which play the greatest roles in the decision of health service use or non-use by Chicanos. CHAPTER II METHOD Subjects A population of 308 household addresses of Spanish- surnamed residents in north Lansing was identified through the Lansing City Directory, the Lansing phone book, Bresser's listing of city addresses and phone numbers, the Cristo Rey Community Center newsletter mailing list, E1, Renacimiento newspaper and publishing office, and a door-to- door survey listing compiled by a neighborhood church. The use of these sources was an attempt to insure that apartment dwellers and people with unpublished phone numbers or no phone at all would be included in the study. Households were included only if they fell in a specified area close to the Cristo Rey Community Center. Census tract and other types of mailing or membership lists typically have not classified individuals according to Mexican American ethnic background. Winnie (1960) noted that there is no "best" criterion for identifying Hispanics in currently available census tract or population data. Each alternative (use of Spanish language, Spanish or Mexi- can ancestry and Spanish-surname) has advantages and dis- advantages. Winnie noted, however, that the Spanish-surname 37 () Ié (”f (I) J J. {‘1‘ rh Ac, 5U 38 criterion is technically as good as any other general- purpose classifier. It is advantageous in that noncensus records which do not always have language use information can still be reviewed using the surname criterion to iden- tify Hispanics. Winnie's study found that the Spanish- surname criterion underestimated the size of the population by about 10 percent. If classification is done on a sub— jective basis with knowledgeable raters identifying indi— viduals, a 5 percent rate of underestimation may be expect- ed. If a categorized list of Spanish surnames is strictly followed as a guideline in compiling Hispanic listings, the underestimation rate may be even greater if the guideline list is not exhaustive. In this research, the author sub- jectively reviewed all source lists using the Spanish- surname criterion. According to Winnie's finding, the total Mexican American population of north Lansing compiled from available lists should be underestimated up to 10 percent. The compiled list thus consisted of Spanish-surnamed households with the specified north Lansing geographic region. This list was then sent to the Ingham County Health Department, Community Clinic Services Division for removal of names of individuals who had been served by the Cristo Rey Health Program within the six months preceding the out- reach project. The Community Clinic Services Division of the Ingham County Health Department maintains central 39 records for all individuals receiving services at various sites. This list was also reviewed by the Cristo Rey Health Program Coordinator for removal of names of individ- uals receiving other services from the Program not noted by the Health Department. After review and revision of the list, 274 Spanish- surnamed north Lansing households were eligible to partici- pate in the outreach project. The experimenter randomly selected and assigned 40 households to each of two treat- ment groups and the control group, for a total of 120 house- holds. The remaining 154 households were randomly assigned to one of the three groups as replacements for households lost in the study due to noncompliance, bad addresses, non- Latino residents, or incorrect listings. This study thus used random selection of a sample from the target population and random assignment from the sample to treatment condi- tions. Subjects were identified by outreach workers as an adult from each household responding to the initial out- reach contact. The final sample of 101 was 31% male, 69% female. The "average participant" was 38.5 years old, had an eighth grade education, was married and had 2.5 children. The majority of the sample was unemployed, but the spouse was generally working outside the home. For the majority, a salary or wage was the primary source of income. For those receiving government assistance, most received Aid to 4O Dependent Children (ADC). Procedure Experimental and Control Conditions The experimental and control conditions in this study are described below. Control Group. This group served as a control by which to measure the effects of the two treatment categor- ies. The individuals in this group received no personal outreach contact by the Cristo Rey Health Program outreach representatives. Control group subjects were not kept from any incidental exposure to information about the program's services acquired through self-referral, word of mouth, radio announcements, newspaper articles or other media cover- age typically used by or given the Community Center. The difference between the control group and experimental group members, then, is the initial personal contact received in the treatment conditions during the first phase of the study. In-Person Contact Group: Contemporary Medical Services Only. Individuals in this group received a direct personal outreach contact by Cristo Rey Health Program Out- reach representatives identifying basic services available through the Program at the Center. These individuals were explained the services and invited to contact the Cristo Rey Health Program by mail, phone, or in person if further information or any services were desired. The contact was Oh (I) 11’ I(’ r) '(1 (I). its Ll. I71 41 fairly personalized in nature, with the outreach worker's approach being one of representing a community health pro- gram offering a variety of services. Outreach workers ad- hered to a standardized format as closely as possible while maintaining a personalized and flexible approach. Individ- uals were also given the pamphlets explaining services available through the Cristo Rey Health PrOgram including phone numbers to call for assistance and a map showing the Center's location. A copy of this outreach informational pamphlet is included in the back of this report. Contacts were made according to predetermined schedules designated by the experimenter. In-Person Contact Group; Contemporary and Traditional Medical Services. The individuals in this group received a direct personal outreach contact by Cristo Rey Health Pro- gram representatives just like the ones in the Contemporary Medical Services Only group. In addition, however, they received information about the availability of curandera or folk healer for consultation at the Center a specified number of hours per week. Along with the pamphlet describ- ing available services, a card indicating the curandera's consultative services at the Center was inserted in the pamphlet to match the information given in the personal contact. As with the Contemporary Medical Services Only group, outreach workers attempted to adhere to a standardized format as closely as possible while maintaining a 42 personalized and flexible approach. Contacts were made according to a predetermined schedule designated by the experimenter. The Client Card. When a "successful" outreach con- tact was made in each group, demographics and some health needs information was reported on the Client Card seen in Appendix C. As with Kushler's (1977) study, if an out- reach worker could establish enough rapport with an indi- vidual-so that the person gave the information requested, a successful outreach was made. In addition to serving as a check on the outreach contact, client cards could also be used as a record-keeping and ongoing needs assessment file. Employing A Curandera Many natural helping networks exist between and with- in groups of people at various levels in any community. In some Mexican American communities, individuals seek the advice of a family member or a local folk healer, a curandero(a), for health-related concerns. These health care givers are typically known through reputation in the barrio. They do not advertise, solicit, or charge a set fee for their services. In this project, it was necessary to find a curandero(a) who was known in the area where the study was taking place. The experimenter asked staff members of the Community Center and various senior citizens in the Center's Senior Citizens Program if they knew who local curanderos(as) 43 were and where they resided. A list of names, addresses and phone numbers was compiled; all were women. Later the Health Program Coordinator and the Experimenter individually and together contacted the individuals named and spoke with them about their treatment and consultative activities. Bearing in mind the basics of folk healing, some individuals were not considered further because they had alternate orientations. None of the women were told of the proposed research project. One woman spoke of her desire to help people through a place like the Community Center's Health Program. In her folk medical practice she used natural herb teas, oils and powders individually or in combination, depending upon the presenting complaint of the consumer. She described each remedio ("cure") to the Health Program Coordinator and Ex- perimenter, relating stories of healing success. She was selected and her name was presented to the Community Center's Director and approved. The entire research plan was then presented in separate meetings to the Center's staff and Board of Directors for their approval. With only two dis- senting votes (fear of reprisal from the medical profession), the plan was approved. The curandera was available four hours per week through the Center's Health Program. Selection, Training and Supervision of the Health Program Outreach Representatives Upper division undergraduates in the university were recruited to serve as Health Program Outreach Representatives. 44 First a listing of Chicano students enrolled in the Univer- sity was obtained. Letters were mailed to 40 eligible students soliciting their participation in the project; seven (7) responded affirmatively. Three (3) Puerto Rican students heard about the project, asked if they could par- ticipate, and were also included in the project. Six (6) females and four (4) males comprised the Outreach Team. Each member was bilingual in English and Spanish. Training sessions were held to teach and clarify out- reach procedures to the Outreach Representatives. The first training phase dealt with outreach procedures, the second with those for follow-up. In each phase the Experimenter first demonstrated appropriate procedures, then representa- tives role-played and practiced among themselves. ‘Repre- sentatives formed groups of three: one played the role of the community member, one was the outreach representative and the third was an observer and recorder. Percent agree— ment reliabilities for training sessions was 96% for the outreach phase and 94% for the follow-up. To determine inter-rater reliability during the actual outreach or follow- up, one representative accompanied another during a contact and recorded data on a separate sheet. Percent agreement reliability was derived by dividing the total number of matching coded responses by the number of total responses on an interview schedule. Percent agreement was 95%. 45 To avoid possible biasing effects of time, weather or other factors, contacts were distributed across four weeks for each phase. During the four week outreach phase, ten households in each of the two treatment groups were contacted. Four weeks after outreach, follow—up interviews were conducted, following the same schedule used during out- reach and adding control group names. Ten control house- holds were also interviewed weekly on the follow-up. Out- reach and follow-up schedules are in the Project Outline in Table 1. Weekly supervisory meetings were held where the pro- ject researcher monitored outreach and follow-up activities. The project researcher was also available for telephone consultation as needed. Measurement of Dependent Variables Primary Dependent Variable. The primary dependent variable used to test for effects of the experimental man- ipulation in this study is described below. Number of People Receiving Services. Since the prime purpose in providing client-service linkage through outreach is to increase the utilization of services by community members, the dependent variable was the number of people receiving services. This was noted as either the individual or a family member receiving a service from the Health Pro- gram. This measure determined any effect which the two treatment modes had upon the number of people in the sample 46 Table 1 Project Outline I. II. III. Week Week Week Week IV. V. Week Week Week Week VI. VII. Lists Compiled. Randomization. Outreach waH Lists of Spanish-surnamed households within specified area compiled. Previously served names removed. Random assignment of names to conditions. Traditional & Contemporary Contemporary Medical Ser- Control vices Only Medical Services 1-10 1-10 11-20 11-20 21-30 21-30 31-40 31-40 Record Outcome Measures up to 30 days from date of Follow-Up Phase CI)\IO\U1 Data Analyses Final Operations contact. Traditional & Contemporary Contemporary Medical Ser— Control vices Only Medical Services l-lO 1-10 1-10 11-20 11-20 11-20 21-30 21-30 21-30 31-40 31-40 31-40 1. Response to outreach 2. Services received 3. Demographics 4. Survey Data Provide entire list to Center. Results reported and explained. 