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This is to certify that the thesis entitled THE EFFECT OF ETHNIC BACKGROUND AND HEALTH LOCUS OF CONTROL ON HEALTH MAINTENANCE PRACTICES RELATED TO THE RISK FACTORS 0F HEART DISEASE presented by Roberta Boyden West has been accepted towards fulfillment . ., of the requirements for M.N . degree in Nursing /’ a / Major professor Date Qtléb /{ {9‘ f5) // 0-7 639 gyaaauz FINES: 25¢ per day per ire... r.ETURNXNG l_._!_SRA'r.v MATEEIALQ: Place in new v‘eturrzfiu remove charge from circulatwn recur-dc 3UL22i2 2004 MAGIC 2 © Copyright by ROBERTA BOYDEN wzsr 1980 THE EFFECT OF ETHNIC BACKGROUND AND HEALTH LOCUS OF CONTROL ON HEALTH MAINTENANCE PRACTICES RELATED TO THE RISK FACTORS 0F HEART DISEASE By Roberta quden West A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF NURSING School of Nursing T980 I" 777 / M00 ABSTRACT THE EFFECT OF ETHNIC BACKGROUND AND HEALTH LOCUS OF CONTROL ON HEALTH MAINTENANCE PRACTICES RELATED TO THE RISK FACTORS 0F HEART DISEASE By Roberta Boyden West In this pilot study the effect of ethnic background on health maintenance practices related to the risk factors of heart disease, ethnic group differences on health locus of control, and the rela- tionship between health locus of control and health maintenance practices for lower-class Black-American and Mexican-American men was examined. Factors which might influence the study variables were identified and discussed. Data were analyzed via the statis- tical techniques of correlation, chi square, and t-test difference between the means. Major study findings were: (1) health maintenance practices related to the risk factors of heart disease were independent of ethnic background; (2) a weak relationship between health locus of control and health maintenance practices was present for the total sample and the Mexican-American group; and (3) the Multidimensional Health Locus of Control scale did not appear to measure three separate dimensions. Major implications address the need to develop assessment tools which measure ethnically influenced health beliefs and practices. To Mom and Dad with all my love ii ACKNOWLEDGMENTS I would like to express my appreciation for the Sigma Theta Tau Research Scholarship and the Professional Nurse Traineeship which enabled me to pursue my graduate education. Dr. Barbara Given, my committee chairperson, has provided much encouragement and emotional support throughout this research project. I would like to extend a special thank-you to her for not only giving her time and help, but also for sharing herself and her convictions which have contributed to my professional development. Sincere thanks to my committee members, Bonnie Elmassian, Judith Mitchell, Dr. Loudell Snow, and Brigid Warren for their support and guidance in directing my research. I am grateful to those within the Black-American and Mexican- American community who shared a part of themselves with me so that I might fulfill my educational goals. A very special thank-you to my husband, Arnott, for his support and encouragement throughout my graduate education. TABLE OF CONTENTS Page LIST OF TABLES . . . . . . . . . . . . . . . . vii Chapter I. THE PROBLEM l Introduction . . . . . . . . . . . 1 Statement of the Problem . . . . . . . . . 9 Research Questions . . . . . . . 9 Definition of Terms--Study Variables . . . . . 9 Definition of Terms--Intervening Variables . . . 13 Limitations . . . . . . . . . . . . . l7 Assumptions . . . . . . . . . . . 19 Overview of the Chapters . . . . . . . . . 20 II. CONCEPTUAL FRAMEWORK . . . . . . . . . . . 21 Overview . . . . 21 The Mexican-American Health Belief System . . . 2l The Black-American Health Belief System . . . . 36 Health Locus of Control . . 53 Health Maintenance Practices Related to the Risk Factors of Heart Disease . . . . . . . . 61 Nursing Theory . . . . . . . . . . . . 67 Summary . . . . . . . . . . . . . . 71 III. REVIEW OF THE LITERATURE . . . . . . . . . . 72 Overview . . . . . 72 Ethnic Background and Health Behavior . . . . 73 The Mexican-American in Health. . . . . . 74 The Black- American in Health . . . . . . 97 Locus of Control and Health Behavior . . . ll4 Locus of Control and Health Behavior Related to the Risk Factors of Heart Disease . . . l16 Health Locus of Control Scale . . . l19 Health Locus of Control and Health Behavior . l2l iv Chapter Ethnic Background and Locus of Control . . Social and Attitudinal Variables. Ethnic Background and Locus of Control Ethnic Background and Locus of Control Scales : Ethnic Background, Health Locus of Control, and Health Behavior . . . . . Summary IV. METHODOLOGY AND PROCEDURE Overview Sample . Settings Instruments . Ethnic Background Instrument . . Multidimensional Health Locus of Control Instrument . . Health Maintenance Practices Instrument. Pretest of the Study Questionnaire Data Collection Procedure Scoring . Ethnic Background Instrument . Multidimensional Health Locus of Control Instrument . . Health Maintenance Practices Instrument. Demographic Data . . Procedures for Data Analysis Variables . . . Techniques for Data Analysis Human Rights Protection Summary . V. DATA PRESENTATION Overview Presentation of Descriptive Data Sample Data . . . Social Class, Health Locus of Control, and Health Behavior . . Geographical Influences/Familial Generation, Health Locus of Control, and Health Behavior . Chronic Illness, Health Locus of Control, and Health Behavior . Presentation of Data Related to the Research Questions . . . . . . . . . Page 125 126 131 134 138 143 143 147 148 148 150 154 156 157 160 160 161 161 169 169 170 173 173 175 175 177 177 180 184 189 192 Chapter Page Health Locus of Control Scale Data . . . . . 200 Summary . . . . . . . . . . . . . . 203 VI. SUMMARY AND IMPLICATIONS OF FINDINGS . . . . . . 204 Overview . . . . . . 204 Interpretation of Inferential Findings . . . . 207 Mean Health Locus of Control Scores . . . . 208 Health Behavior Categories . . . . . . . 219 Summary of Research Question 1 . . . . . . 228 Summary of Research Question 2.. . 241 Incidental Findings and Limitations of Findings . 243 Implications fOr Nursing. . . . . . . 250 Recommendations for Future Research . . . . . 261 APPENDICES . . . . . . . . . . . . . . . . . 266 A. LETTERS 0F CONSENT . . . . . . . . . . . . 267 B. ENGLISH VERSION OF INSTRUMENT . . . . . . . . 281 C. SPANISH VERSION OF INSTRUMENT . . . . . . . . 288 D. LETTER READ BEFORE GROUP . . . . . . . . . . 295 E. LETTERS ACCOMPANYING QUESTIONNAIRE . . . . . . 300 F. CONSENT FORMS, ENGLISH AND SPANISH VERSIONS . . . 305 G. CLASSIFICATION OF STATES . . . . . . . . . . 308 H. STATISTICAL HYPOTHESES . . . . . . . . . . 310 I. HUMAN RIGHTS PROTECTION . . . . . . . . . . 312 0. DESCRIPTION OF PRETEST SAMPLE . . . . . . . . 315 BIBLIOGRAPHY . . . . . . . . . . . . . . . . 318 vi Table 10. 11. 12. 13. LIST OF TABLES Black-Americans Described by Social Class and Geographical Influence . . . . . . . Mexican-Americans Described by Social Class and Familial Generation . . . . . . Black-Americans Described by Social Class and Mean Health Locus of Control Scores Mexican-Americans Described by Social Class and Mean Health Locus of Control Scores . . . Ethnic Background Described by Social Class and Health Behavior . . . . . . . Black-Americans Described by Geographical Influence and Mean Health Locus of Control Scores Mexican-Americans Described by Familial Generation and Mean Health Locus of Control Scores Black- Americans Described by Beographical Influences and Health Behavior . . . . Mexican-Americans Described by Familial Generation and Health Behavior . . . . . Ethnic Background Described by Chronic Illness and Mean Health Locus of Control Scores Ethnic Background Described by Chronic Illness and Health Behavior . Cross Tabulations of Ethnic Background by Health Behavior Categories . . . . . Correlation Coefficients for the Relationship Between Health Locus of Control and Health Maintenance Practices . vii Page 178 178 181 181 183 185 186 187 188 190 191 194 196 Table Page 14. Means, Standard Deviations, and T-Values for Differ- ences Between Ethnic Groups on Mean Health Locus of Control Scores . . . . . . . . . . . 197 15. Summary of Statistical Tests . . . . . . . . . 199 16. Alpha Reliabilities for the Multidimensional Health Locus of Control Scale . . . . . . 201 17. Intercorrelations of Multidimensional Health Locus of Control Scale . . . . . . . . . . . . . 202 viii CHAPTER I THE PROBLEM Introduction This study is concerned with two ethnic groups, each having a well developed health culture. The health belief systems of Mexican- Americans and Black-Americans will be examined with the premise that the health behavior of these populations is greatly influenced by their respective health cultures. Both groups have retained much of the folk medical belief system that once was the basis of scientific medicine in the eighteenth and nineteenth century (Dorsey & Jackson, 1976; Gonzales, 1976; Jacques, 1976; and Martin, 1976). The folk medical system is a health culture that is incongruent with that held by the dominant society. It is important, therefore, for health professionals to acquire a knowledge base about this health belief system. Health professionals need to work within the framework of alternative health belief systems if they are to have an impact on the health status of those individuals who possess distinct health cultures. The determinants of health behavior is thus an area of interest and relevancy for health professionals to study if health care is to be delivered effectively to those in need. Rosenstock (1975) and Hochbaum (1970) have discussed the variables of perceived sus- ceptibility, perceived severity, costs, and benefits in relation to health behavior. These variables comprise the Health Belief Model (Becker, 1974). Numerous studies have provided empirical evidence to support the use of this model in predicting health behavior.* Rosenstock's (1966) and Kasl and Cobb's (1966) examina- tion of the literature reveals that taking preventive action and participating in health promotion programs based on beliefs about perceived susceptibility and benefits was usually taken by those in a high socio-economic group, who were young adults, white, female, and well-educated. Demographic and sociopsychological variables such as these have a modifying effect on each of the variables in the model. Knowledge about a disease and prior contact with it are structural variables which also influence health behavior (Becker, 1974). The demographic, sociopsychological, and structural variables as the modifying factors in the model are especially relevant to study because they most often are the areas of conflict between the consumer and the provider (Spector, 1979). However, to what extent age, sex, race, religion, social class, and culture affect health behavior is currently not well established. Rosenstock (1975) attributes much of the variance in health behavior to the effect of some of these modifying factors in what he terms the "culture of poverty". He asserts that due to the culture *See, for example, reviews of the literature by Hochbaum (1970), Kasl and Cobb (1966), and Rosenstock (1975). of poverty poor people don't exhibit the beliefs required to par- ticipate in preventive health care. He also states that poor people possess less information about health and illness than do those with a higher income. Additionally, because of a need to choose between "the necessities of today and the contingencies of tomorrow", Rosenstock states that lower income people do not place as high a value on health as do higher income people (1975, p. 214). Con- tributing to this attitude are feelings of helplessness and "a psychological inability to cope with a hostile environment" (p. 214). There is, therefore, a reluctance