47 receiving health services. All services were recorded daily by Health Program personnel. Services included con- sultations, requests for educational materials, attendance at special health classes, referrals, visits to the physi— cian, visits to the curandera, immunizations, blood pres- sure checks, weight measurement or other services received through the Health Program. Follow-Up Survey Attitudinal Variables The Followfigp Survey. Approximately one month after the outreach contact was made all subjects in the two ex- perimental groups and those in the control group were inter- viewed in their homes by an outreach representative. The interview was conducted in a fairly standardized procedure, with interview schedules available in both English and Spanish. Interviewers identified themselves as representa— tives from the Cristo Rey Health Program. They informed individuals that they were talking with community members about attitudes, needs and opinions concerning health care. Subjects were informed that the information provided by the respondent was confidential and could be used by the Center in program planning. If the respondent agreed, the repre- sentative obtained their signature on a form giving the consent to participate (see Appendix D). The questionnaire in Appendix E was then administered by the representative. The data from the follow-up Interview were used to help interpret the findings of the experimental manipulation. 48 They also provided a description of the project partici- pants and a measure of their health beliefs, perceptions and attitudes. Construction and Use of Scales The survey questionnaire is comprised of various established scales and some survey items designed to measure a variety of areas. These include health locus of control, attitudes toward contemporary and traditional folk medicine, general mental health status, general physical health status, knowledge of services provided by the Center, willingness to use the Center's services, and general demographic information. With previously developed scales reliability coeffi- cients were initially calculated on all scale items. If an item did not correlate significantly with the scale, it was removed and scale reliability was recalculated until an acceptable level was reached. When the survey questionnaire was originally devel- oped, a number of items were included to examine areas of interest to the study for which there were no previously constructed scales. After the data were collected, items were grouped logically and empirically. Item intercorrela- tions were noted and scales were tentatively formed. Re- liability coefficients were determined and items which did not correlate with the scale were removed or others which correlated well were added. Reliabilities were recalculated 49 and the process repeated until an acceptable level was reached. The Health Locus of Control Scale (HLC). The HLC was originally developed and validated in order to provide a health-related locus of control scale over the more gener- alized Rotter I-E Scale (Wallston & Wallston, 1975). Items such as "Good health is largely a matter of luck," and "If I take care of myself, I can avoid illness" constitute the ll-item scale. Items are scored on a 6-point Likert scale ranging from "Strongly Disagree" to "Strongly Agree." Scores ranged from 11 to 66. Reported alpha reliability was .72. The scale is comprised of items 38 to 48 in the follow-up questionnaire. Coefficient alpha for the HLC in this study was .49. Reliability was considerably lower when all items were used. Items which did not correlate with the scale were removed; five items formed the final HLC. The HLC is intended to measure the extent to which a person has a sense of control over his health status. The higher the score on the HLC the greater the extent of external control. The Index of Psychological Well-Being (IPWB). The Index of Psychological Well-Being is intended to measure the general mental health status of project participants. It is an 8-item index which asks participants to indicate how often they experience certain feelings such as "Depressed or very unhappy" or "Bored." When IPWB was used as a 50 dependent variable, findings paralleled those of the Mid- town Manhattan Study. Berkman's (1971) findings indicate that the IPWB correlates positively with physical health status. It also correlates with ethnicity, education, oc- cupation, employment and marital status. The IPWB is comprised of items 49 through 56 of the follow-up questionnaire. All items were retained in analy- ses; coefficient alpha was .65. Perceptions Regarding Health Scale (PRHS). Ware, Wright and Snyder (1974) developed the Perceptions Regard- ing Health Scale (PRHS) as a series of indices measuring an individual's perceptions about his/her health status. Sub- scales were constructed on six dimensions: Current Health Status, Prior Health Status, Health Outlook Index, Health Status Anxiety and Resistance-Susceptibility to Illness. Items such as "I'm as healthy as anybody I know," or "I never worry about my health":fixnnthe 32-item scale. Each item is rated on a 5-point Likert scale ranging from "Def- initely True" to Definitely False." Items are summed to obtain total scale scores. Reported test-retest reliability coefficients for the six subscales were: Current Health, .81; Prior Health, .70; Resistance to Illness, .60; Health Anxiety, .52; and Acceptance of Illness, .70. The PRHS in this study consists of 18 items drawn from the six subscales. Reliabilities calculated on the six subscales in this study were low, so items were examined 51 as a whole, then regrouped according to their intercorrela— tions. Items which did not correlate were removed and the testing procedure was repeated. Three subscales measuring health perceptions and their alphas resulted: Current Health and Possible Illness (r=.63); Illness Anxiety and Acceptance (r=.58); and Prior Health and Future Resistance (r=.50). Items 20 through 37 comprise these subscales in the follow-up questionnaire. -Needs Scale. The Needs Scale was used by Kushler (1977) in an experimental outreach project to the elderly. It is intended to assess the participants' self-rating of needs in nine areas: housing, employment, health care, in- come, crime, education, nutrition, transportation and loneli- ness. All items were retained in this study; alpha was .87. They comprise item 19 in the follow-up survey. Clarity of Outreach Scale. Items 5 through 8 were included in the follow-up questionnaire to check for the clarity of the initial outreach contact. Three of the items which intercorrelated formed a scale to provide an index of Outreach Clarity. Alpha was .87. Attitudes Towards Folk Medicine Scale. Since a thoroughly-tested instrument measuring health attitudes of Mexican Americans has not been developed, the experimenter used various questions from other investigations and some newly-created items to measure health attitudes in this study. Items measuring "Hostility towards Doctors" and 52 "Traditional Attitudes Toward Medicine" were taken from Welch's (1973) study of sociocultural factors and health care utilization by Mexican Americans. Items from a study of health attitudes and behaviors of Houston Chicanos (Farge, 1975) were also employed. These items comprise questions 57 through 69 of the follow-up questionnaire. Items 64, 65, 67, 68 and 69 formed a scale intended to measure attitudes toward folk medicine. Alpha for the scale is .61. Fluency Scale. Items 96, 97 and 98 form a scale which measures the participants' fluency in the language Opposite that in which they were interviewed. If a person was interviewed in Spanish, the fluency scale measures how well that person can speak and understand written and spoken English. The scale measures Spanish fluency for those interviewed in English. Alpha for the scale was .87. Demographic Information. Items eliciting demographic information such as respondent's age, education, marital status, employment, number of persons in household, place of origin, length of current residence and other areas are included in the follow-up survey. This information provides a general description of the sample while allowing one to examine relationships between demographics, outcome measures and the basic issue of seeking or not seeking services. Some items are taken from Teske and Nelson (1973); others were created by the experimenter for use in this study. 53 Other Areas of Interest. In addition to the scales and demographic information described, questions in the follow-up survey sought to explain service use or non-use by Mexican Americans. Questions asked opinions about medical services and government assistance, reactions to being con— tacted by Health Program representatives, reasons for current use or non-use of services, possiblity of future service use, and sources of community information. Concluding Operations The original unrevised list of Spanish-surnamed residents was provided to the Center and the Health Program upon completion of the outreach and follow-up phases. In— formational booklets explaining health services available at the Center which were used in the study were distributed to the general public through clinics, public health offices and at the Center. All community members were thus able to learn of the Health Program services. Copies of project findings were also given to the Center's Director and the Health Program Coordinator, followed by consultation to explain and discuss findings. CHAPTER III RESULTS The Sample Subject Mortality. The final sample size deviated slightly from the number originally designated per treat- ment group. Both selection and assignment of names were randomized, maintaining the experimental design. The sub- ject mortality at each phase of the project is shown in Table 2. Mortality in the outreach phase for the treatment groups and in the follow-up phase for the control group was high because of bad addresses, nonLatinos residing at the address, no one home, abandoned house, etc. Mortality in the follow-up phase for treatment groups occurred because the subject could not be located or was uncooperative. There was no significant difference in mortality be- tween groups when total initial attempts (Groups I and II at Outreach, Control at Follow—Up), total unsuccessful at- tempts (Groups I and II at both Outreach and Follow-Up; Control at Follow-Up) and final confirmed sample for each group were compared (X2 = 1.98, df = 2, p <<.38). The final sample size was large and fairly evenly distributed 54 55 .cmummeoo mum msoum >3 mHmEmm UmEuHmcoo Hmcflm can Ammsonm Hamv mumEmuum asmwmmousmcs Hmuou .HmpuonHom v Q m mm. HMUHme wumuomfimucoo I .wm.H N "Houucou .nomwuuso HH a H mmsouwv mumewuum HMHDHCN Have» “cmn3 u x .xpsum ca mummflofiuumm Ou manfimflam mcaosmmson Hmuoe n mHmEmm cmEHHmcoo answmm coflumEHomcH HMUNcmz xaom a mmofl>umm HH Hcho mmofl>uom Hmoflpwz wumuomEmucoo u H “Houucou u 04 QHNN Na NNH o o Na Ha Ha o mezmzonmm< Haeoe ONH av om o o OH OH OH o cwconma moHonmmsom HmHuHcH HmH Nm NOH o o Nm Hm Hm o omcSHmm< mnemEmomHmmm Hm om Hm o o om SN mN o moHocmmsom ucmEmomHmmm woman: HGN mMH HmH mm mm No me mm o cmHEEmuud muomucoo Nm Nm as m 4 mN om om o muomucoo stmmmoosmca Hmuoe ON N mH H N H N m o mncmchmm mumooq ou magmas HH o m N N N N m o mocMHHmeoocoz H H m o o H H N o mmmnvnm zoom oz Nm NH mm o o NH aN NH o mocHuchoz "muomucou stmmmoonmco NNH HOH HN Nm Nm Nm mm mm o cmanmeoo muomucoo Hmuoe one 0 HH H 6 HH H .o HHBOB oz3 muflamuuoz uomnnsm m manme "cofluflmomeou wHQEmm Hmcflm 56 across conditions. The sample was thus acceptable. Effectiveness of Randomization Before testing for treatment effects, it is impor- tant that the groups be checked for equivalency on all other variables. To determine whether groups were equiva- lent, 25 demographic and descriptive variables were tested for significant differences between groups. One variable varied significantly between groups: educational level. All three groups had participants with no formal education, but two of the groups had a combined total of five people with some college, bachelor's, graduate or professional degrees. The mean number of years of schooling for each group varied accordingly. With only one significant dif- ference noted between groups, randomization resulted in functionally equivalent groups in the study. Treatment Effects Primary Outcome Measure After an outreach representative explained the Health Program informational booklet to a subject but before an attempt was made to complete the client card outreach check, the subject was asked to sign a consent form for participa- tion in the study. Subjects were retained for follow—up and subsequent analyses only if the subjects consented to par- ticipate and completed the client card outreach check. 57 No significant differences in service use were noted between groups for type of information given in the contact. A significant difference in service use is seen for out- reach contact in general (p < .05). The number of partici- pants in each group who either personally used or had a family member who used the services since the outreach con- tact is shown in Table 3. Table 3 Receiving a Service by Type of Contact Contemporary Traditional & .Medical Ser- Contemporary Control vices Only Medical Services Tbtal Received Service 0 5 5 10 Did Not Receive Service 37 27 27 91 Tbtal 37 32 32 101 2 X = 6.42 df = 2 p < .05 To determine whether the three groups varied along attitudinal and belief dimensions, certain follow-up survey variables were examined. Oneway analyses of variance re- vealed no significant differences on measures of Health Perception (PRHS), Health Locus of Control (HLC), Needs, Psychological Well-Being (IPWB), or Attitudes toward Tra- ditional Folk Medicine. 