to utilize the white middle class professional health care system, and a tendency to rely instead on the lay referral system. The lay referral system is culturally specific, and is distinguishable from the professional health care system. In the Mexican-American health culture it includes the female of the family, the neighborhood healer, and the curandero; in the Black-American health culture it includes the female of the family, the healer who receives his gift from God during a religious experience, and the healer who is born with the gift to heal. However, are variations in health behavior truly due to the "culture of poverty" as Rosenstock proposes? Are differences in health behavior due to lg§§_know1edge about health and illness, or do they reflect a different knowledge base about health and illness? Perhaps poor people do possess health beliefs conducive to positive health behavior, beliefs which are not the same as those held by the dominant society. A different knowledge base regarding health behavior may provide a more accurate explanation for Rosenstock's (1975) and Kasl and Cobb's (1966) findings than does the culture of poverty concept. A substantial percentage of those individuals who are members of the culture of poverty are also from minority ethnic backgrounds. According to the 1970 census, the Black-American population com- prises 12.3 percent of the total population. The National Urban League believes this figure to be an undernumeration of at least 1.8 million people. Of the million and a half families in the United States below the poverty level in 1970, 29.9 percent were Black-American families (Spector, 1979). Spanish-speaking individ- uals comprise 4.6 percent of the total population (Spector, 1979). In 1971 the Cabinet Committee on Opportunities for Spanish-Speaking People estimated that this figure should be closer to 5.9 percent. According to the 1977 census projections, by the mid-eighties Spanish-speaking individuals will comprise the largest single min- ority group in the United States (Dorsey & Jackson, 1976; Spector, 1979). Of the total Spanish-speaking population, approximately half are people of Mexican origin. In 1969, the number of Spanish origin families who were below the poverty level was five times greater than the total number of families below the poverty level who were not Spanish-speaking (Spector, 1979). These figures indi- cate that in the United States a status of poverty often accompanies membership in a minority ethnic group. It may be that ethnic back- ground and it's influence on one's health belief system has a greater impact on health behavior than the culture of poverty concept. Hochbaum (1970) and Suchman (1964) have both addressed the impact of social influences as a factor influencing health behavior. Hochbaum indicates that it is the values, beliefs, and attitudes of one's social group that influence what health behavior is learned and what normative behaviors are practiced. The individual absorbs the group's "characteristic health beliefs, attitudes, and tradi- tional practices through the examples and influences of those around him" (Hochbaum, 1970, p. 47). The social group thus possesses a "health culture", defined as: the total structure of beliefs and practices concerning health and illness that are shared by all or most of the members of a society--that is, a structure that sets them apart from members of other population segments of the same society. (Hochbaum, 1970, p. 44) One's ethnic group is certainly a specific population segment which has its own "health culture". The Health Belief Model (Becker, 1974) incorporates ethnicity as a modifying factor influencing health behavior. In an ethnic group where the health culture is rigidly defined and normatively developed, group members will exhibit health behavior congruent with their health culture. The health behavior may or may not be congruent with that prescribed by the modern health care system. Consequently, this researcher takes issue with Rosenstock's (1975) concept of a culture of poverty that influences health behavior to the extent he implies. Rather than less knowledge about health and illness, those individuals who are members of the culture of poverty may possess a different knowledge base regarding health and illness. The variable ethnic background may determine one's health belief system and knowledge base for health behavior to a greater extent than Rosenstock's culture of poverty. The health locus of control concept is another variable that has been discussed and researched with regard to health behavior (Wallston, Maides, & Wallston, 1975; Wallston, Wallston, Kaplan, & Maides, 1976). The dimensions of health locus of control are: internal, chance, and powerful others. They reflect individual perceptions regarding who or what holds the control for good health (Wallston, Wallston, & DeVellis, 1978). The concept proposes that an individual's health behavior is influenced by his locus of control orientation. Studies by Kaplan and Cowles (1978), Wallston, Maides and Wallston (1975), and Wallston, Wallston, Kaplan, and Maides (1976) indicate that it is a worthwhile area for further study with regard to the determinants of health behavior. The influence of ethnicity and socio-economic status on locus of control has been discussed in a review of the literature by Lefcourt (1966). He states that "in groups whose social position is one of minimal power either by class or race tend to score higher in the external-control direction" (Lefcourt, 1966, p. 212). The effect of ethnicity and socio-economic status on health locus of control is currently unknown. However, this researcher contends that ethnicity has a greater impact on health locus of control orientation that does socio-economic status. The indirect influence is the alternative health belief system held by those from minority ethnic backgrounds. This study will examine the concepts of ethnicity and health locus of control to determine their effect on health behavior. Additionally, the influence of ethnic background on health locus of control will be studied. These two variables will provide insight into the health belief system held by those who participate in the study. The variable social class will be held constant. The second aspect of this study is to examine a particular health behavior to ascertain whether study participants actually practice what they believe about their health. Health maintenance practices related to the risk factors of heart disease is the health behavior that will be analyzed. Heart disease is statistically an epidemic, and it is the chief cause of death and morbidity in the United States (McIntosh, Stamler, & Jackson, 1978). Over six hundred thousand Americans die each year from coronary artery disease. For survivors the likelihood of dying in the subsequent five years is five-fold (McIntosh, Stamler, 8 Jackson, 1978)- Personal habits and patterns of daily life are the major contributing factors toward the development of heart disease. Nursing professes to provide health care to "holistic man". In order to accomplish this "holistic man" needs to be understood. Man responds and adapts to forces in his culture. His adaptations are a part of his human nature and survival, and may be interpreted as self-care adaptations (Leininger, 1970). Health and illness behavior reflects a part of this cultural response and self-care adaptation. Leininger (1976) writes that health professionals who fail to recognize the importance of different health belief systems may "miss the means to understand . . . values and needs and to provide health care linkages . . ." to the dominant health care system (p. 14). Spector (1979) asserts that health care must reflect an adjustment of approaches to "coincide with the needs of clients rather than conflict" with them (p. 79). Only then can self-care adaptations be utilized to promote the health and survival of holistic man. Orem's (1971) nursing theory states that nursing's goal is to promote the attainment of the highest level of self-care possible. Man's highest level of self-care is shaped by his cultural response and adaptation. For nursing to assist man in attaining his optimal self-care ability, knowledge of man's cultural resources is necessary. Beliefs about attaining and maintaining health, which may be influ- enced by ethnic background and health locus of control orientation, are a part of the cultural resources nursing has to draw upon to maximize self-care ability. The need for this study is exemplified by the fact that nurses often assume their patients adhere to the modern health care system when in reality health behavior may be influenced by a commitment to a different belief system. Because nursing asserts that it is dedicated to the health maintenance and promotion of all people, individual differences in health belief systems must be recognized. Without this recognition nursing is not really devoting itself to the health of "holistic man" or meeting its own goal of promoting the highest level of self-care possible. Thus, it is believed that this study will contribute to the knowledge base of nursing regarding health behavior and will suggest additional nursing interventions designed to promote positive health behavior. Statement of the Problem This research study is concerned with the effects of ethnic background and health locus of control on men's health maintenance practices related to the risk factors of heart disease. Researchgguestions 1. What is the relationship between ethnic background and health locus of control as it affects client health main- tenance practices related to the risk factors of heart disease? 1a. What is the effect of ethnic background on client health maintenance practices related to the risk factors of heart disease? 1b. What is the relationship between health locus of control and client health maintenance practices related to the risk factors of heart disease? 2. What is the effect of ethnic background on health locus of control in men 40 to 60 years old? Definition of Terms--Study Variables Ethnic background is considered an independent variable. For the purposes of this study, it is defined as the self-identification 10 by study participants of the predominant ethnic influence in their life, as either Mexican-American or Black-American. Self- identification is the method used because it is consistent with the data collection method used by the United States Bureau of the Census, and research studies conducted by the United States Depart- ment of Public Health and Michigan State University. This method is supported by Dr. Nan Johnson, a Demographer at Michigan State University (March, 1978), and Dr. Loudell Snow, a Medical Anthropol— ogist at Michigan State University (October, 1978) who has researched health beliefs and practices of minority groups (Snow & Johnson, 1977). In the event of a mixed parentage, study participants will be able to identify the_predominant ethnic influence in their lives as they perceive it to be. This approach is supported by Dorson (1971) who states that "ethnic traditions don't blend in a mixed marriage but either cancel each other out or result in one tri- umphing" (p. 47). For the purposes of this study, ethnic background is defined by the following items: Black-American Caucasian Mexican or Mexican-American Other Health locus of control is also considered an independent variable (see research questions 1, la, and 1b). It is treated as the dependent variable for research question 2 only. Locus of con- trol is defined as the "degree to which the individual perceives that the reward follows from, or is contingent upon, his own behavior or attributes versus the degree to which he feels the 11 reward is controlled by forces outside of himself and may occur independently of his own actions" (Rotter, 1966, p. 1). Internal locus of control "refers to the perception of positive and/or negative events as being a consequence of one's own actions and thereby under personal control" (Lefcourt, 1966, p. 206). Individuals with an internal locus of control as applied to health "believe that the locus of control for health is internal and that one stays or becomes healthy or sick as a result of his or her behavior" (Wallston, Wallston, & DeVellis, 1978, p. 160). For the purposes of this study, internal health locus of control is defined by items 1, 6, 8, 12, 13, and 17 on the Multidimensional Health Locus of Control scale (see Appendix 8). External locus of control "refers to the perception of positive and/or negative events as being unrelated to one's own behavior in certain situations and therefore beyond personal control" (Lefcourt, 1966, p. 206). Individuals with an external locus of control as applied to health believe that "the factors which determine their health are such things as luck, fate, chance, or powerful others, factors over which they have little control" (Wallston, Wallston, & DeVellis, 1978, p. 160). Wallston, Wallston, and DeVellis (1978) believe that prediction of health behavior can be improved by examining the dimensions of external control separately, i.e. the fate and chance dimension and the powerful others dimension. Individuals with a chance health locus of control orientation believe that the control of their health lies with fate or chance, and there is nothing they themselves can do to affect their health status. 12 For the purposes of this study, chance health locus of control is defined by items 2, 4, 9, ll, 15, and 16 on the Multidimensional Health Locus of Control Scale (see Appendix 8). Individuals with a powerful others health locus of control orientation believe that the control of their health lies with the behavior and actions of significant others, whether it be family members or health profes- sionals. For the purposes of this study, powerful others health locus of control is defined by items 3, 5, 7, 10, 14, and 18 on the Multidimensional Health Locus of Control scale (see Appendix 8). Health maintenance_practices related to the risk factors of heart disease is considered a dependent variable in this study (see research questions 1, 1a, and lb). Health behavior is defined as: any activity undertaken by an individual who believes he is healthy in order to prevent disease or to detect it in an asymptomatic state (Kasl 8 Cobb, 1966). Health maintenance practices related to the risk factors of heart disease is a health behavior directed toward the prevention of heart disease, which thereby promotes and maintains health. The identified risk factors of heart disease are: smoking, hypertension, hypercholesterolemia, obesity, and lack of physical exercise (McIntosh, Stamler, & Jackson, 1978). For the purposes of this study, health maintenance practices for the risk factors smoking, hypertension, obesity, and lack of physical exercise are operationally defined by items 1 through 5 on the Health Maintenance Practices scale (see Appendix 8). Additionally, dietary intake of foods that are high in sodium and cholesterol operationally define health maintenance practices 13 related to the risk factors of hypertension and hypercholesterolemia. For the purposes of this study, high sodium foods are defined by items 2, 4, 5, 7, 10, 11, and 13 on the Health Maintenance Practices scale (see Appendix B). High cholesterol foods are defined by items 1, 3, 6, 8, 9, 12, and 14 on the Health Maintenance Practices scale (see Appendix 8). Definition of Terms--Intervening Variables Social class is a potentially intervening variable which will be held constant in this study. Hollingshead (1957) has developed the "Two Factor Index to Social Position" to estimate the positions individuals occupy in the status structure of society. One's social position is estimated by his education and occupation (Hollingshead, 1957). The educational scale is based on the assumption that those individuals with similar educations will possess similar tastes and attitudes, and exhibit similar behavior patterns. Education thus reflects both knowledge and cultural tastes. The occupational scale is based on the assumption that occupations have varying values attached to them by society, and a ranking of occupational functions which implies that some individuals exercise control over the occupational pursuits of others. Occupation thus reflects the skill and power individuals possess as they carry out the functions of society. The combination of these two factors, education and occupation, provide a determination within approximate limits of 14 the social position an individual occupies in the status structure of society (Hollingshead, 1957). For the purposes of this study, social class is operationally defined by Class III, IV, and V of the Two Factor Index of Social Position. These classes have been selected to study because they represent the lowest social positions of individuals in our society, and because the role of social class in determining health behavior has hot been firmly established. .The existence of a chronic illness is considered to be a potentially intervening variable as it may influence client health maintenance practices related to the risk factors of heart disease. For example, an individual with known hypertension is probably more likely to get his blood pressure checked regularly than one who has hypertension and is not aware of it or one who does not have hyper- tension. Individuals who have already entered the modern health care system for reasons due to chronic illness will probably have a different perception of their health. This perception may be deter- mined by their degree of acculturation into the system, or it may be determined by the strength of commitment to their ethnic health beliefs and values. Their locus of control orientation may also have an effect on health perceptions, specifically perceptions regarding the control of their health. Study participants will be asked to indicate if they have the following chronic illnesses related to the risk factors of heart disease: hypertension, hyper- cholesterolemia, obesity, and chronic obstructive pulmonary disease. Diabetes, renal disease, liver disease and cancer are additional 15 chronic illnesses which may be intervening variables. The other risk factors of heart disease, smoking and lack of regular exercise or physical activity, are not in themselves chronic illnesses and therefore are not considered to be intervening variables. The instrument which measures health maintenance practices will assess for the existence of these risk factors. Additional demographic data, which determine familial generation, and/or geographical influence are potentially intervening variables. These variables are: birthplace, years of life spent there, years of life in Michigan, parents' birthplace, and grandparents' birth- place. Data pertaining to these variables will be collected and used to further describe the study sample. They may be particularly impor- tant in the Mexican-American sample. A Mexican-American individual whose parents were born in Mexico may possess health beliefs and prac- tices that are more ethnically influenced than a Mexican-American individual who is third generation American-born, and whose health beliefs and practices may reflect a more "Anglicized" perspective. For this reason, in addition to a description of study participants by these variables, health locus of control and health maintenance practices will be described by ethnic background and familial generation and/or geographical influences. For the purposes of this study, a native-born (Mexican) individual is defined by the following criteria: born in Mexico and lived there since age six or older. A first-generation (Mexican-American) individual is defined by the following criteria: born in the United States and parents and grandparents born in 16 Mexico; or born in Mexico but has lived in the United States since age six or younger. Age six has been selected as the cut-off because it is at this age that a child usually enters school, where his spheres of influence broaden. The input he receives is from a different perspective than that of his family. This input is a part of the socialization process, which provides a great range of influences to contribute to and impact the development of a belief system concerning health and illness. Second-generation (Mexican- American) is defined by: born in the United States, parents born in the United States, and grandparents born in Mexico. Third- generation (Mexican-American) is defined by: born in the United States, and parents and grandparents also born in the United States. In the event parents and/or grandparents are born in different countries, the study participant's birthplace and years of life in the United States will be the deciding factor. In the Black-American population, these demographic variables may illustrate differences between those who grew up in the south and those who grew up in the north. It is expected that there will not be great differences because of the constant flow of communica- tion and close kinship ties found in Black-American families who are geographically separated (Snow, 1979; Stack, 1974). For the pur- poses of this study, a Black-American individual with a southern influence on health beliefs and practices is defined by the follow- ing criteria: born in a state classified as south and lived in that state since age six or younger. A Black-American individual 17 with a northern influence on health beliefs and practices is defined by: born in a state classified as north and lived in that state since age six or younger. In the event an individual lived in his birthplace less than six years, years of life in Michigan and/or parents and grandparents birthplace will be the deciding factor. Limitations 1. (Racial prejudices and/or biases may be inferred by study participants. Because study participants are members of minority groups, they may feel that this research is an attempt to discredit their health beliefs and practices or an attempt to prove their health beliefs and practices are inferior as compared with the modern health care system. As a result, study participants may not answer items honestly, and may instead answer items as they believe they shggld, in accordance with the belief system of the modern health care system. 2. There will be no testing of knowledge about heart disease and its risk factors. Therefore answers may reflect study partici- pants' ethnic beliefs concerning the identified risk factors, as for example, the Black-American's conceptual confusion of "high blood" for high blood pressure. 3. This study reflects health maintenance practices as defined by the modern health care system. Questionnaire items will not dis- criminate practices that are ethnically influenced. For example, a Black—American may not have his blood pressure checked every year, but he may instead monitor his dietary intake so as to not eat too many "rich foods" and thereby avoid the possibility of "high blood". 18 4. Because it is well publicized that Black-Americans are at a greater risk and have a higher incidence of heart disease than any other segment of the population, Black-American study participants may be more motivated to engage in health maintenance practices related to the risk factors of heart disease. Their motivation may give them an advantage over Mexican-American study participants, an advantage which may be reflected in the scores of the health maintenance practices instrument. 