58 Other Differences in Primary Outcome Measure and Attitudinal Variables While no significant differences were noted for type of contact across the primary outcome measure and attitud- inal variables, differences were seen when subjects were classified along different dimensions. These dimensions were chosen in an attempt to distinguish between cultural and socioeconomic factors in Mexican American health care. When subjects were grouped according to language spoken during the interview, significant differences were noted in the Illness Anxiety and Acceptance and Health Locus of Control Scales. Oneway analyses of variance indi- cated that subjects who were interviewed in Spanish experi- ence greater health anxiety than their English-speaking counterparts. They were also more external in perceived control over their health. These comparisons are shown in Table 4. A marginal significant difference in Use of Service is noted when subjects are grouped according to whether or not they receive government assistance (SSI, SSDI, ADC, Welfare, etc.). A oneway analysis of variance indicated that those receiving government assistance used Health Pro- gram services more than those not receiving government assistance (Use is designated by a low score; nonuse by a high score). Results are shown in Table 5. 59 mnao. wmmeo mooo. mmmfio mo. ucmoa INHcmHm mooo. ucmofi -anmHm 0 III mmhb.vH H mm.¢ NmQH.vH m on.v Hamm.ma M coflumfl>wa saw: 2 onmccmum vmoh.hmvm ovmm.mm ovvv.ahmm moh.m vmam.mo vmam.mo m mmumswm can: mmumsmw mo Esm Houucou we msooq spammm m m oomo.mH o Hm.m ooom.ma m mo.m HNmH.NH m coflumfl>mo 2mm: 2 nnmwcmum ooom.mmmm ommN.HN hmmo.HmON mNm.¢H mvmm.vom mvhN.vom M mwumsvm cmmz mwumswm mo 85m mocmummoo< pcm Nuwflxc< mmmcaaH O ,4 MO 0 O r-( l lra m m [u D 03 ON HG) m Hmuoa Asmwamcmv N msouw anmflcmmmv a msouw Hmuoe masono cHnqu mmsouw cmmsumm monsom Hmuoe Anmflamcmv m msouw Anmflcmmmv H macaw Hmuoe mmsouo segue: mmdouw :mw3umm mousom 3mfl>umucH mo mmmsmcwq ou mcflcuooo< mmHQMHHm> Hmcflcsuflpud a mHnme 60 Table 5 Receiving a Service by Receipt of Government Assistance Sum of .Mean Signif- amnce DE Sggggs res F hunt.<1mga2 Between Groups 1 .5224 .5224 3.048 .08 .0205 Wchin Groups 96 16.4571 .1714 Total 97 16.9775 Standard N. Mean Deviation Group 1 (No Assistant) 63 3.9524 .2799 Group 2 (Assistance) _§§ 3.8000 .5841 Total 98 3.8980 Significant differences are noted on various attitud- inal variables when subjects are grouped according to educa- tional level. Significant differences are noted on all three subscales measuring health perceptions. Oneway analy- ses of variance indicated that more educated subjects (ninth grade and above) reported significantly better prior health histories and perceived resistance to future illness and better current health status than those with an eighth grade education or less. Less educated subjects reported signif- icantly more anxiety about their future health than those with more education. On the health locus of control dimension, less educa- ted subjects showed significantly greater externality in the extent to which they felt they had control over their 61 health; more educated subjects showed greater internality. Results of these analyses based on educational level group— ings of subjects are reported in Table 6. Table 6 Attitudinal Variables by Educational Level Current Health & Possible Illness Scale Sum of Mean Signif- Source D§_ Squares Squares §_ icant Omega2 Between Groups 1 201.9127 201.9127 6.240 .01 .0497 ‘Within Groups 98 3171.1273 32.3584 Total 99 3373.0400 Statbrd Groups N_ Mean Deviation Group 1* 47 24.85 5.5560 Group 2 _§3_ 27.69 5.8031 Total 100 Illness Anxiety & Acceptance Scale Sum of MBan Signif- 2 Source Q§_ Squares Squares F_ icant Omega Between Groups 1 118.1043 118.1043 5.105 .02 .0394 Within Groups 98 2267.2557 23.1353 99 2385.3600 SI 3 d Groups N_ .Mean Deviation Group 1 47 16.2340 5.0356 Group 2 _§3_ 14.0566 4.6011 Tbtal 100 15.0800 Prior Health & Future Resistance Scale Sum.of Mean Signif- 2 Source E Squares m E icant M Between Groups 1 71.6603 71.6603 4.671 .03 .0351 ‘Within Groups 99 1518.6961 15.3404 Total 100 1590.3564 Standard Grogpg N_ .Mean Deviation Group 1 48 17.5208 4.3662 Group 2 53 19.2075 3.4605 Total IUI' 18.4059 62 Table 6 (cont'd.) Health locus of Control Scale Sum.of PEEK] Signif— 2 Source 95. Squares Squares F. icant Omega Between Groups 1 137.8756 137.8756 5.935 .01 .0466 Within Groups 99 2299.8868 23.2312 Total 100 2437.7624 Standard Grogps N_ Mean Deviation Group 1 48 16.0000 4.6402 Group 2 _53 13.6604 4.9767 Tbtal 101 14.7723 *Group 1 = 8th grade education or less Group 2 = 9th grade education or more Correlational Analyses To investigate further the question of health service use by Mexican Americans the remaining analyses in this study delineated the relationships between the primary out- come, attitudinal measures and other survey variables. Pearson correlations of all variables are shown in Table 7. Pearson correlations indicate that three demographic variables were significantly related to service use: age, sex and receipt of Medicaid assistance. Younger people, females and Medicaid recipients tended to use the Health Program services more often. Since few demographic vari- ables significantly related to service use, they contribute little towards explaining Mexican American service utiliza- tion patterns. A person's perception or opinion of the outreach con- tact might also be related to service use. Pearson correla- tions indicated that a person's reaction to the outreach 63 coflmscmuum now pmuomnhoo .1. mo v mo Ho v on Hoo v on G_V.NHNN. nommN. mNmo.- Noeo.- oonH. coooH.- mmoH. mHNo.- mmm. mumuHHHz mommm.- moNo.- ammmN.- UNomN. NomH.u ammoo. oHHH.- omNmH.- NNH.- Hoonom nmmHN. NHmo. mmmom. mmmH. ummNH.u U«NoN. Hmmo. momo. UmmmN. .onmm mon mMN. omoo.- mNoN. mmmo. oomNH.u mNNN. NNmo. ono. ommmN. .onmm Happy HmmH.u HmN.- O.mmHH. moNo.- Hmoo. mNmmN.u HoNo.- HoHo. mmmN.u mom moHo. moo. mHeo.- NmoH.u moNo.u NoHo.- momo. mmNo. o mNN. .nmum HmuHumz mNNo. Homo.- omomN.- mNoH. omNH.- ommNN. HmmH. moNH.u onom. och .omuoo OmmmH. ommo. mHNo. Homo. MHmo. mmmo. mmHo.u ommo. momo.- .Hgocm .omnoo oNoH. 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HmHN. :oHuommm u BHHHU mozmoqm mzmH mon . meHmHmm xzmHHH meHmmoo mommz enema NeHmmHo a. mCOflHMHmHHOU Cowhmmnm h magma 64 mo v mm Ho v on Hoo. v on ommmm. NNNo.u omomH. mmmo.: Nemm. mmoH.n mmmo. mmmo.- ommH. .momH ocoomm mmmmo.u mmmo.: 6mmoN.u mmmo. moNNm.u mmHH. NNmo.u HNHo. o.oome .o:MH 36H>umucH nHHmN. mmHmm. HNNH. oooeH.u mmmo. NNMH.- oooH. mmmo. ammmN. xmm mmmo.- mmmo. mmmH.u mHoH. NmNH. Nmmo. NomH.u mmmH.u ooHoN.u mm>Hno Monro eHHo. NNHH.I momo. mooH. omoH. NNmo.u mmNo. NoHo. omoH.u mom mmmo oHoH. mmHo.- NmoH. mmMH.u Nmoo.u NmHH.u emoo.n mooH. mNmH. mm>Hna UmHmH. NNoo. moNo. Nooo. mNmH. NmoH.u NomH.u NNmH.u ommH.n mmez mmmo. mmHH. oNoo. mHmo. mHN.n OommH. mHmo. oooo. mHm. mnmoHomz onmH.u mmmo.- moNo.n memo. vommH.u mmmo. mmNo.- ooHo.u NooN.u onoHomz nNmmN.u O.mmme mNHo.u ooomH. mHNH.u NoHH. mNmo.- Nooo. 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HHoo.- mcHoHomz_xHom g8 WHmDB MZHUHQE mean—8h Emmmmmm EOE/M gag CECE HMO OPHEOUV N. manna. 66 mo v mo Ho v on Hoo ”v mm mmNo. mmNH.n ooomH. mmoH. mHoHo.u HmHo. omHo. mHomm. mmoH.u .oomH ocoomm mmmmmr mNmo. mmmo.- HNmo.u mHNoH. mNmo.- mmNH.u ommmH.u Nmmo. .ooMH zmH>nmch mmoo. mmmm.n mmNmm. Hmmo. mmHH.- mooN. mHmH. mNmom.u mmmo. xmm omH. omN. NmmH.- omNmH.u omNo. MmomH.u Q.mmme mono. mmoo.: mm>Hno “mayo nmomN. onH. Nmoo.- mmoo.- omHmH.- Nmmo. mmmo.- HooH. mmmo.: mom moms mmN.- anmN.n mmomm. eoHN. nmmmN.- onH. ommoN. NNNo. Hmoo.u mm>Huo omoo. NNmo. mNmo.- mmHH. mmHHN.- QHMMN.I noomN.u NmmH. NNHo.u mean: mmmo. mmmo. mmmH.- mmmo. oHMH. noomN. ommmH. moomm.u NNeo. mnmoHomz mommo. momNm. mmmoo.u mNMH.n Hmmo. noHoN.u mmHH.- mmmo. ooHoN.- onoHomz . mmNom. mNomo.- mmon.u mmmo. mmmH.u uNomH.n oonH. HomH.- meoocH chucoz . mmmmm.u moom.u mNNNm. o_ooNN.. mmoN.u omNo. Nomo.- .moooo .ocH . 088. 932.. 082. MmmmH. $8.. ES. 8635 65.. . mmmHm.n . mmHH. HNNo. nmmNN.u NmmH. mnmuHHoz . oHoo.- mmoo. mmomm.u momo. Hoonom I woon. mNmNm.u HmHH.u .onmm mon . mmNoo.- momH.u .onmm Hmuoe . oomoH.u mom I .umum Hmanmz oszezoz mooooozH mzuozH mmmeHHHz. Hoomom onm o m onmmeoe mu< ememmmz TULCOOV N. magma. 67 mo v mo Ho v on Hoo v mm . mmome.n mHmo. HmoH. nmmNN. NHNH. ONomH. neoNN.u ono. .ocmH oncomm . 03.2.- mmNo. mNmH.- ommer ommon omoo. Nmoo. 6qu EEchH . UmNoH... mmNo. noomN. mmHof mmmHm. mmHH.- xwm .. nmNeN. mmooof ommmH. oNNH... mmoo. 83E 856 . nommN... mmmmm. mNNo... 32. 8m m8: . mmoH... Homof 92me 838 . Hoo... HRN. mime . MmmmN. 886mm . oHBHoQH ozfioocm ozfiezm xmm >550 mommmmo mmfimo mgr madame onoHomz TULCOUV h magma. 68 contact and the perceived clarity of the contact and serv— ice use were significantly related. The more positive the reaction to the outreach contact, the greater the tendency to use services; also, the clearer the contact, the greater the use. Finally, Pearson correlations were computed to in- vestigate relationships between service use and the atti- tudinal measures. Service Use and Health Locus of Control Scale were significantly related, with persons manifesting internal control tending to use services more often than those externally-oriented. Relationships Between Attitudinal Variables Pearson correlations were computed between attitudin- al variables to determine whether attitudes toward tradi- tional folk medicine, health perceptions, needs, and psychological well-being were significantly related, possi- bly forming a schema through which Mexican Americans View health care. The Current Health and Illness Anxiety subscales correlated significantly as did Current Health with Prior Health Perceptions subscales. Individuals who report good health status tend to experience less health-related anxiety and report a better health history than individuals report— ing poorer health status. A person's Current Health and Prior Health Percep- tions are significantly related to psychological well-being. 69 One reporting good current health status tends to report better mental health as well; a report of good prior health history is also related to better mental health. A significant relationship is also noted between Perceived Current Health Status and Attitudes toward Folk Medicine. A Mexican American in this study reporting good current health also tended to express negative attitudes toward traditional folk medicine. Alternatively, one who perceived his health status as poorer viewed folk medicine more positively. Relationships Between Other Survenyariables To help explain patterns of health service use by Mexican Americans, relationships between survey variables tapping opinions of contemporary and/or free medical care and other survey variables were also examined through Pearson correlations. The Free Health Services opinion variable correlated significantly with the Ability to Afford Doctors variable. One with the Opinion that free health services are no good may also feel that he cannot afford doctors. The Free Services variable also correlated posi- tively with the variable tapping one's sense of embarrass- ment at visiting a doctor. A person who has a negative opinion of free health services may also be embarrassed to go to a doctor. The Needs Scale and Attitudes toward Folk Medicine variables had inverse relationships with the Free Health Services variable. An individual with high needs 70 may tend to also feel that free health services are no good. A person holding a positive attitude towards folk medicine will also react positively to free health services. The Embarrassment variable is also related to three follow-up scales. The Current Health Scale and Embarrass- ment correlate positively; one with good health currently will not be embarrassed at visiting a physician. Similarly, the Prior Health Scale and Embarrassment variable are posi- tively correlated. One with good prior health history will not be embarrassed at visiting a doctor. Finally, a person with good mental health will not experience embarrassment at visiting a doctor, either,au;indicated by the correlation between Psychological Well-Being Scale and Embarrassment. The Ability to Afford doctors is negatively correlat- ed with one's score on the Needs Scale. The higher the person's needs, the less he can afford to pay a doctor. Monthly income was significantly related to various survey variables. Monthly income is positively related to the Prior Health Scale, with people of lesser income report- ing poorer health histories. Lower income people also re- port lesser psychological well-being and lower second language fluency. These subjects also reported more posi- tive attitudes towards Folk Medicine and greater Embarrass- ment at visiting,a doctor. Finally,1ower income subjects significantly agree that free health services are inferior, while also reporting an inability to afford doctors. 