5. The majority of study participants will be selected from those in attendance at a religious service. Whether or not they are regular church-goers or are members of the church will not be ascertained. Additionally the degree that religion is or is not an intervening variable affecting health behavior will not be explored. 6. There is no reliability established for the Health Main- tenance Practices measure, and because of the time constraints of this study, it will not be undertaken. 7. The reading/grade level of the Health Maintenance Practices measure is not known, and it is therefore not known whether the instrument is appropriate for this study's sample population. 8. Wallston et a1. (1978) assert that it is useless to measure health locus of control orientation without also measuring the value of health. However, the instrument they suggest to measure health value is considered to be inappropriate for this study population. Due to the scope of this study, health value will not be measured. 19 Assumptions l. One's ethnic background shapes or at least greatly influences health beliefs and practices during the socialization process of childhood, and the effects persist into adulthood. 2. Study participants will be capable of identifying the dominant ethnic influence in their lives. 3. In the event of a mixed parentage, study participants will be able to identify the predominant ethnic influence in their life. 4. Health behavior influenced by an ethnically influenced health belief system and health locus of control is amenable to nursing intervention. 5. Study participants all have the same exposure to mass media where awareness of the risk factors of heart disease is possible. 6. Ethnic health beliefs have a greater influence over health behavior than do other barriers commonly associated with low socio- economic status. 7. The identified health maintenance practices are all health behaviors which can be engaged in without having to enter the modern health care system. 8. Black-American study participants will be able to read and comprehend "proper" English, just as those Mexican-American study participants who choose a Spanish questionnaire will be able to read and comprehend "proper" Spanish. 20 Overview of the Chapters In this chapter an introduction to the study, statement of the problem, research questions, definition of terms, limitations, and assumptions have been presented. In Chapter II the study variables are developed into a conceptual framework to show their interrela- tionship and how they each contribute to self-care as described by Orem (1971). In the review of the literature, Chapter III, the sources of ideas relative to the research questions are documented, and the rationale for this study is further substantiated. The methodology and procedures utilized in this study are pre- sented in Chapter IV. Specifically, in this chapter, the population, settings, instruments, data collection procedures, scoring of data, procedures for data analysis, and human rights protection are pre- sented. Data describing the study sample and data pertaining to the research questions are presented in Chapter V. In Chapter VI, the summary and interpretation of findings are presented. Addi- tionally, incidental findings, limitations of results, implications for nursing, and recommendations for future research are presented. CHAPTER II CONCEPTUAL FRAMEWORK Overview In this chapter the variables ethnic background, health locus of control, and health maintenance practices related to the risk factors of heart disease will be presented. The major concepts that will be discussed are: the health belief systems of Mexican- Americans and Black-Americans, their impact on health locus of control as a derivation of social learning theory, and their influ- ence on health behavior and the risk factors of heart disease. These concepts will be developed into a conceptual framework to show their interrelationship and how they each contribute to self- care as described by Orem (1971). The conceptual framework will provide the foundation and rationale for this study (see Figure l). The Mexican-American Health Belief System Health and illness in the Mexican-American culture reflect a delicate social system and a strong religious orientation that dom- inates every facet of the Mexican-American way of life. "God ... is omnipotent", and the destiny of one's personal life is in His hands (Samora, 1978, p. 66). Because one's reward comes in the next world, the work in this world is to save one's soul by 21 22 .mmmmmmu game: we weapon» xmmc mg» on umpmpmc mmuwpumca mucmcmucwme gwpmm; co Pocpcou mo mzuop gopmm; use uczogmxumn upcgum mo uummmm mgh .mmmwmwc “gem; mo mcouumm xmwc as» 08 empaFme as: "we moH>HhHmom mo muz<=u Annamzom mmmmmwu acme; mo weapon» xmwc mg» on umuapwc as: "we mmmzho '\MHMW moH>Hhmsmn sppmm; uumgvvmc op onHzm>mmth wszmzz Pocucou mo made; zapmm: .F mczmwd ucaocmxumm uwccpm 23 unquestioningly complying with God's will. It is "a life of sub- mission and acceptance" (Baca, 1969; Samora, 1978). Samora con- siders this attitude not only a fatalistic conception of life, but "a defeatist conception, suggesting that there is little, if any- thing, that one can do about the course of life's events" (p. 67). Beliefs concerning health are not precluded from this dominating influence. The Mexican-American's perception of good health is best under— stood by considering the meaning of illness. Illness is classified by its etiology rather than by its symptoms. A "good" or "natural" illness is the consequence of upsetting the balance of the natural world regulated by God. Health is reinstated by rectifying the dis- turbed balance. A I'bad" illness, or "mal puesto", is the consequence of a bewitchment sent by human adversaries employing Satanic forces. "Mal puesto" is cured by countermagic or by removing the source of harm (Madsen, 1973; Rubel, 1966). In discussing "natural illness", Madsen (1973) writes that "a harmonious relationship between the natural and supernatural is considered essential to human health and welfare, while disharmony precipitates illness and misfortune" (p. 70). Disharmony may result from: (1) an improper functioning of one's body; (2) hostility between individuals or families; or (3) those "unseen forces" known as germs (Rubel, 1966). Illness is perceived as a misfortune sent 'by God, a misfortune that is seen in the same light as an automobile accident or the loss of a job. God may also send illness because "things were going well for us" (Rubel, 1966), implying that to 24 "succeed is to fail" (Lucero, 1979), a failure that is accepted as God's will. The concept of the humoral theory of disease is inherent in maintaining harmony and proper functioning of one's body. It stems from the Hippocratic belief system whereby a proper balance of the bodily humors (blood, phlegm, black bile, and yellow bile) is neces- sary for good health. Each humor has a quality of hot or cold, and wet or dry. Folk medical beliefs and practices* today are mainly concerned with the hot-cold dichotomy and with blood as a hot bodily humor. A healthy body is conceived of as a temperate blend of hot and cold substances, and illness is the result Of an excess of heat or cold in the body (Clark, 1959; Currier, 1969; Foster, 1978; Lucero, 1979; Madsen, 1973; Rubel, 1960, 1966; Snow, 1974). The hot-cold dichotomy is also used to classify foods, beverages, herbs, and medicines. The mode of classification is not necessarily rele- vant to the thermal state of the substance, but rather to its effect on the body. A hot illness is treated with a cold substance. Like- wise, a cold illness is treated with a hot substance so that the correct balance may be restored and health again attained (Clark, 1959; Currier, 1969; Foster, 1978; Rubel, 1960; and Snow, 1974). Natural illness may also result from disharmony between individuals and families. Strong emotions, such as anger or depression, can upset the balance of the bodily humors and produce * The term folk medicine is used here in contrast to scientific medicine practiced by the American health care system. 25 abnormal temperatures within the body. Especially important here are the humors choler, the yellow bile of anger, and melancholia, the black bile of depression (Clark, 1959; Madsen, 1973; Rubel, 1966). Women and children are especially susceptible to the emotions of others because they are weaker than males (Madsen, 1973). Pregnancy is a time of danger for the unborn infant because he is so easily influenced by his mother's experiences. Cultural prescrip- tions define a woman's thoughts, emotions, and behavior during pregnancy in order to maintain harmony with the natural and super- natural and ensure a well and normal infant (Clark, 1959; Madsen, 1973; Snow & Johnson, 1977). Health maintenance practices are designed to protect the "delicate balance" of infants who "lack physical and spiritual adjustment to life“ and to prevent the incidence of folk diseases that are more likely to occur in this population. For example, "mal de ojo", or "evil eye", is the result of an individual possessing "strong vision" or "strong power" over weaker individuals. Madsen (1973) writes that "mal de ojo" is a reflection of envy, a strong emotion in the Mexican-American culture. The force of the evil eye is projected unintentionally onto another by excessive admiration or attention. The harmful force of the evil eye can be removed by touching the child who has been admired, thereby preventing "mal de ojo" and maintaining health (Clark, 1959; Lucero, 1979; Madsen, 1973; Rubel, 1960, 1966). Thus, there are health maintenance practices that the Mexican- American can engage in to avoid the illnesses which fall into this 26 category. However, since these folk diseases are more likely to occur in women and children, the health behavior is prescribed for them. There was no documentation found in the literature regarding health maintenance practices that are specifically engaged in by men with regard to this particular category of illness. Another source of a natural illness sent by God is immoral behavior which causes disharmony between an individual and his social and spiritual environment. Risk-taking and engaging in "stupid" behavior may be followed by a "good" illness, as for example, a broken leg resulting from an automobile accident where the individual was driving recklessly (Rubel, 1966). According to the theories of folk medicine, natural disease results from either a willful or an unconscious disruption of the balance of God's world. Thus, the Mexican-American is cautioned to control his emotions and behavior as culturally prescribed in order to maintain harmony with the natural and the supernatural and thereby ensure good health (Madsen, 1973; Rubel, 1966; Spector, 1979). An unnatural illness, known as "mal puesto", is perceived as a "product of undue influence one individual exercises over another" (Rubel, 1966, p. 155). "Satanic forces" or witchcraft is employed against an enemy. It is used by someone outside the nuclear family, and the recipient is considered to be victimized. Bewitch- ment may be in the form of illness or other instances of misfortune. The circumstances which may lead a person to use witchcraft are: a strife in interpersonal relations, a spat between lovers, an 27 unrequited affair, or strong jealousy between families (Madsen, 1973; Rubel, 1966). Envy of material gains is the most common motive, and fear of bewitchment is most evident among lower-middle class Mexican-Americans who have followed the Anglo goal of economic advancement (Madsen, 1973). "Mal puesto" clearly reflects the tenacity of social relationships within the Mexican-American culture. Rubel (1966) writes that "mal puesto" functions as a "social device by means of which members of one household perceive others outside it as attempting to influence and sanction their behavior" (p. 171). It is mentioned here as part of the Mexican—American belief system of health and illness because there really is no clear distinction between an illness of a natural etiology and one which is unnaturally induced by witchcraft except when the concept of chronicity is introduced. That is, the origin of an illness may change during its course, so that the longer the duration of the illness, the more likely it is to be diagnosed as "mal puesto". Therefore any illness not responding to folk or scientific treatment is clearly in the realm of witchcraft, and the use of countermagic is indicated as the mode of treatment (Madsen, 1973; Rubel, 1966). The implication for health professionals who deliver health care to Mexican-American clients with chronic illnesses is clear, and is especially relevant to this study. Since the identified risk factors of heart disease are either themselves chronic illnesses or are precursors to heart disease, alternative modes of treatment such as countermagic that may be utilized by Mexican-American individuals must be recognized and dealt with by health professionals. The 28 belief that a chronic illness is due to witchcraft will result in health practices not recognized by the modern health care system. These beliefs and practices may or may not affect the degree to which health maintenance practices endorsed by the modern health care system are practiced. Belief in witchcraft and countermagic may additionally determine the degree of compliance with prescribed treatments. It is important, therefore, for health professionals to be cognizant of these ethnically influenced health beliefs and their impact on health maintenance practices related to the preven- tion of chronic illness, particularly with regard to the risk factors of heart disease. There are several alternatives available to the Mexican- American for treatment of natural illnesses. The female of the family represents the first level in the lay referral system, where the knowledge of health maintenance and curing of mild illness is a primary responsibility of the woman's role (Madsen, 1973; Rubel, 1966). The second avenue is the neighborhood healer, or folk curer, a member of the community who is considered a specialist because "(they) have learned more of the popular medical lore of their culture" than have others (Clark, 1959). Neighborhood healers are consulted after the efforts of the family resources are shown to be ineffective (Kay, 1977; Rubel, 1966). They have more experience and especially know how to cure folk diseases such as "mal de ojo". The third alternative is the "curandero" ("curandera") who obtains his (her) ability to "appease the spirits" and heal as a special 29 gift from God. An individual who is the recipient of a "divine election" is "chosen by God to help the sick" and the calling is not to be ignored (Baca, 1969; Madsen, 1973; Rubel, 1966; Samora, 1978; Spector, 1979). The curandero is also consulted for health mainten- ance, as the prescribed treatments that are congruent with nature will assure one of a long life, free of illness (Dorsey & Jackson, 1976). The fourth recourse the Mexican-American has to choose from is the physician, who is slowly gaining acceptance in the Mexican- American culture (Rubel, 1966; Madsen, 1973; Kay, 1977). Thus, the Mexican-American may shop around and go from one level of healer to another. If one is ill, it is wise to take every possible precaution including natural and supernatural approaches, as it is "the cure that is important, by what means or by whom is purely academic" (Rubel, 1966, p. 175). However, from whatever class of healer the Mexican-American chooses, the success or failure of the cure is dependent upon God's will. Prayers to the saints, Masses, or pilgrimages are made on behalf of the ill person (Clark, 1959; Kay, 1977; Madsen, 1973; Rubel, 1966; Samora, 1978; Spector, 1979). Rubel (1966) writes that "God . . . is final arbitrator of sickness and health, life and death . . ." (p. 199). The Mexican-American is caught in a conflict between the scientific theories of modern medicine and the supernatural theories of folk medicine. There is an increasing reliance on the modern health care system for illness recognized by both folk and scientific medicine. For example, "fallen fontanel", or depression of the 30 anterior fontanelle of an infant, is thought to be caused by the infant falling, and symptoms are crying, fever, vomiting, and diarrhea. Kay's (1977) informants are noting that physicians correlate these symptoms with dehydration, so now Mexican-Americans are beginning to use the term "lack of water" as synonymous with "fallen fontanel". However, illnesses recognized only by folk medicine are still very much a part of the Mexican-American belief system, as for example "mal de ojo" where the essence of cure is to re-establish the dis- turbed balance of the patient. The modern medical system's denial of the existence of such illness is seen as proof that physicians have limited knowledge (Madsen, 1973; Rubel, 1966). Madsen (1973) states that much of the resistance to scientific medicine results from rejection of the germ theory of disease. Because germs, or "animalitos" cannot be visualized, it is difficult for Mexican-Americans to believe in their existence. They are thought to be an "invention dreamed up by Anglo doctors to dupe the people" (Madsen, 1973, p. 74). However, the germ theory of disease is slowly gaining credibility as a consequence of the effectiveness of over-the-counter drugs, public health education, and public school education. The major incentive for acceptance is that some curanderos attribute some diseases to germs, and will even prescribe injections of antibiotics for their patients. The quick relief brought about by the injections carries a lot of weight with the Mexican-American (Madsen, 1973). 31 Thus, Mexican-Americans will utilize both health care systems simultaneously. The survival of the folk health culture is due to its success in achieving cures for illness and the recognition that health is a valuable commodity worth preserving (Dorsey and Jackson, 1976). The curandero's success is attributable to the fact that he is an "established pillar" in the community who possesses first hand knowledge of lifestyles, family relationships, and ethnically influenced health beliefs and practices. As Dorsey and Jackson (1976) assert, the present health care delivery system does not offer health care that "is comprehensive, relative to their needs, or sensitive to their culture or economic situation" (p. 70). For the Mexican-American, the curandero provides the individualistic health care that the modern health care system does not. Addition- ally, because the curandero is successful in maintaining health and curing disease, Mexican-Americans have a lot of faith in his abil- ities, which is a prime motivator for seeking out his services (Dorsey & Jackson, 1976). The Mexican—American's adherence to the folk health care system has also been attributed to the degree of acculturation into the dominant society. Clark (1959) and Saunders (1954) argue that the Mexican-American's utilization of the folk health care system is significantly related to a commitment to their own cultural beliefs and values. Madsen (1973) states that the extent of belief in super- natural diseases depends upon the degree of anglicization, and that further, the concept of illness as a punishment from God is most 32 resistant to change. He further argues that social class has an affect on the utilization of the folk health system, an assertion supported by Snow (1978). Madsen's observations are that the lower class depends most heavily on the services of the curandero, the lower middle class portrays some skepticism toward folk medicine but utilizes it along with modern medicine, and the upper middle class visits a physician to gain prestige and concurrently relies on prayers as an essential element of cure. The upper class depends entirely upon physicians and prayer. Both of the latter classes will, however, consult a faith healer as a last resort and in an extreme situation, such as a chronic illness. Dorsey and Jackson (1976) disagree with Madsen's position. They state that the Mexican-American will utilize the folk health system endorsed by his ethnic background by choice. They argue that the degree of anglicization is irrelevant because no matter how angli- cized he is, the Mexican-American will still retain the beliefs passed on to him by his ethnic group. Dorsey and Jackson admit that due to the influence of the dominant society's germ theory of disease, acculturated Mexican-Americans will ridicule the folk health belief system and deny its existence. But social class has not yet been proven to be a barrier to the use of the curandero. Whether or not the Mexican-American folk health belief tran- scends social class, the fact remains that the system does exist, and it is practiced. Health practitioners in the modern health care system must recognize and respect this alternative health belief system and study its effect on health behavior. Because Madsen 33 (1973), Snow (1978), and Dorsey and Jackson (1976) have not yet reached a consensus about the impact of social class on the reten- tion of ethnically influenced health beliefs and practices, this variable will be held constant in this study so that only those in social class III, IV or V as defined by Hollingshead (1957) will participate. At least it is agreed upon by all the authors cited above that the health behavior engaged in by those in lower social classes is influenced by the folk health belief system. Family generation and familial practices may also have an impact on the utilization of the folk health care system. The Mexican-American family is a strong social unit with an extended family network. Family interaction is guided by clearly defined role behavior which stresses respect and obedience to elders and male dominance (Madsen, 1973; Rubel, 1966). Dorsey and Jackson (1976) assert that the family unit is not a static system in that it does respond to societal change. For example, an individual born outside of his country of origin often is not as familiar with the traditions, beliefs and customs of his ethnic background. However, if the family and significant others adhere to the folk health belief system, the individual is more likely to practice it. This study will attempt to gain a perspective of the impact that family gener- ation has on the Mexican-American health belief system by collecting appropriate demographic data. Credit for a cure produced by modern medicine is often attrib- uted to folk medical treatments that preceded, accompanied, or fol- lowed scientific treatment (Madsen, 1973). Rubel (1966) states that: 34 the unusual acclaim awarded each victory of a tradi- tional means of healing can be understood as an effort to validate the worth of the Mexican-American culture in the face of constant and severe criticism by Anglos, especially in the area of health-related beliefs and behavior. Each victory . . . is a validation of the Mexican-American way of life (p. 195). In summary, the health belief system of the Mexican-American has its roots in Indian, Latin-American, European, and Spanish influences (Dorsey & Jackson, 1976). Health is viewed holistically as a state of equilibrium, where a person is seen as "a being whose health and welfare are guided by the maintenance of a balance between the natural and supernatural. A loss of this equilibrium is considered a basis for illness, emotional, physical or mental" (Dorsey & Jackson, 1976, p. 54). Equilibrium and health is maintained by eating the proper foods, working the proper amount of time, and performing in the proper way. Additional measures undertaken to maintain good health are prayer, the