71 Reasons Given py Supjects for Regponse or Non-Response to the Outreach Contact A series of questions were included in the follow- up questionnaire to determine reasons why subjects did or did not use Health Program services after the outreach con- tact. Other related items were also included. Among the individuals who reported receiving an out- reach contact, 87.5% reacted positively towards a personal home visit by a Health Program representative, 8.9% were neutral, and 3.6% were negative (see Item 4 of question- naire). Responses to Item 10 indicated that 83.5% of the ten individuals who reported personal or family use of the health program did so because of the services available. The social activities at the Health Program (special class- es or groups, etc.) was the reason why 16.5% of those who used the services did so. Among the individuals who received the outreach con- tact but did not use the Health Program services, 53.6% reported that they had had no need, 3.5% said they were not sure about the outreach information, 3.5% said that the Center did not seem friendly, and 16.7% said they simply never got around to it. The remaining 23.2% of the non- users gave "other" reasons for non-useaimedical coverage through insurance elsewhere, negative attitudes towards the Center in general, etc. (see Item 13 of the questionnaire). 72 Frequencies showing the percentages of the individ— uals in the sample who personally received or had family members who received services from health professionals elsewhere in the last year are shown in Appendix F. When asked if they would consider using the Health Program services in the future (Item 15), 96.4% of the re- spondents said they would; 3.6% said they wouldn't. Two other items related to possible service use were included in the questionnaire and asked of the entire sample. When asked if they felt others looked unfavorably upon those who received government assistance, 58.4% of the sample said yes, 31.7% said no, and 9.9% did not know. When asked for their preference in a physician's ethnicity, 22.7% always or usually preferred a Mexican American physician when possible, 11.9% always or usually preferred an Anglo physician, and 65.3% stated that the physician's ethnicity really didn't matter. CHAPTER IV DISCUSSION The primary purpose of this study was to experimen- tally investigate the problem of caregiver-consumer link- ages and the provision of culturally relevant health services to Mexican Americans in Lansing, Michigan. It used an informational outreach component to investigate whether the knowledge of the availability of a curandera's (folk medical practitioner's) services in a health center would significantly affect service utilization rates by Mexican Americans. It also investigated attitudinal, per- ceptual, belief and socioeconomic correlates of Mexican American health care behavior. Two treatment and one control group comprised the sample in this study. One treatment group received out- reach visits at home in which they were informed of Contem— porary Medical Services available through a neighborhood health program. The second treatment group received the same information as the first treatment group but were also told that the services of a curandera or folk healer were available through the Health Program. The control group received no outreach contacts whatsoever. Four weeks after outreach, all groups were contacted for a follow-up survey. 73 74 Primapy Outcome A primary measure determined the effectiveness of the outreach contacts: receipt of a service through the Health Program. There was no significant difference between treatment groups on receiving a service. The knowledge of available folk medical services was not a strong enough factor to result in greater service use by the second treat- ment group. This finding supports other studies in which the role of curanderismo or folk medical beliefs was fairly small in health service utilization (Edgerton, Karno & Fernandez, 1970; Welch, Comer & Steinman, 1973). Another explanation might be that people do not admit to practicing curanderismo openly (Madsen, 1964). While traditional folk medical beliefs might play a role in how Mexican Americans View certain illnesses or health care, they appear not to be a significant factor in health service utilization in this study. Other variables were examined in an attempt to ex- plain views of health care in this sample. In this study the contact itself, not the folk medi- cal dimension, resulted in increased service use. The in- person contact mode showed the same effectiveness in studies by Kushler (1977) and Bergner and Yerby (1968). Approaching someone in their home with service information is most effec- tive in increasing service use. 75 Follow-Up Survey Scales A number of health attitude, belief and perception measures were included in a follow-up interview which was conducted on the entire sample one month after outreach. The data indicate that there were no significant differences between treatment groups on these survey scales. The out— reach contact provided health service information, but it was not powerful or relevant enough to result in deeper changes in health attitudes, beliefs or perceptions. Kushler (1977) reported similar findings in his outreach experiment with the elderly. To investigate whether cultural or socioeconomic factors affected the correlates of Mexican American health care, subjects were grouped according to language spoken during the interview, source of financial support or educa- tional level. Differences in follow-up survey scales were noted. Those interviewed in Spanish scored higher on the Health Anxiety scale than subjects interviewed in English. Individuals interviewed in Spanish also had greater extern- ality on the Health Locus of Control scale than those inter- viewed in English. If one considers those who were interviewed in English as more acculturated into the Anglo culture, these findings are similar to the differences be- tween Blacks and Whites found on the Health Anxiety Scale (Ware, 1974), and in Health Locus of Control (Wallston, 1975). Blacks expressed greater anxiety and health 76 externality than whites. While cultural influences could be credited for these differences, it is important to note that these were the only health scale dimensions in which significant differences were seen; perhaps socioeconomic factors play a major role. The Spanish-speaking Latino, like the Black, is frequently of low income and limited in social mobility. With continuous socioeconomic struggles, health becomes just one more concern for which little can be done. As a result, the individual expresses higher health anxiety and greater externality in health locus of control than the English-speaking Latino who may be more active in society's mainstream. When subjects are grouped according to educational level, a similar pattern emerges. On Current Health, Prior Health and Health Anxiety subscales, people with less than an eighth grade education indicated poorer health status, more health anxiety and worse health histories than those with more education. These findings parallel those of Ware (1975). These differences bespeak more than differences in years of schooling; they represent its impact on economic conditions, social mobility and health. With poor living conditions and little hope of relief, current health will be worse and health anxiety greater. A significant difference in receipt of a service is seen when subjects are grouped according to source of support or receipt of government assistance. Recipients of government 77 assistance received services from the Health Program after outreach more often than those not receiving government assistance. This may be expected since the Center where the Health Program is located most frequently serves indi- viduals on government aid. Correlates with Service Use To further examine the question of what best deter- mines health service use among Mexican Americans, correla- tions were computed between the Service Use variable and various demographic and survey variables. Of 25 variables investigated, only three demographic variables and the Health Locus of Control Scale correlated significantly with service use. Most contribute little to explaining Mexican American health care patterns and point further to the possible role of socioeconomic factors in service use. Age and sex cor- related significantly, with women and younger individuals using the Health Program services more often. Bachrach (1972) noted similar patterns in his investigation of mental health service use by Chicanos. These findings may be ex- pected in this study since young housewives most frequently take their children to the Pediatric Clinic at the Health Program. Most hours of Operation at the Health Program are also during working hours, SO one would expect mainly young women and children to use the services. The significant relationship between health locus of control and service use is supported in the literature 78 (Wallston & Wallston, 1975). An individual who perceives that he has control over his health status will take steps at maintaining or improving it. Relationships Between Follow—Up Survey Scales Relationships between follow—up survey scales were examined in order to determine whether or not certain con- cepts were interrelated and formed a conceptual health schema for Mexican Americans. The Current Health and Health Anxiety subscales were significantly related as were Current Health and Prior Health subscales. One would expect these findings since prior and current health status would influ— ence the anxiety one experiences over matters of health. The literature on the development Of the scale supports this finding (Ware, 1974). The Scale of Psychological Well-Being was signifi- cantly related to the Current and Prior Health Subscales. There was also a significant correlation between monthly in- come and prior health and psychological well-being. Berkman (1971) also reported a significant association between physical health status and mental health; good prior and current health status are related to good mental health. In this study, too, psychic and somatic health and illness are related. The literature has reported that Chicanos with psychological difficulties most frequently express somatic complaints. Previous research and the findings of this study are congruent. The relationships of prior health and 79 psychological well-being to monthly income also indicate the economic determinants of these health variables. A person with greater financial strength will have had better living conditions and greater access to better health care, resulting in a better health history and sense of psycho- logical well-being. The relationship between the Current Health Scale and Attitudes toward Folk Medicine indicates that a Mexican American in this study in good physical health tends to report negative attitudes toward folk medicine more fre- quently. This may be explained by the fact that a person with better health is more mobile and able to draw actively from community resources. It may also reflect good experi- ences with health care that peOple with good health have had. For the person with poorer health who is more restrict- ed Or has had bad experiences with health care, folk medicine is an accessible, reasonable alternative. In terms Of the questions posed in this study, the relationships between these follow-up survey scales reveal a complex Of perceptual and attitudinal correlates that may be more easily explained in socioeconomic rather than cul- tural terms. Good current physical health, sound health history and good mental health may be most affected by economics--the access a person has to good health care and adequate living conditions--not solely by ethnic group mem- bership. A study by Welch et a1.(l973) also indicated that 80 socioeconomic components determine Mexican American atti- tudes toward health care and patterns of service use. Relationships Between Other Survey Variables Correlations between items asking Opinions of con- temporary and/or free health services and other survey vari- ables were computed in order to explain patterns Of health care use among the Mexican Americans in this sample. The items which asked the subject's agreement with the statement "Free health services are no good" correlated significantly with five other survey variables: the Ability to Afford Doctors variable, the Embarrassment Variable, the Needs Scale, the Attitudes toward Traditional Folk Medicine Scale and Monthly Income. An individual who feels that free health services are no good typically has a lower in- come, cannot afford doctors, is embarrassed to go to a doctor, and reports many unmet needs. If one feels that free health services are good, he also has positive atti- tudes toward folk medicine. A possible explanation for these findings is that a person who can't afford doctors and has many unmet needs may have had poor treatment or a bad experience with free health services previously. Consequently, he may have many needs and feel he cannot afford a doctor, but the free health services available and the type of treatment received are not good, either. With a history Of bad experiences and an element Of pride, a person may also be embarrassed to 81 go to a doctor, especially if the services are free. A person who believes free health services are good will tend to have a positive attitude towards folk medicine. This is congruent since the services of a curandera are free unless the patient wishes to pay a gratuity. The Embarrassment variable related with four other variables: Current Health, Prior Health, Monthly Income and Psychological Well-Being. A person who has a good in- come, sound health history and good current physical and mental health will not be embarrassed to visit a doctor. For one who is not wholly healthy or has little money, how- ever, going tO a doctor may be frightening, embarrassing or intimidating. It might reflect prior bad experiences with doctors, a sense of stigma attached with ill health, or em- barrassment at having limited resources to cover health care expenses. Reasons Given py Subjects for Response or Non-Response to the Outreach Contact The primary outcome analyses in this study determined the effectiveness Of the outreach treatment. The correla- tional analyses tried to determine relationships between the various health attitude, perception and belief scales, other survey variables and service use. The final question in this investigation entails reasons for use or non-use of health program services after outreach contact. 