wearing of religious medals or amulets, using appropriate herbs and spices, and demonstrating exemplary behavior (Dorsey & Jackson, 1976; Spector, 1979). Good health is a condition for the day, and is equated with "the state of being free of pain, of being able to perform one's activities, of being normal" (Baca, 1969, p. 92). Spector (1979) has commented on the conflicting reports regarding the authority base for hood health. Good health has been noted to be the result of good luck. One will lose his good health if his luck changes (Spector, 1979). From this perspective good health is looked upon as "a matter of chance, with little that one can do about it" (Baca, 1969; Samora, 1978). On the other hand, 35 good health is perceived as a reward for good behavior, a gift from God which should not be taken for granted (Spector, 1979). The health behaviors which are an integral part of the Mexican-American lifestyle are seen only as precautionary measures to maintain health and prevent illness. They are not considered absolute or guaranteed to be effective since good health is a blessing from God (Baca, 1969; Spector, 1979). Thus, the theories of preventive medicine which modern medicine ascribes to are not understood and are resisted because one cannot prevent a natural occurrence sent by the will of God (Baca, 1969; Madsen, 1973; Samora, 1978). It is clear that Mexican-Americans possess a distinct knowledge base regarding health and health behavior. It is important to note that in spite of the fact that a fatalistic thread runs through their perception of good health, Mexican-Americans still engage in health behavior designed to protect their health and prevent illness. Some of this health behavior is in conflict with that suscribed to by the modern health care system. One aspect of the Mexican-American health belief system worth emphasizing is the presence of the curandero or folk healer as a member of the community's referral system. His influence with the Mexican-American community is a potential resource to be tapped when providing health care to this ethnic group who has its distinct "health culture". Of particular interest to this study is the belief that chronic illness is the result of witchcraft. Health maintenance practices related to the risk factors of heart disease may reflect this perspective. However, the literature is devoid of evidence which specifically documents 36 the Mexican-American's health practices related to the risk factors of heart disease. It is hoped that this study will provide some insight into the influence of the Mexican-American health belief system on their health maintenance practices related to the risk factors of heart disease. The Black-American Health Belief System Health and illness in the Black-American culture reflects the cultural perceptions that the world is a dangerous and chaotic place, that an individual is susceptible to attack, and that external resources must be employed to ward off the attack since the individ- ual possesses no internal resources (Rainwater, 1970; Snow, 1977, 1974). The attacking force for man as a "child of nature" is nature's elements; for man as a "child of God", it is divine punish- ment; and for man as a social animal, the danger lies with exploita- tion by others in the form of witchcraft (Snow, 1974, 1977). The theme of "everyone and everything is out to get you“ dom- inates day to day life, including health beliefs. For the Black- American this theme may be understood in light of the racial oppres- sion, social subordination, and economic marginality prevailing in his life (Abrahams, 1970; Rainwater, 1970). Life is seen as a hustle, where there is a constant need to compete and manipulate events in order to cope and survive (Abrahams, 1970; Snow, 1974, 1977). "The one who does best is the one who manipulates the most and is manipulated the least" (Abrahams, 1970, p. 19). Rainwater (1970) states that this attitude even extends to peers, where life 37 teaches one that his peers are "dangerous, difficult, and out to exploit him or hurt him . . ." Ninety-one percent of his study sample agreed with the statement, "It's not good to let your friends know everything about your life because they may take advantage of you" (p. 69). Seventy percent agreed that this statement referred to one's relatives as well. One learns at a young age to ”go for himself" as no one else will. This attitude is based on the fact that all community members are in the same financial constraint, and there isn't enough to go around for everyone (Snow, 1978). The Black-American is thus confronted with "a world full of dangers--not just the physical dangers . . . but also the interpersonal and moral dangers of his exploitative milieu" (Rainwater, 1970, p. 371- 372). The manipulation of events that is necessary to survive applies as well to the realm of health and illness. Here man is seen as a victim in the conflict between the natural and the unnatural. The natural represents the world as God intended it to be. The unnatural represents a disruption of the natural laws and is therefore dangerous and evil. Health is classified as a natural phenomena; illness may be either natural or unnatural depending on its etiology. Harmony with the forces of nature is necessary for good health. Each indi- vidual is responsible for knowing the natural laws and manipulating events to ensure good health (Jacques, 1976; Snow, 1974, 1977; Spector, 1979). Snow (1977) writes that this belief system is especially punitive in that even though "everyone and everything is out to get you", if misfortune or illness does occur it is the fault 38 of the individual for not behaving as culturally prescribed and obeying the laws of nature, God, and society. Health for man as a "child of nature" is formulated on the premise that everything in nature is linked together. To maintain harmony with nature and prevent natural illness one must understand the direct linkage between the body and natural phenomena. The belief is that the body is affected by such natural phenomena as the phases of the moon and the time of the year. Man, as a part of nature, should be able to read the "signs" surrounding these observ- able phenomena and thereby maintain good health. For example, the zodiac signs and the farmer's almanac are utilized to determine such health practices as the best time to have surgery or to wean a baby. The use of these external resources thus preserves harmony with the forces of nature (Snow, 1974, 1977). The concept of sympathetic magic also demonstrates the linkage relationship between the body and natural phenomena, and it affects health related beliefs and practices. There are two types of sympa- thetic magic: imitative and contagious. Imitative magic is based on the premise that like follows like. The individual imitates the effect wanted, as for example, by placing a sharp object under the bed to "cut" labor pains (Snow, 1974, 1977; Winslow, 1969). Con- tagious magic is based on the assumption that a part stands for the whole. An example here is that a clipping of hair represents the I whole person, so that what is done to the hair is done to the person. Contagious magic plays a major role in witchcraft (Snow, 1974, 1977; Winslow, 1969). 39 Knowledge of the body and its functioning is another means to maintain harmony between nature and man. The concept of the humoral theory of disease also plays a role in the health belief system of the Black-American. Good health depends upon the humors and their properties of hot or cold, and wet or dry, remaining in balance. Illness results from an imbalance of the bodily humors. Treatment consists of restoring the imbalance with the appropriate hot or cold food, beverage, herb, or medication. Phlegm and blood are the humors of importance in the folk medical beliefs and practices of Black-Americans (Snow, 1974, 1977). Phlegm, or "slime", is cold and wet, and its presence is a measure of uncleanliness. Cold damp air is always dangerous as it produces an excess amount of cold, wet phlegm, upsetting the body's natural balance. The presence of phlegm, so often associated with upper respiratory infections, is a positive indication that too much cold is present within the body. Its entrance into the body was the most frequently mentioned cause of illness by Snow's informants regardless of age, sex, or education (Snow, 1977). The individual is to blame because he did not engage in the appropriate health behavior, that is, he exposed himself to the cold, provided a route of entry for the cold damp air, and didn't use "mother wit" and protect his body by wearing warm clothing (Snow, 1974, 1977). Blood as a hot, dry bodily humor receives the most consideration for the maintenance of good health. The status of the blood reflects the status of the body system. It is continually changing, responding 40 to the internal stimulus of dietary intake and the external stimulus of the natural phenomena (Snow, 1974, 1977). Dietary practices influence the volume of blood. Following the principles of imitative magic, foods which will increase the amount of blood are rich and red, such as red meat, grape juice, and beets. Foods which will decrease the amount of blood are astringent sub- stances which open pores and promote the excretion of blood through sweating, such as vinegar, lemon juice, epsom salts, or the brine from pickles or olives. The extremes of "high blood" and "low blood" are dangerous, and are treated by manipulating the diet. For example, an individual acquires "high blood" by eating too many rich foods; treatment consists of eating astringent substances (Snow, 1974, 1976, 1977). Knowledge of the Black-American's dietary beliefs and practices is of particular interest to this study because of the effect that dietary practices have on the risk factors of heart disease. Natural phenomena influence the generation of blood, its cir- culation, and its viscosity. Health regimens reflect the effect of natural phenomena on blood. For example, it is believed that blood thickens in the winter to keep the body warm, and thins out during warmer weather. The body is filled with impurities which are carried throughout the system by blood. During the winter the impurities sink in the body and are inactive until spring, at which time "the sap is rising and impurities start rising too" (Snow, 1974, 1977). Spring is a time to "clean up" as advised by the farmer's almanac. Health maintenance practices are "based on the premise that the body 41 is about to come back to life and had better be purified, oiled, and generally tuned up" (Snow, 1974). Similar to the literature on health behavior in the Mexican- American ethnic group, the available resources on the Black-American health belief system pertain especially to health behavior engaged in by women and children. Strengths and weaknesses during the life cycle are factors which have an impact on health maintenance prac- tices. Because women are weaker than men, they are particularly susceptible to disease at those times associated with reproductive functions (Snow, 1974, 1977). For example, menstruation is another natural process by which the body rids itself of the impurities that might otherwise cause illness. However, because the uterus is believed to be opened during menstruation, there exists the pos- sibility that cold may enter the body, stop the natural flow, and cause the menstrual fluid to back up to the brain to cause "quick TB" or a stroke. A woman who is menstruating represents destruction, infertility, and death. Thus there are cultural taboos to protect herself and to protect others and the environment from her (Snow, 1974, 1977; Snow & Johnson, 1977). Because good health is associated with harmony and balance. susceptibility to illness is present with extremes. Therefore, weakness in the life cycle is also correlated with age. Babies and children have "thinner blood" and are weaker than adults. The unborn infant is the weakest of all because he is so easily influ- enced by his mother's experience. Ethnically influenced prescrip- tions define a pregnant woman's behavior, thoughts and emotions in 42 order to maintain the natural harmony within the body. The elderly is another segment of the population at risk for ill-health. They have "thinner blood", and their bodies are weak. It is at this age that an individual experiences the consequences of his health behavior during his younger years if he did not use "mother wit" and take care of himself. For example, the explanation for the degenerative bone diseasesrafthe elderly is that cold enters the body when it is young, settles into its joints, and begins "to work with the body" when it is weak to produce "rheumatism" (Snow, 1974, 1977). To live a long life is proof that one lived by the proper habits endorsed by his ethnic background (Jacques, 1976). Man as a "child of God" has a spiritual component of his being that precludes separating health beliefs from religious beliefs. There is therefore a religious explanation for health and illness. Here a stern and punishing God is seen in the same light as a stern and punishing parent who is strict because he loves his child and wants to make sure the child is "raised properly". God may send illness as "divine punishment" for misbehavior. "So many times the Lord get vexed with us when we do things. Like sickness I would say sometimes is a whup to us, just like whuppin' a child . . ." (Snow, 1974, p. 84). Natural illness in the form of "divine punishment" is the individual's own fault because he did not obey God's rules which serve to keep the soul from sin and the body healthy. The possession and flaunting of material goods without sharing them and "thinking you're better than others" are sinful behaviors punishable by God. This type of illness cannot be cured by medical doctors 43 because they do not know how to drive the sin out of the body. Prayer and faith in God is the treatment modality by which harmony with God is re-established and health regained (Snow, 1974, 1977). Just as man is a victim in the conflict between the forces of nature, he is also affected by the ongoing conflict between the forces of good and the forces of evil (Dorson, 1971; Jacques, 1976; Snow, 1974, 1977; Spector, 1979). These external forces are con- tinuously working on man's spirit, which cannot differentiate the good from the bad without the help and protection of God. If behavior is especially bad, God will withdraw His protection, leaving the individual susceptible to evil and influences and an unnatural illness (Snow, 1974, 1977). The greatest danger lies with the health of man as a social animal. The Black-American's perception of an exploitative environ- ment is present in his health belief system in the concept of witchcraft. Exploitation is the principle underlying witchcraft, also known as "rootwork", "hoodoo", and "voodoo". The belief is that there are persons who have an ability to utilize unusual powers, often evil forces, to control the behavior of others. Witchcraft is often utilized by someone from within the family or immediate social net- work, and the recipient is said to be victimized. Bewitchment may be in the form of illness or other instances of misfortune. The illness is an unnatural one because it's etiology is unnatural. The circumstances which most often lead a person to use witchcraft are 44 sexual jealousy and envy (Dorson, 1971; Rocereto, 1973; Snow, 1974, 1977; Whitten, 1973; Wintrob, 1973). Snow (1974) writes that "there is no more graphic example of personal inadequacy and the deep distrust and ambivalence that many feel in their social ties" (p. 87). Wintrob (1973) believes that the essential element of "rootwork" is the belief of the victim that he is under "a spell". Rocereto (1973) reports that she has personally cared for patients who believed they were such victims of "rootwork". They experienced vomiting, profuse perspiration, convulsive movements, muscle weak- ness, and paralysis with no organic etiology and no relief from medical or nursing treatment. In fact, one of the chief symptoms of rootwork is that the more the individual goes to a doctor the worse he gets. The necessary mode of treatment is the removal of the rootwork by a "conjureman" (Rocereto, 1973; Snow, 1974, 1977; Spector, 1979; Wintrob, 1973). One explanation given for the belief in "rootwork" is that it is a mechanism by which groups explain societal forces over which they have no control (Snow, 1974, 1977; Winslow, 1969). Relative to the Black-American belief system of health and illness, "root- work" explains illnesses which are not logically explainable (Rocereto, 1973). All illnesses are believed to be curable, a belief based on the premise that "everything has its opposite", as for instance: "for every birth there is a death, every illness has its cure . . . in every herb a healing purpose" (Snow, 1974, p. 84). 45 Therefore, Black-Americans do not understand or accept chronic ill- ness as defined by the modern health care system. For a disease which the medical doctor labels as "chronic" with no known cure, the Black-American may manipulate events and try another herb or medi- cine, find another doctor, and pray harder. If all this fails, the disease is clearly the result of evildoing by an enemy, or witch- craft (Snow, 1974, 1977). These beliefs are of particular relevance to this study since the identified risk factors of heart disease are either themselves chronic illnesses or are precursors to heart disease, a chronic ill- ness. Firstly, high blood pressure is conceptually confused with "high blood". The folk treatment“finrhypertension follows the belief that "everything has its opposite". It therefore makes no sense to the Black-American with hypertension to be told he will have to take medication for the rest of his life when he believes that the treat- ment of choice for his "high blood" is to manipulate his diet and eat such "low blood" foods as lemons, vinegar, epsom salts, or the brine from pickles or olives. This practice is obviously at odds with that endorsed by the modern health care system where the treat- ment modality for hypertension is to eliminate foods that are high in sodium from the diet. Secondly, the belief that chronic illness is due to witchcraft implies that Black-Americans engage in health behaviors that are unknown to health professionals. These beliefs and practices may affect the degree to which health maintenance practices (adhered to by the dominant society) are followed, espe- cially after the concept of time has been introduced. That is, 46 the Black-American may try the medical treatment, but if after a period of time when he sees that he still has the chronic illness, his health behavior may reflect the folk medical treatment and be directed toward countermagic. It is important, therefore, for health professionals to study the impact that ethnically influenced health beliefs and practices have on the Black-American's health maintenance practices related to the risk factors of heart disease. There are several external resources available to the Black- American for treatment of illnesses. The same natural, religious, and unnatural elements present in beliefs about illness etiology also exist in the classification of healers. The power to heal is a gift from God, and the types of illnesses one can heal depends upon the degree of that power. The first level of healer is the individual who has learned his trade from another. In this category is the housewife who was taught home remedies by her grandmother, and the doctor who was taught medicine by health professionals. This healer has knowledge as his power source and can cure illnesses caused by the forces of nature. The next class of healer "gets the call" or "the gift of healing is put into the hands" by God during a religious experience. The power source here is a "spirit-helper", and the curing tech- niques are prayer and "laying on of hands". All natural illnesses are in the realm of this healer's ability, including those of “divine punishment". The third and most powerful type of healer is that individual born with the gift of healing. This healer has special powers, a "sign of God's highest approval", and can cure 47 natural and unnatural diseases. He clearly surpasses the power of the medical doctor (Snow, 1974, 1977; Spector, 1979). Thus, the decision of which type of healer to consult depends upon the etiology of the disease. It is not unusual to seek help from more than one type of healer at the same time. No matter which external resources are utilized, prayer and faith are vital elements in the search for a cure (Snow, 1977; Spector, 1979). “God, of course, is ultimately responsible for all cures . . ." (Snow, 1977, p. 79). The Black-American's perception of a dangerous, exploitative world contributes to his hostility toward the modern medical system, where it is not surprising to find that "feelings of mistrust run deep" (Stack, 1974). For the Black-American, the medical doctor is in the same class of healer as the housewife or the herb doctor who has learned his trade from another. Yet, the medical doctor charges exorbitant prices, and it is therefore believed that the doctor is only interested in making money rather than helping his clients. Because herbs and medicines which were once available over-the- counter are now chemically produced and require a prescription, there is a fear of not really knowing what is in them. It is also believed that the pharmacist is in collaboration with the physician to take more money from the people (Snow, 1974, 1977). Rocereto (1973) notes that fear of ridicule of the folk medical belief system is another inhibiting factor in the non-utilization of the modern health care system. 48 For the Black-American, “receiving health care is all too often a degrading and humiliating experience" (Spector, 1979, p. 240). Racism is still very much in existence in the modern health care system (Spector, 1979; Jacques, 1976). The Black-American continues to be viewed as someone beneath the white health care provider. This form of discrimination is experienced by Black-Americans rather than seen overtly. "It is not a secret among the people of the Black community . . . (that they) are the 'material' on whom students learn and practice and on whom research is done" (Spector, 1979, p. 240). The reasons are obvious, then, why the Black-American's attitude toward modern health care practitioners reflect a type of "survival strategy" (Jacques, 1976, p. 120). The endurance of the folk health care system is a survival strategy that dates back to the post-slavery era, when because of racial discrimination, inaccessibility, and the high cost of health care Black-Americans utilized home remedies and the services of the healer to maintain health (Jacques, 1976). The belief in the power of an individual to heal is reflective of a deep religious faith (Spector, 1979). The church has traditionally held a major role in the Black-American community. It is considered an institution of health, education, welfare and political activity. One of its most enduring traditions is in the form of religious healing where the casting out of devils is vital to health maintenance and cure of disease (Jacques, 1976). Spector (1979) notes that there is no class or status distinctions in the use of folk healer. The Black- 49 American has faith in the practices of the healer because his methods have been "tried and tested", and because the Black-American believes in them. Of vital importance is the relationship between the healer and his client, a