82 Service recipients most frequently used the health program because Of the services available. Those who did not use the services typically reported no need. There are three possible explanations for this finding: (1) either the outcome period was too short and no need would arise within one month (assuming most people would come for treat- ment rather than prevention services) (2) their health needs are being met elsewhere or (3) they don't actually have many health needs. The follow-up survey revealed that in the past year 69.3% of the respondents indicated that they or someone in their household received the services of a medi- cal doctor; 19.8% an Obstetrician, 17.8% a surgeon, 9.9% a chiropractor, 3.0% a psychologist; 1.0% a marriage counselor and 1.0% a curandera. Other reasons for non-use Of the Center's health services were medical coverage through in- surance or a health maintenance organization, or negative attitudes towards the Community Center. The majority of respondents (96.4%) said they would consider using the Health Program services in the future. If the center is perceived as typically concerned with the delivery of social services, however, and 58.4% of the sample felt others looked down upon people receiving govern- ment assistance, perhaps the image of the Center and an element Of pride also affect service use. Since ethnicity of the doctor was not important to most respondents, econom-' ic and other influences may be most important in determining 83 health service use among subjects in this sample. Organiza- tional variables may also influence the extent to which in— dividuals use health services (Denton, 1978). Values, expectancies and routine procedures in the health care sys- tem may not be congruent with those Of the patient seeking help. This discrepancy may result in client dissatisfaction and decreased service use. In summary, the folk medical dimension of the out— reach contact did not significantly increase the rates at which Mexican Americans in the sample used the Health Pro- gram services. Folk medicine, therefore, does not appear to be a significant barrier to contemporary health service use by Chicanos. A significant difference in service use was noted for contact itself; in-person outreach is effective in increasing service use. Health attitudes, perceptions and beliefs were not related to receiving a service in this study and most fre- quently reflect socioeconomic influences. A more educated person Of higher income is physically and mentally healthier and perceives greater control over his health than someone Of lower income. A lower income person is frequently not as healthy and may feel less control over his health. This person cannot usually afford doctors, is embarrassed tO visit a doctor and typically considers free health services inferior. These findings reflect, perhaps, the differential health care which various social classes of people receive. 84 Attitudes toward health care may thus reflect past experi- ences with health care that are determined largely by social class. Research Issues and Limitations There are difficulties inherent in any research, and field research presents some special problems Of its own. In this study, subject mortality was high on initial contact largely because Of the profile Of the community. Low in- come people move often and public records are not always up-to-date. Bad addresses, nonLatino residents and numer- ous other factors presented some difficulty in completing contacts, but the final sample was acceptable because there were no significant differences between groups on most dimensions. The time allotted for the outcome measure may not have been long enough for service need to arise for many reSpondents. Parameters for any field measure may present disadvantages. An important difficulty in the study was the lack Of a check on whether or not subjects in treatment groups received information about the curandera's services in the Health Program. It is possible that the low use of the curandera's services were partially due to lack of knowledge Of her services in addition to little belief or perceived need for traditional folk medicine. 85 Language is an important issue in conducting re— search with Latinos. For randomly selected and assigned households in which there is no background information, one does not know beforehand what language to speak in a house- hold. The interviewer is thus left to approach the indi— vidual as he feels appropriate, being sensitive to linguis- tic difficulties or preferences the person might have. The interviewer may use his primary language in addressing the subject or he may be assigned a language in which to conduct the interview. Either way, use of a particular language may be prompted in the reSpondent. One alternative is to allow the person to speak first; the other is to speak in a third language unknown to the subject and note the language in which the subject replies. Neither alternative is appro- priate. The issue is important, however, for other concepts and dimensions in Chicano research may vary with language, and results may differ depending on the language spoken. Translation Of instruments is a similar issue in Latino research. Not all statements or expressions can be directly translated; in doing so, the researcher risks "losing something" in the translation. Back-translation is an attempt at equalizing bilingual versions Of materials. An English instrument is thus translated into Spanish by one person, then translated back to English by another. With Chicano research, even back-translation has its limita- tions. Spanish, like any language, varies regionally. In 86 a place where people Of many regions and educational levels are located, it is difficult to obtain a constant, appro- priate level of language. In investigating patterns of health use in this sample, the follow-up questionnaire asked whip but not whgpg other health services were received by the individual and family members in the last year. This information might help to better understand their health service utilization patterns. Research Implications & Future Directions The questions of health service utilization and cor- relates Of health care posed in this study present important implications for health care research, policy formation and service delivery to Mexican Americans. The results Of this study indicate that in-person contact is most effective in increasing service use among Mexican Americans. The program planner must consider finan— cial and manpower costs involved in conducting outreach and weigh them against the type Of information being conveyed and the rates of increased service use noted. This study further found that an added folk medical dimension of health care did not significantly add to serv— ice use by Mexican Americans. These findings indicate that, while folk medicine may influence a Latino's conception of health and illness, their inclusion in health service does not appear to increase the rate at which the person uses 87 the services. This finding and the relationships between other variables investigated indicate that economic and other factors may play a major role in determining health care use by Mexican Americans. Living conditions and acces- sibility to services may influence a person's past and current health and the extent to which he is anxious or feels control over his health. The low income person who feels free health services are no good may actually be re- flecting previous bad experiences with free health services. It may not be whp renders health treatment but the pypg and quality of services rendered that determine whether or not Chicanos use the services. Health service planners and pro- viders must be sensitive tO the needs, lifestyles and frus- trations of those with low income. Moderate or no fees, accessibility to services, and flexibility in procedures are possible changes that may help the services better meet the needs of the client. Sensitivity to linguistic differences and cultural values are also important in delivering rele- vant health services to Mexican Americans. Future research in this area must address itself to a number of basic and important questions. Sensitive and relevant instruments must be created specifically for re- search with Mexican Americans in order to avoid difficulties inherent in translation or use of instruments created upon white middle class populations. 88 The issue of cultural versus socioeconomic factors and expectancies in Mexican American health behavior is important and should be further investigated using a varie- ty Of research techniques. Future Mexican American health care research must look at the agreement between patient expectancies and service delivery values and procedures. A discrepancy between the two may result in client dissatisfac- tion and decreased service use. Increased service use by Mexican Americans may not be noted until health services are equitable, with existing re- sources allocated so that benefits are maximized. As noted by Norman (1969), supplying more resources in the same, estab- lished ways, will only result in parallel health care systems for those with and without the means to pay for services re- ceived. Instead, a reevaluation Of medical training programs, health care providers and health system operations are nec- essary in order to expend resources in the most appropriate manner, sensitive to the populations being served. As long as the low income and minorities are excluded from partici- pating in decision-making, parallel health care systems will continue with these groups receiving lesser services. Primarily, future research in the health care of Mexican Americans should investigate whether health services benefit Mexican Americans. Research in the determinants Of health status among Mexican Americans might explain more about health care choice than do attitudinal correlates. If 89 the findings of this study are replicated and indicate a significant role of socioeconomic variables in determining Mexican American health care, perhaps health service policy and delivery should address themselves more to the direct relief of economic stress and promotion of health among Chicanos than to focusing upon treatment Of illness. APPENDIX A HISTORICAL OVERVIEW OF MEXICAN AMERICANS APPENDIX A HISTORICAL OVERVIEW OF MEXICAN AMERICANS Historically, Texas has had the largest percentage of the national Mexican American population. Currently, California's Chicano population approximately equals (if not exceeds) that of Texas. Together, the two states ac- count for approximately seventy-five percent Of all Mexican Americans nationally. The other southwestern states of Arizona, New Mexico and Colorado account for most of the remainder (Burma, 1970). World War II introduced masses of Mexican Americans into the industrial labor force in Wis- consin, Michigan, Ohio and Illinois. Literature on Mexican Americans is not uniform in its terminology. This may reflect the diversity of the group itself and ways they are viewed by other ethnic groups. Termed "Latin Americans" or "Mexican Americans" in Texas, "Spanish Americans" in northern New Mexico and south- ern Colorado, "Mexican Americans" or "Chicanos" in California or "La Raza" ("The Race") nationally, they are bound across social classes by a sense of nationalism and ethnic identity (Burma, 1970). Mexican Americans live in rural and urban areas. They vary politically, economically, and education- ally. Generational differences in values and behavior patterns are frequently noted. This diversity within Mexi- can Americans is important tO consider when studying or 90 91 working with them. The Spanish and Mexican ancestors of the contemporary Chicano settled over four hundred years ago in what is now the Southwestern United States. The Spaniards relied heavily upon native and mixed-blood (mestizo) citizens of Mexico for settling and developing the area. The Mexican people continued to excel in labor and craftsmanship despite Spanish exploitation. Although settling in the Southwest was extensive, the area was sparsely populated. Gradually the European and native Mexican influences mixed and life for most people became a blend Of Spanish and native Mexican or Indian traits. The Mexican language was used for governmental, religious and academic purposes. Roman Catholic practices were modified by Indian customs. Migration and cultural mixture continued. In 1921 the Republic Of Mexico was created (Forbes, 1970). Legislatures and councils were formed and Indians and mestizos were granted full citizenship and equality. The influence of Spanish authoritarian rule, however, fre- quently subverted attempts at establishing a solidly work- ing republic. Foreign settlers Often did not follow Mexican rule. In Texas, for example, Anglo-Texans refused to follow land-title regulations or set their slaves free. The new Republic was fraught with financial difficulties; growth was painful. The Republic gradually grew despite illiteracy and an unequal distribution of wealth and power (Forbes, 1970). 92 Craftsmen and skilled laborers moved north tO Cali- fornia in the 1830's. The Sonoran mining techniques were widely adopted during the California Gold Rush. Eastern Texas and northern California were most im- mediately affected by the U. S.-Mexican War of 1846-1848. After 1852 the influence of the Gold Rush changed central California's language to English because Mexican miners were barred from the Sierra Nevada mines. From San Luis Obispo, California to San Antonio, Texas, however, the Mexican lifestyle dominated. Southern California remained a Spanish-speaking area until the 1870's. The Spanish lan- guage, bilingual schools, Spanish newspapers and Mexican political representation in government remained until 1878 (Forbes, 1970). Lifestyles continued to change with the influx of Anglo-Americans from the Eastern United States. Drastic changes occurred because most of these newcomers were un- sympathetic to the Mexican culture and unwilling to assimi— late. Schools became English-only institutions, new styles of architecture were introduced, and Mexican leadership was stifled. Mexican Americans eventually became the "forgotten Americans" (Sanchez, 1940). A new surge of Mexican immigrants seeking agriculu tural employment occurred in the early 1900's. Employment in California, Colorado, Arizona and south Texas resulted in numbers Of new Mexican residents, many Of whom are 93 ancestral to the contemporary Chicano (Grebler, Moore & Guzman, 1970). In the early 1920's Mexican American agricultural workers began moving north to Illinois, Michigan and Ohio in search of seasonal employment. Inadequate housing, poor sanitation, low wages, ill health and continuous moving for employment was and still is a way of life for many mi- grants. Many families "settled out" into various midwestern communities to establish a more secure life (Salas & Salas, 1972). The Midwestern Mexican American pOpulation grew tre- mendously in the early 1940's because of the World War II labor shortage. Mexican Americans seeking employment in industrial settings settled in the Midwest; the number of Chicano communities in the region increased (Salas & Salas, 1972). The settling Of Mexican Americans in Michigan in general and Lansing in particular will be elaborated in another section of this overview. The Mexican Americans were not passive during these various periods of transition. Hundreds of thousands had to overcome difficult Obstacles in order to survive and im- prove their standard of living. Mexican Americans national- ly experienced prejudice by the majority culture. Language, skin color, economic, educational and political elements have been and continue to be major difficulties the Mexican American must deal with in contemporary society. The 94 Chicano's background Of cooperation and sharing make it difficult for an individual to ease into and advance in a highly competitive, less personalized society. Nonetheless, they have gradually advanced and established secure communities. There has been a resurgence of Spanish language news- papers, periodicals and mass media broadcasts during the past twenty years. Traditional and contemporary Mexican American theater, music and dance are evidenced today, par- ticularly in the Southwest. Politically, Chicanos have witnessed a few, but insufficient, advancements. In the Southwest there are some Mexican American civic, business and political leaders. Overall, however, they are not ad— equately represented in all aspects of American life (Forbes, 1970). Nationally Mexican Americans are heterogeneous, with variations in values, aspirations and lifestyles. The group could be divided according to socioeconomic status, since individuals range from wealthy ranchers or businessmen to migrant workers. Acculturation, or the degree to which the Mexican American adOpts values and mannerisms or identifies with the Anglo-American culture is another dimension along which the group may be divided (Forbes, 1970). Regional divisions are usually the most apparent. These factors con- tribute to the group's diversity; there are also basic ele- ments which Mexican Americans have in common. kn 95 Primarily, Mexican Americans are proud Of their her- itage, preserve and promote it. Local educational agencies, brotherhood societies, historical organizations and patri— otic committees are some of the most prevalent Mexican American community—based organizations. The extended family generally practices certain customs and sharing, fostering Mexican American traits as a part Of daily life. Arts, cooking, theater and dance, music, religious Observances, and other customs are perpetuated in the same way. Spanish language publications and mass media promote further cultur- al identification (Forbes, 1970). The use of Spanish is a common bond which also varies among Mexican Americans. Many speak Spanish predominantly, with little or no English. Others are fully bilingual; some speak only English. Many, however, speak a combination of English and Spanish with adequate fluency in neither. The Spanish-speaking person may be at a disadvantage in commun- icating effectively in an English-speaking culture. Spanish, like any language, is more than spoken words alone. It is a way of thought and expression of life. The Mexican American may thus find himself unable to express his thoughts and feelings appropriately in English. While it contributes to the individual's culture, one may en- counter language difficulties when a less-accepting cultural group is encountered (Abad, Ramos & Boyce, 1977). 96 Mexican Americans nationally are experiencing cultur- al transitions which require an adaptive balancing Of Mexi- can and Anglo cultures. This balance may be difficult, but a resurgence of ethnic pride has helped Mexican Americans advance. Mexican Americans in the Midwest Very little has been written about the Midwestern Chicano. In the early 1920's Mexican and Mexican American families in the Southwest (particularly in the Rio Grande Valley Of Texas) began coming to Illinois, Michigan and Ohio in search Of agricultural employment. As seasonal employees, whole families moved from migrant camp to migrant camp harvesting crOps. The families were generally large and forced to live in ramshackle housing with little or no plumbing. Wages were low and working hours were long. Usually all able-bodied members of a family worked the fields. At that, an entire family scarcely made enough money to survive (Salas & Salas, 1972). When one crop was harvested, the families moved on to another site ready for harvesting, and the cycle continued.‘ Winters were spent "at home" in Texas; warmer seasons were spent working the fields on the migrant circuit. The numbers of migrants coming to Michigan annually has declined drastically because much work is now done mechanically. The state still witnes- ses a smaller migrant stream. Many Chicanos currently re- siding in the Midwest were migrant farmworkers or children 97 Of migrant farmworkers who "settled out" of the migrant stream into various communities. In Michigan, many settled in Imlay City, Capac, Holland, Bad Axe, Caseville, Muskegon, Erie, Pontiac, Monroe, Adrian and Port Huron. Their settle- ment in Lansing will be discussed later in this section. Thousands of Mexicans and Mexican Americans moved to the Midwest seeking industrial employment during the World War II labor shortage. Many settled out migrants moved to various cities to work. Barrios or Mexican neighborhoods grew in urban areas. In Michigan, Detroit witnessed the greatest settling by Chicanos (Salas & Salas, 1972). Mexican Americans in Lansing, Michigan Many Chicanos came to Lansing, Michigan in the 1920's to harvest crops. As labor demands changed in the 1940's, thousands Of workers were employed by industry. Mexican Americans in Lansing are largely migrants to the city, with over half of them being farmworkers or children of farm- workers settling in the area (Haney, 1978). Many Chicanos in Lansing retained agricultural jobs after settling; a large number worked in local factories. Some Chicanos also held government jobs at the state capitol (Haney, 1978). The Chicano community in Lansing developed even more in the 1950's. Many Mexican laborers were imported through con- tract agreements. Because Of the recession, even more mi- grants from rural South Texas came in search Of work in 98 fields and factories. Though mechanization caused a decline in the demand for migrant farmworkers, Chicano migration tO Lansing continued. Chicanos with friendship, kin or former employment ties returned to Lansing and used these support- ive networks to adapt to their new life in the city (Haney, 1978). Lansing Chicanos have been viewed as segregated, culturally distinct, and highly visible (Haney, 1978). Most Mexican Americans reside in the northern section of Lansing. "In Lansing, Chicano-mess was maintained by continued visiting with Texas and Mexican relatives, the influx of new Texas and Mexican immigrants, and the presence of the barrio which served as a symbol of cultural distinctiveness. These factors continued Chicano visibility but also perform- ed supportive functions for the overwhelming majority Of poor, uneducated, Mexican-born, and underemployed negatively- selected Lansing migrants" (Haney, 1978, p. 311). Haney (1978) also noted that the greatest prOportion Of Lansing's Chicano population was employed in construction or other unskilled manual labor. Many were underemployed in service occupations. Many had little or no formal education and earned less than the average Lansing resident. A size- able proportion of the Chicanos in Lansing were unemployed and aided by social services. Many of these underemployed or unemployed people were Mexican-born or border region farmworkers. "This segment Of the Chicano population is the 99 most powerless yet largest of all, and the actual size of the un-and underemployed Chicano population Of Lansing is probably greater than statistics indicate. Although most analysts would distinguish between the nominally employed and the unemployed, these sectors of the Lansing Chicano population share an important feature. They are all sub- ject to uncertainty, even if they are dependent on trans- fer payments for subsistence" (Haney, 1978, p. 167). This project is directed to this segment of the population. L APPENDIX B CURANDERISMO: MEXICAN AMERICAN FOLK MEDICINE APPENDIX B CURANDERISMO: MEXICAN AMERICAN FOLK MEDICINE Curanderismo is a term used specifically in trans- cultural psychiatry to refer to Mexican American folk psy- chiatry (Gonzales, 1976). Curanderismo may more broadly be viewed as the general domain of Mexican American medical concepts and practices. Typically it does not dichotomize 7"“"‘"“1 between psychic and somatic difficulties, but views man as having the mind and body balanced and interactive. Illness occurs when man is in disharmony with God, his family, his environment or fellow man (Kiev, 1968). Folk medical be- liefs and practices, rituals concerned with health preser- vation or restoration, and the use of folk curers or \ curanderos(as) associated with curanderismo are reviewed in this section. Traditional Mexican and Mexican American folk medi- cine is derived from 15th and 16th century European medical practices, traditions of the Roman Catholic Church in Spain, and practices of Aztecs, Mayans and other native Mexican tribes (Kiev, 1968). Many concepts are similar to those in modern medicine. Some apart from modern medicine are gal ojo, susto, empacho, mal puesto, and caida de la mollera. Each is briefly described below. Mal ojo, translated literally as "bad eye, occurs as a result of excessive admiration or desire of one person 100 101 towards another. Symptoms include sleeplessness, severe headaches and general malaise. The treatment for the dis- order is to have the admirer (who cast the mal ojo unin— tentionally) caress the victim. Children and women are believed to be most susceptible to mal ojo (Gonzales, 1976). Spppp, or "fright" is believed to result from emo- tional trauma. Listlessness, unrestful sleep, energy loss and occasional night sweats are characteristic of the dis- order. Rubel (1964) noted that susto occurs when an indi- vidual's body and soul become detached. When the spirits wander freely, soul loss or §p§£p_occurs. If treated at home, the victim is administered herb tea (usually hierba hpgng), and swept lightly with a palm or other branch, while prayers are being recited. Frequently curanderos(as) are consulted for assistance with EEEEQ' The healer will talk with the patient to try to determine the genesis of the illness. The patient may be massaged or sweated when the body and soul are being reunited. The patient may also be swept or rubbed with an object which will draw out the illness (Rubel, 1964). Empacho, a gastrointestinal blockage, is believed to result when a ball of food clings to the wall of the stomach and obstructs digestion. Empacho is thought to be caused by poor food quality or contamination by an enemy (Gonzales, 1976). Generally, empacho may occur when one individual is allowed to override another person's autonomy. Treatment 102 for empacho involves ingestion of small doses of gpgpa, a mercury derivative, and prayers recited during the gentle massage and pinching of the Spine. Caida de la mOllera (fallen frontanel) usually affects only young children, especially infants with a fragile skull structure. The mollera or frontanel is the tOp-most section of the skull. It is held in place by the counter-pressure of the upper palate. A blow to the head or other accident may dislodge the frontanel; the mollera may sink. The upper palate depresses and the oral passage- way becomes blocked. Caida de la mollera may also result from pulling the nipple out of the child's mouth too vig- orously. When this happens, the frontanel is believed to be sucked down into the palate. One or any combination of three procedures may be used in treating caida de la mollera. An adult may push one finger against the child's palate to push it back into place. The child may also be held over a pan of water so that the tips of the hair are barely touching the water. A poultice made from soap shavings may also be applied to the depression. Use of all three pro- cedures is believed to be most effective in treating this disorder (Gonzales, 1976). Mal puesto, sorcery, is thought to result from one of three kinds of interpersonal relationships: an unrequit- ed love affair, a lover's quarrel, or invidiousness between individuals or nuclear families (Gonzales, 1976). Mania is 103 the characteristic symptom of mal puesto; it is character- ized by its chronic, incurable nature (Rubel, 1966). Brujeria or witchcraft are terms used interchangeably with mal puesto. Rubel's investigation (1966) found no evidence of brujas or witches causing or curing mal puesto. Illnes- ses may frequently be attributed to witchcraft, but the sorcerers are usually unspecified. When there are invidious elements, la gente (other peOple) or 103 vecinos (the neighbors) are blamed for causing mal puesto. In a lover's quarrel, the individual is easily identified (Gonzales, 1976). The disorders described may be classified as natural and unnatural, or mal naturales and mal artificiales or mal puesto. Mal naturales occur naturally or are Providen- tial; mal artificiales are considered within the devil's realm. The folk illnesses described reflect interpersonal relationships and their difficulties. These disorders are not exclusive or comprehensive, but are the ones most generally described and verified among Mexicans and Mexican Americans. APPENDIX C CLIENT CARD APPENDIX C CLIENT CARD CLIENT CARD (TARJETA DE CLIENTE) DATE NAME NOMBRE Last (Apellido) First (Primer ncmbre) Middle Initial ADDRESS PHONE DIRECCION TELEFONO DEMOGRAPHICS (DEI'DGRAFICOS) Age: Sex: Edad Sexo: Male (Masculino) Female (Femenino) languages spoken: Higlish only Spanish only Spanish & English Lenguas hablados: No mas inglés No més espahol Espanol e Inglés Marital Status: Married Widowed Single Divorced/ Separated Estado Civil: Casado(a) Viudo(a) Soltero(a) Divorciado(a)/ Separado(a)___ NAMES AND.AGES OF ALL PEOPLE LIVING IN THE HOME: NOMBRES Y EDADES DE TODAS LAS PERSONAS VIVIENDO EN CASA: Name Age Name Age NCMBRE Edad Nanbre Edad length of Residence: In Michigan In Lansing In current home Tianpo en Residencia: En Michigan En Iansing En el presente casa Occupation: Yes NO What/Where Oocupacién: Si No Cual/Donde 104 105 FINAbCIAL REBCIIRCES (RECURSOS FINAACIEROS) Primary: Pension Insurance Salary/Wage Social Security Primaria: PensiOn Seguro Salario/Sueldo Seguro Social Private Income Support from relative (s) Entrada Privada Ayuda de pariente (5) Supplemental: SSI SSDI DSS (WELFARE) ADC Other Suplanental: SSI SSDI IBS (WELFARE) Am Otro Approx . income per month Ehitrada aprox. de cada mes: $ Medicaid card YES NO Medicare card YES NO Tarjeta de Medicaid: SI NO Tarjeta de Medicare: SI NO_ NDBILITY- (MOVILIDAD) Mobile: Walks Drives Public Transp. Private Transp. M5vil: Anda Maneja Trans Pfiblico Transp. Privado (Outreach worker note) : Impaired Walker Crutches Wheelchair Other Deteriorado: Andador Muletas Silla de ruedas Otro Chronic Problems: (Problemas crOnicos): Other Comments Outreach Worker Date APPENDIX D CONSENT FORM APPENDIX D CONSENT FORM The outreach worker from the Cristo Rey Health Program has explained to me the reason for his/her visit to my home and the general purposes of the study being conducted. I have been asked to take part in the study, and I understand that if I do I am also free to quit partici- pating at any time with no consequences to me. I understand that the information I give to the outreach workers in this study will be looked at along with the opinions of many others in this ocmmunity, and that my name will not be used in the findings of the study. If I want to find out about what the study found, I may ask through the Cristo Rey Health Program. I understand that this study may not directly benefit me but may help the Program to better plan health services and further understand people's views on health care. Participant Date Outreach Worker Date FORMA DE COI‘BEN'I'D’IIEN'IO El trabajador de extensién del Programa de Salud de Cristo Rey me ha explicado 1a razOn per su visita a mi casa y los objectivos generales del estudio que estén oonduciendo. Estoy invitada a participar en el estudio, y yo entiendo que si participo, estoy libre a salir de la participaciOn en cualquier tiempo sin oonsecuencia a mi. Yo entiendo que la informacién que doy a los trabajadores en el estudio va a estar examinada junta con 1as Opiniones de muchas otras en esta oommidad y que mi nombre no va a estar usado en los resultados del estudio. Si guiero saber que son los resultados del estudio, puedo preguntar por el Programa de Salud de Cristo Rey. Yo entiendo que este estudio posiblemente no va a dar beneficios a mi directamente pero puede ayudar a1 Programa a planear Irejores servicios de salud y entender mas 1as Opiniones de la gente sobre el cuidado de salud. Participante Fecha Trabajador Fecha 1 0 6 APPENDIX E THE FOLLOW-UP QUESTIONNAIRE APPENDIX E THE FOLLOWHUP QUESTIONNAIRE Hello! My nane is and I'm from the Cristo Rey Carmunity CEnter Health Progrann Is at hate? I'd like to Speak with him/her, please (WHEN RESPONDENT IS PRESENT, CONTINUE). ,I'd like to take a feW'minutes to ask you a few questions about you and your family's health. WHEN YOU AND THE RESPONDENT ARE (IIETXHFEEEL BEGIN THE INTERVIEW. 'WILLINGNESS TO USE THE HEALTH PROGRAM 01. Have you heard of the Cristo Rey Health Program? 1. YES . . . .GOTO Q2 2. NO . . . .GOtle6 3. Other Q2 . How did you hear about the Health Program? 1 . television 2 . radio 3. newspaper . friends relatives outreach contact at hane . . GO TO Q4 don't renember other O‘U'lab cow 107 Interviewer ' 5 Name Subject No. Date Time AM/PM iHolal Mi nombre es y yo soy del Programa de Salud del Centro Comunitario de Cristo Rey. Esté en casa? Me gustaria hablar con el/ella, por favor. (WHEN RESPONDENT IS PRESENT, CON- TINUE) . , Ire gustaria tomar unos minutos para hacerle unas preguntas sobre su salud y la de su familia. WHEN YOU AND THE RESPONDENT.ARE COMFORTABLE, BEGIN THE INTERVIEW. ‘WILLINGNESS TO USE THE HEALTH PROGRAM Q1. Ha Ud. oido del Programa de Salud de Cristo Rey? 1. SI . . . .GO TO QZ 2. NO . . . .GO TO Q16 3. Otro Q2 . Cdmo supo sobre el Programa de Salud? l. televisién 2. radio 3. periOdioos 4. amigos 5. parientes 6. oontacto personal oon alguien del Programa de Salud . . GO '10 Q4 no se acuerda otro Q3. Were you contacted by a worker from the Cristo Rey Health Program? 1. Yes 2. NO . . . .GO TO Q16 3. Other 4. Can't remember Q4. What did you think about the person coming to your home to contact you? I VDULD LIKE TO ASK YOU SOME QUES- TIONS ABOUT THE VISIT WHICH THE HEALTH PROGRAM WORKER PAID YOU EARLIER. I'LL READ THE STATEMENT AND YOU CAN SHCIN ME YOUR RESPONSE ON THIS CARD (SHCM CARD) . Not at all A little Sarewhat Quite a lot Very much UI-waH O O 0 Q5. Was it clear what the worker was talking about? Q6 . Did you think the Program would be helpful to you? Q7. Did the Program seem like it would be a friendly place? Q8 . How much need did you have for their services? Q9. Since you were contacted by the Health Program worker, have you used any of the Health Program services? . Yes . No . . . .GO TO Q11 . Other . Can't remember bWNH Q3. Se puso en contacto con Ud. e1 trabajador del Programa de Salud de Cristo Rey? 1. Si 2. No . . . .GO TO Q16 3. Otro 4. No se acuerda Q4 . Qué piensa sobre la persona veniendo a su casa a ponerle en contacto con Ud. ? ME GUSTARfA HACERLE UNAS PREGUNTAS. SOBRE 1A VISITA QUE LE HIZO EL ‘I'RABAJADOR DEL PROGRAMA DE SALUD. on A LEERMEL DECIARACION Y UD. PUEDE ENSENARME SU RESPUESTA EN ESTA TARJETA (SHOW CARD). 1. Nada 2. Un poquito 3. M53 0 nenos 4. Bastante 5. Mucho Q5. Estaba claro de lo que estaba hablando e1 trabajador? Q6. Cree Ud. que el programa 1e puede ayudar? Q7. Piensa Ud; que el pro- grama ser1a un lugar amigable? Q8. Cuanta necesidad tenia por sus servicios? Q9. Desde cuando se puso en contacto con Ud. e1 trabajador del Programa de Salud, ha usado Ud. algunos de los servicios del Programa de Salud? 1. Si 2. No . . . .GOTOQll 3. Otro 4. No se acuerda QlO. Q11. 012. 109 What influenced you to care Q10. to the Cristo Rey Health Pro- gram? (Or, what interested you in the Cristo Rey Health Program?) 1. The services available 2. The social activities 3. Curiosity, I wanted to know more about the Health Program 4. They seemed friendly 5. Other Has anyone else in the house- Qll. hold used any of the Health Progranlservices Since you were contacted? 1. Yes . . . .GO TO QUESTION #12 2. NO . . . .GO TO QUESTION #13 3. Don't know 4. Can't remember 5. Cther Who else in the household has Q12. used the services? GO TO Q14. NAME RELATION Que 1e interesO para que viniera a1 Programa de Salud de Cristo Rey? (O, qué 1e interesO en el Programa de Salud de cristo Rey?) 1. los servicios que hay 2. Las actividades sociales 3. Curiosidad, queria saber més sobre el Pro- grama de Salud 4. Se ven amigables 5. Otro Desde cuando se puso en contacto con Ud. e1 trabajador del Programa de Salud, han usados alguien en su casa algunos de los servicios del Programa? 1. Si . . . .GO TO TFAJA “‘21 A; ‘ 1 QUESTION #12 2. NO . . . .GO TO QUESTION #13 3. NO sé 4. NO se acuerda 5. Otro Quién en la casa han usados los servicios? 'IO '10 Q14. NOMBRE RELACION Q13. Ql4. Q15. Q16. What influenced you npp_to contact the Cristo Rey Health ProgranG 1. had no need 2. don't believe in help like that 3. seemed unfriendly 4. not sure what they were talking about 5. too far away 6. never got around to it 7. other 110 Q13 ‘What are the most important things that the cristo Rey Health Progranlndght be able to help you with? In the future, would you con- sider calling the cristo Rey Health Progranxif the need arises? 1. Yes 2. NO 3. Other Where do you.get.most of your information about.what goes on in.the U1¢> c>oxPa FJUJUJUl )~.nlo1c.e H WHNfiWUT b00000 Chi-4 H O O O U'lub (JON-b 0.5m H O O 0 0‘0) \IN 0 UJQ H O O \IN \IN 0 N00 0 I 7‘41- lfl\l -' V l.- K! . ITEM 16. 17. Source of Come mmnity Info. (Continued): Newspapers Friends Relatives Neighbors Don't Know Cther Number in house- hold using: Family Doctor General Practitioner RESPONSE Yes TOtal Yes Tbtal Yes TOtal Yes NO Total Yes Tbtal Yes Total 3 HmdmmthH otal BimwaI—‘O FREQUENCY PERCENT HNLA) no 0 l-‘OU'IQWQDO ooxoxomooooq ITEM 17. 18. 19. Number in house- hold using (Continued): OB/GYN Surgeon Chiropractor Psychologist Marriage Counselor Curandera Opinion Of treat- :ment of Chicanos by health personnel Needs of Hispan- ics: Housing RESPONSE SECOND—IO E. EWNHO E 8H0 gU'IAUJNf-‘O E 6.2. SIFJCD E O 1 Tbtal 127 NOne/Neutral Positive Negative Tbtal NO PrObLem Somewhat a PrOblem very Impt. PrOblem Total Paeahanauwed H O I...‘ [.4 0 KO Hubfl |'-" O I—‘O 101 Nd 41 31 _22 101 PERCENT None 0000 \lflm H O O O O 128 ITEM RESPONSE FREQUENCY PERCENT 19. Needs of Hispan- ics (Continued): Employment No Problem 43 42.6 Sorewret a Problem 21 20.8 very Impt. Problem _32’ 36.6 Tbtal 101 100.0 Health Care No Problem 50 49.5 Somewhat a Problem 25 24.8 very Impt. PrObLem ._26_ 25.7 Total 101 100.0 Income NO PrOblem 41 20.6 Somewhat a Problem, 21 20.8 very Impt. Problem _39. 38.6 TOtal 101 100.0 Crime No Problem 52 51.5 Somewhat a Problem 27 26.7 very Impt. Problem _Jgg 21.8 Tbtal 101 100.0 Education NO Problem 43 42.6 Somewhat a Problem 23 22.8 very Impt. Problem. 34 33.7 Blank __1_ 1.0 TOtal 01 100.0 Nutrition No Probleml 57 56.4 Somewhat a Problem 20 19.8 very Impt. Problem. _24_ 23.8 TOtal 101 100.0 Transportation No Problem. 54 53.5 Somewhat a Problem 26 25.7 very Impt. Problem _ng 20.8 TOtal 101 100.0 Loneliness NO Problem 63 . 6 Somewhat a Problem 22 2 very Impma Problem _16_ 15. Total 101 100. ITEM HEALTH PERCEPTIONS SCALE ITEMS 20-37 20. Health Perception: NOW Excellent 21. Health Perception: Get Sick Easier 22. Health Perception: Feel better now than before 23. Health Perception: “Ell be sick in future 24. Health Perception: Never WOrry 25. Health Perception: Don't like to go to Doctor 129 RESPONSE Definitely False Mbstly False Don't Know Mostly True Definitely True Total Definitely False Mostly False Don't Know Mostly True Definitely True Tbtal Definitely False Mostly False Don't Know Mostly True Definitely True Total Definitely False Mostly False Don't Know Mostly True Definitely True Tbtal Definitely False Mostly False Don't Know Mostly True Definitely True Total Definitely False Mostly'False Don't Know .Mostly True Definitely True Tbtal 10 14 20 27 30 TOT 16 29 _41_ 101 14 15 35 28 101 11 46 15 23 RH 18 28 23 30 101 39 20 12 28 101 PERCENT Nu.) l—‘H queue-w O. O O \l\l\O\O\O H O O O O tor~.>)a N1m>u1c>uw O hJ O O O I O O c>a>aam>\1aa H uh w 0 O o O moowr—uo . O O O C mmomm l-‘ O O O l-‘ (JO-b HbNO‘U‘I O O O Q \lmoooo H O 0 but» \DOWOQ O O O osmoxoxo p.» O O O P‘h’h‘h‘k‘ m>oxc~u1no O \o\JC>\JU1F4U1U1Q)U1KJFJ\J OOOO@\D\D\O\D\DO\OOOOO\O H O O \O O O O I O \D l-‘kD H O \D wmo O OkOl-J O l-‘ O \D NNU'IO O CORGI-d O g.» can» 0 OOkD O 0.5:» O l 137 ITEM RESPONSE FREQUENCY PERCENT 80. Participants' Occupation ---------- - - - - 81a. Spouse _ NOt relevant 26 25.7 Employed Yes 44 43.6 No 31 30.7 Total 101' 100.0 81b. Spouse's Occupation ---------- - - - 82. Years living in 0-5 years 11 10.9 .Michigan 6-10 years 15 14.8 ll-lS years 12 11.9 16-20 years 17 16.8 21—25 years 19 18.9 26-30 years 5 4.9 31-35 years 12 11.9 36-40 years 6 5.9 41—45 years 2 2.0 46-50 years 0 0.0 51-60 years 1 1.0 61-70 years 1 1.0 Tbtal 101' 100.0 83. Years living in 0-5 years 16 15.8 Lansing 6-10 years 20 19.8 11-15 years 17 16.9 16—20 years 17 16.9 21-25 years 13 12.9 26-30 years 5 4.9 31-35 years 6 5.9 36-40 years 5 4.9 41-45 years 1 1.0 46-50 years 0 0.0 51-60 years 0 0.0 61—70 years __;1 1.0 Tbtal 101 100.0 84. Years in Current l-5 years 50 49.5 Home 6-10 years 18 17 . 8 ll-lS years 20 19.8 16-20 years 6 5.9 21-25 years 5 5.0 26-30 years 1 1.0 31-35 years __1_ 1.0 Tbtal 101 100.0 138 RESPONSE FREQUENCY PERCENT Is Lansing Yes 16 15.8 original home- No 85 84.2 town? Total I61— life—0' City or Town Midwest 27 26.7 where raised Southwest 49 48.5 (region) Mexico 20 19 . 8 Western U.S. l 1.0 Other 4 4.0 Total W Ibo—6 Primary Source None 24 23.8 of Income Pension 8 7,9 Salary/Wage 59 58.4 Social Security 8 7.9 Private Income 1 1.0 Support by relatives 1 1.0 Total W 100.0 Supplementary None 6 5 64 . 4 Income SSI 3 3.0 SSDI 3 3.0 ADC 25 24.8 Welfare/Other __5_ 5.0 Total 101 100.0 Approximate Blank 2 2.0 Monthly Income $0-100 3 3.0 100-499 24 23.7 500-999 43 42.6 1000-1499 18 17.8 1500-1999 7 6.9 2000-2999 2 2.0 3000-3999 1 1.0 4000+ l 1.0 Total "0T 100.0 Medicaid Card Yes 40 39.6 No _6_l_ 60.4 Total 101 100.0 Medicare Card Yes 11 10.9 No 90 89.1 Total IGI 100.0 Subject walks to Yes 34 33.7 various places in No _6_7_ 66.3 community Total 101 100.0 ITEM 93. 94. 95. Subject drives to various places :hlcxmmmnity Subject rides bus to various places in<31mmmuty Subject has some- one drive them to various places in crummmity LANGUAGE FLUENCY 96. 97. 98. 99. 100. Speaks opposite language of interview understand written opposite language of interview Understands spoken language opposite of interview Listens to Spanishr language radio broadcasts .Medical preference 139 RESPONSE Yes 72 No 29 Total "161’ Yes 21 No 80 Total 1'01“ Yes 55 No 46 Total IO—I Fluently 36 Fairly well 19 Get by, but not very well 17 very poorly 22 Not at all _Z Total 101 Fluently 22 Fairly well 17 Get by, but not very well 14 very poorly 21 NOt at all 27 Total 161‘ Fluently 41 Fairly well 30 Get by, but not very well 16 very poorly l4 NOt at all __Jl Tbtal 101 Yes 82 No .12 Total 101 Always prefers MWA. doctor 6 Prefers M.A. doctor 17 Does not matter 66 Prefers A.A. doctor 7 Always prefers A.A. doctor __ji Total 101 H m c «3 NH ONE-'Ch O 0 @0000 00000 H NNl-J i—‘N O on—ao mow O O \lmKD [.4 O 0 HH no owm mo 0 O O O 0 com Q¢ o |'-‘ Ol—‘(D 0 coal—- 0 O OCDN O 1 UNI" mmmm O I towooxo U1 0 101. 102. 103. 104. Knowledge of Mexican American doctor in community Name of Mexican American doctor Do others think poorly of govern- ment assistance recipients Names of referrals to Cristo Rey Health Program 140 RESPONSE Yes No Total Yes No Don't Know Blank Other Tbtal PERCENT 26.7 73.3 100.0 REFERENCES REFERENCES Abad, V., Ramos, J., & Boyce, E. Clinical Issues in the Psychiatric Treatment of Puerto Ricans. Monograph £4. Spanish-Speaking Mental Health Research Center, UCLA, 1977, 25-34. Bachrach, L. L. Utilization of state and county mental health hospitals by Spanish-Americans in 1972. National Institute of Mental Health, 1972. Bergner, L. & Yerby, A.S. Low income and barriers to use of health services. New England Journal of Medicine, 1968, 278(1), 541-546. Berkman, P. L. Measurement of mental health in a general population survey. American Journal of Epidemiology, 1971, 94, 105-111. Brumfield, W. A., Jr., Fox, R. I., & Goldman, J. J. Reaching the target population. Public Health Reports, 1968, 1, 597—602. Burma, J.H. Mexican Americans in the United States: A Reader. Cambridge, Massachusetts: Schenkman Publish- ing Company, Inc., 1970. Burruel, G. & Chavez, N. Mental Health Outpatient Centers: Relevant or Irrelevant to Mexican Americans? In Tulipan, A. B., Atineave, C. L. & Kingstone, E. Beyond Clinic Walls, University of Alabama Press, 1974. ‘ Castro, F. G. Level of acculturation and related consider- ations in psychotherapy with Spanish Speaking/Surnamed Clients. Occasional Paper #3. Spanish Speaking Mental Health Research Center, UCLA, 1977. Clark, M. Health in the Mexican American Culture. Los Angeles: University of California Press, 1959. Colorado Commission on Spanish Surnamed Citizens. The Status of Spanish Surnamed Citizens in Colorado: Report to the Colorado General Assembly, January 1967. 141 142 Denton, J. A. Medical Sociology. Boston: Houghton—Mifflin Company, 1978. Edgerton, R. B. & Karno, M. Mexican American bilingualism and the perception of mental illness. Archives of General Psyghiatry, 1971, 34, 286-290. Edgerton, R. B., Karno, M., & Fernandez, I. Curanderismo in the metropolis. American Journal of Psychotherapy, 1970, 44, 124-134. Farge, E. J. La Vida Chicana: Health Care Attitudes and Behaviors of Houston Chicanos. San Francisco: R & E Research Associates, 1975. Fields, 5. Folk Healing for the Wounded Spirit. Innova- tions: Highlights of Evolving Mental Health Services, 1976, 4(1), 2-18. Forbes, J. D. Mexican Americans. In John H. Burma. Mexican Americans in the United States: A Reader. Cambridge, Massachusetts: Schenkman Publishing Company, Inc., 1970, 7-16. Gaitz, C. M. Barriers to the delivery of psychiatric services to the elderly. Gerontologist, 1974, 44(4), 210-214. Garza, M. Personal interview with Ingham County Commissioner. Lansing, Michigan, July 1979. Gonzales, E. The Role of Chicano Folk Beliefs and Practices in Mental Health. In Carol A. Hernandez, Marsha J. Haug and Nathaniel N. Wagner, Chicanos: Social and Psychological Perspectives. St. Louis: C. V. Mosby Company, 1976, 263-281. Goodrow, B. A. Limiting factors in reducing participation in older adult learning opportunities. Gerontolo- Grebler, L., Moore, J. W. & Guzman, R. C. The Mexican American People: The nation's second largest minor- 1 y. New York: The Free Press, 1970. Haney, J. B. Migration, Settlement Patterns and Social Organization: A Midwest Mexican-American Case Study. Ph.D. Dissertation, Michigan State University, 1978. Heller, C. 8. Mexican American Youth: Forgotten Youth at the Crossroads. New York: Random House, Inc., 1966. 143 Humphrey, N. D. Mexican Repatriation for Michigan-Public Assistance in Historical Perspective. Social Science Review, 1941, 45, 505. Jaco, E. G. Mental Health of the Spanish-American in Texas. In Marvin K. Opler (Ed.), Culture and Mental Health. New York: Macmillan, Inc., 1959, 467-488. Jaco, E. G. Patients, Physicians and Illness: A Source- book in Behavioral Science and Health. London: The Free Press, 1979. Jones, A. & Seagull, A. A. Dimensions of the Relationship Between the Black Client and the White Therapist: A Theoretical Overview. American Psychologist, 1977, 34(10), 850-859. Karno, M. & Edgerton, R. B. Perception of mental illness in a Mexican American community. Archives of General Psychiatry, 1969, 2, 161-164. Katz, E. & Lazarsfeld, P. F. Personal Influence. New York: The Free Press, 1955. Kiev, A. (Ed.). Magic, Faith and Healing: Studies in Primitive Psychiatry Today. New York: The Free Press of Glencoe, 1964. Kiev, A. Curanderismo: Mexican American Folk Psychiatry. New York: The Free Press, 1968. King, S. H. Perceptions of Illness and Medical Practice. New York: Russell Sage Foundation, 1962, p. 53. Klippel, E. R. & Sweeny, T. W. The use of information sources by the aged consumer. Gerontologist, 1974, 44(2), 163-166. Koos, E. L. The Health of Regionville: What the People Thought and Did About It. New York: Hafner, 1967. Kushler, M. C. Alternative modes of conducting outreach to low income elderly: An experimental examination. Master's Thesis, Michigan State University, 1977. Madsen, W. Mexican-Americans of South Texas. New York: Holt, Rinehart & Winston, Inc., 1964. McKinlay, J. B. Some approaches and problems in the study of the use of services--an overview. Journal of Health & Social Behavior, 1972, 44, 115—152. u . ‘~ "VAL—ALI.— 4 . _-..__.._ i l 144 McWilliams, C. Gitting Rid of the Mexicans. American Mercury, 1933, 28, 322-324. Mead, M. (Ed.). Cultural Patterns and Technical Change. UNESCO, Paris, 1953, 9-10. In S. H. King, Percep- tions of Illness and Medical Practice. New York: Russell Sage Foundation, 1962. Montiel, M. The Social Science Myth of the Mexican- American Family. E1 Grito, 1970, 2, 56-63. Moustafa, A. T. & Weiss, G. Health Status and Practices of Mexican Americans. Mexican-American Study Project, Advance Report 11. Los Angeles: Graduate School of Business Administration, University of California, Los Angeles, 1968. Nall, F. C. & Speilberg, J. Social and Cultural Factors in the Responses of Mexican-Americans to Medical Treat- ment. Journal of Health and Human Behavior, 1967, 8, 299-308. Norman, J. C. Medicine in the Ghetto. New York: Appleton- Century Crofts, 1969. Padilla, A. M., Ruiz, R. A. & Alvarez, A. Community mental health services for the Spanish-Speaking/Surnamed population. American Psychologist, 1975, 29, 892-905. Parsons, T. In E. G. Jaco, Patients, Physicians and Illness: A Sourcebook in Behavioral Science and Health. London: The Free Press, 1979. Paul, B. D. (Ed.). Health, Culture and Community. New York: Russell Sage Foundation, 1955, p. 467. Phillipus, M. J. Successful and unsuccessful approaches to mental health services for an urban Hispano-American population. Journal of Public Health, 1971, 42, 820-830. Rotter, J. B. Social learning and clinical psychology. Englewood Cliffs, New Jersey: Prentice-Hall, 1954. Rubel, A. J. The epidemiology of a folk illness: Susto in Hispanic America. Ethnology, 1964, 2(3), 263-268. Rubel, A. J. Across the Tracks: Mexican-Americans in a Texas City. Austin: University of Texas Press, 1966. 145 Rush, R. R. & Kent, K. E. M. Communication channel selec- tion considerations for reaching older persons. Unpublished, 1975. Salas, G. & Salas, I. The Mexican Community of Detroit. In M. M. Mangold (Ed.), La Causa Chicana. New York: Family Service Association of America, 1972, 161-178. Sanchez, G. 1. Forgotten People: A Study of New Mexicans. Albuquerque: University of New Mexico Press, 1940. Saunders, L. Cultural Differences and Medical Care: The Case of the Spanish-Speaking People of the Southwest. New York: Russell Sage Foundation, 1954. Teske, R. H. C., Jr. & Nelson, B. H. Two scales for the measurement of Mexican-American Identity. Inter- national Review of Modern Sociology, 1973, 3(9), 192-203. U. S. Bureau of Census, Washington, D. C.: U. S. Govern- ment Printing Office, 1971. Wallston, B. S., Wallston, K. A., Kaplan, G. D., & Maides, S. A. Development and validation of the Health Locus of Control (HLC) Scale. Journal of Consulting and Clinical Psychology, 1975. Ware, J. E., Jr., Wright, W. R., & Snyder, M. K. Measures of perceptions regarding health status: Preliminary findings as to scale reliability, validity and administration procedures. Technical Report MHC-74- 22, Carbondale, Illinois. Weaver, J. L. National health policy and the underserved: Ethnic minorities, women and the eIderly. St. Louis: C. V. Mosby Company, 1976. Welch, S., Comer, J. & Steinman, M. Some social and atti- tudinal correlates of health care among Mexican Americans. Journal of Health and Social Behavior, 1973, 24(9), 205-213. Winnie, W. W. The Spanish surname criterion for identifying Hispanos in the Southwestern United States: A Pre- liminary Evaluation. Social Forces, 1960, 22, 363-366. Woods, F. G. Cultural conditioning and mental health. Social Casework, 1958, 4, 327-333. 146 Yamamoto, J., James, Q. C. & Palley, N. Cultural problems in psychiatric therapy. Archives of General Psy- chiatry, 1968, 22, 45-59. Zola, I. K. Culture and Symptoms—-An Analysis of Patients' Presenting Complaints. American Sociological Review, 1966, 22, 615-630. "‘lllllllll“