relationship of mutual caring and respect (Jacques, 1976; Spector, 1979). The folk health belief system thus provides the Black-American with what the modern health care system does not. As Spector (1979) points out, "the historic problems of the Black- American community need to be appreciated by the health care pro- vider who wants to juxtapose modern practices in the content of some of the traditional health and illness beliefs" (p. 230). In summary, the Black-American health belief system reflects African, Native Indian American and White American influences (Jacques, 1976; Spector, 1979). The foundations of their beliefs of health and illness are "grounded in the African's beliefs about life and the nature of living", where life is a process rather than a state (Jacques, 1976, p. 115). Because one's nature possesses an "energy force", all things, living and dead, are believed to influ- ence each other. Therefore, through the correct knowledge and behavior one can control or at least influence his destiny (Jacques, 1976). Good health to the Black-American encompasses the physical, emotional, and spiritual aspects of his being. (It is important to note that the spiritual aspect of health is not known in the modern health care system.) Health implies a state of harmony between an individual and others in his environment. The concept of wellness 50 is related to an ability to labor productively. Illness is loss of self, a sense of disharmony with one's soul which may be expressed physically, socially, emotionally, or spiritually (Jacques, 1976; Spector, 1979; Snow, 1974). The attainment and maintenance of good health is dependent upon obeying the laws of nature, God, and society, and manipulating events to avoid being caught in the ongoing conflict between these external forces. The theme that present carelessness can cause future illness is conducive to positive health behavior. A life of moderation promotes good health. Brunswick (1972) reports that 90 percent of Black adolescents in Harlem believe that good health depends mostly upon "looking after yourself". Cowles and Polgar (1963) found that regardless of socio-economic status Black-Americans practice such measures as cleanliness, moderation in diet, exercise and sleep, and avoidance of exposure to keep healthy. Snow's (1977) informants participate in a series of purification rites each spring for nine days to clean out the impurities in the body and “lubricate the system". Rocereto (1973) even reports preventive measures for witchcraft: "My folks always taught us to be aware of conjure people . . . but to recognize that we could lick their spells by proper eating, proper rest, and healthy thinking" (p. 418-419). The medical doctor is not routinely consulted or considered to be the person to go to for health maintenance and prevention of disease. Rather the folk healer, who has extensive knowledge of "materia medica", i.e. the use of roots, minerals and plants in the treatment 51 of illness and maintenance of health, is the authority figure in the Black-American community (Jacques, 1976; Spector, 1979). It is clear then, that like Mexican-Americans, Black-Americans possess a distinct knowledge base regarding health and health behavior. It is important to note that in spite of the themes of exploitation and mistrust which dominate their health belief system, Black-Americans still engage in health behavior designed to protect their health and prevent illness. Some of this health behavior is not congruent with that held by the modern health care system. There are several aspects worth emphasizing. The first is the prominent role played by the religious healer in the Black-American health belief system. His intimate knowledge of health behavior and his influence within the community is a poten- tial resource to be tapped when providing health care to this ethnic group who has its distinct "health culture". The second issue that has particular relevance for this study is the Black-American's conceptual confusion of "high blood" for high blood pressure and the folk treatment for its cure. This confusion may very well affect the health maintenance practices related to this risk factor of heart disease. The last point to stress is the belief that chronic illness is the result of witchcraft. Health maintenance practices related to the risk factors of heart disease may reflect this per- spective. However, With the exception of that pertaining to hyper- tension, the literature is devoid of evidence which specifically documents the Black-American's health practices related to the risk factors of heart disease. It is hoped that this study will provide 52 some insight into the influence of the Black-American health belief system on their health maintenance practices related to the risk factors of heart disease. For the purposes of this study, an ethnic health belief system is defined as the attitudes, values, and beliefs which affect health behavior in a way that is distinguishable from other segments of a society (see Figure l). The operational definition of ethnic background is the self-identification by study participants of the predominant ethnic influence in their life as either Mexican- American or Black-American. In the case of a mixed parentage, it is assumed that study participants will be able to identify the predominant ethnic influence in their life. This assumption is supported by Dorson (1971) who states that "ethnic traditions don't blend in a mixed marriage but either cancel each other out or result in one triumphing" (p. 47). The health belief systems of Mexican-Americans and Black- Americans have been described. Issues that have particular relevance for this study have been pointed out, as for instance, the impact that social class and familial generation has on one's ethnically influenced health behavior. The rationale for the control of social class and the collection of certain demographic data in this study has been established. It has been noted that for both ethnic back- grounds beliefs concerning the etiology of chronic illness are at variance with those held by the modern health care system. The lack of literature relative to health behavior related to the risk factors 53 of heart disease has also been noted, again in preparation for the establishment of the rationale for this study. The concept of health locus of control will now be discussed. The relationship will be drawn between health locus of control and the ethnically influ- enced health belief systems that have been described. In this way the conceptual framework for this study will be further developed. Health Locus of Control The locus of control concept is derived from Rotter's social learning theory (1954), which says that the likelihood that any behavior or event will transpire is influenced and determined by: (l) the individual's belief that his behavior will bring about a reinforcement, that is, the individual sees a causal relationship between his action and his goal; and (2) the value of the reinforce- ment to the individual. The reinforcement acts to fortify the expectancy that a particular behavior will ensure the same reinforce- ment in future situations. Because events are regarded differently by each individual, what is a reward or reinforcement for one may not be for another. In addition, a difference may exist in perceived personal controls of rewards within the same situation (Rotter, 1954, 1966). The control of reinforcement measures the concept of instru- mentality, "the strength of contingency between acts and their effects" (Lefcourt, 1966, p. 206). An individual may desire the particular reinforcement, but he may believe that he does not have the required behavior to obtain it. This person may be "described 54 as anticipating no contingency between any effort on his part and the end results in the situation" (Lefcourt, 1966; p. 207). Therefore, locus of control may be depicted as the “degree to which the individual perceives that the reward follows from, or is contingent upon, his own behavior or attributes versus the degree to which he feels the reward is controlled by forces outside of himp self and may occur independently of his own actions" (Rotter, 1966, p. 1). The implied assumption here is that the reward or outcome of behavior is of value to the individual. Rotter (1966) developed the Internal-External scale to measure generalized locus of control beliefs. Internal control "refers to the perception of positive and/or negative events as being a conse- quence of one's own actions and thereby under personal control" (Lefcourt, 1966, p. 207). The individual who believes that his own actions or behavior will significantly influence the desired outcome has an internal locus of control. External control "refers to the perception of positive and/or negative events as being unre- lated to one's own behavior in certain situations and therefore beyond personal control" (Lefcourt, 1966, p. 207). The individual who believes that there is nothing he can do to alter an outcome; that the outcome is inevitable no matter what actions he takes or behaviors he exhibits has an external locus of control. Strickland (1973) noted the relationship between internal con- trol and health or well-being. Yet Wallston et a1. (1976) felt that Rotter's instrument was too generalized to be utilized for prediction of health behavior. The Health Locus of Control scale 55 was developed by them so that the relationship between locus of con- trol and health behavior could be more accurately established. Health and its value were isolated as a variable. The resulting scale (HLC) is a health specific indicator of generalized expectancy of locus of control reinforcements. Although it is specific to the area of health, the scale is general enough so that its purpose is not intended to be a specific measure of expectancy in a particular health situation (Wallston et al., 1976). Essentially the one dimensional HLC scale measures beliefs about the control of one's health. Individuals who are "health internals" "believe that the locus of control for health is internal and that one stays or becomes healthy or sick as a result of his or her behavior (Wallston, Wallston, & DeVellis, 1978, p. 160). At the other end of the continuum are the "health externals", who "are presumed to have generalized expectancies that the factors which determine their health are such things as luck, fate, chance, or powerful others, factors over which they have little control" (Wallston, Wallston, & DeVellis, 1978, p. 160). Contributions by Levenson (1973) exploring a multi-dimensional aspect of the original generalized locus of control led Wallston et al. to develop the Multidimensional Health Locus of Control Scale (MHLC) (1978). It is based on the belief that the prediction of health behavior can be improved by examining the dimensions of external control separately, i.e. the fate and chance dimension and the powerful others dimension. The MHLC scale includes six measures each of internality (IHLC), powerful others (PHLC), and chance 56 (CHLC) externality. When the MHLC scale was administered at a health fair, the authors found that individuals who voluntarily searched for relevant health information scored significantly higher on the health internality dimension and lower on the chance dimension. Since the concern of this study is with the relationship between health locus of control and health maintenance behaviors related to the risk factors of heart disease, for the purposes of this study health locus of control will be delineated by the following (see Figure 1). An individual with an internal health locus of control believes that there are actions he can take regarding the risk factors associated with heart disease that will decrease the chances of his acquiring heart disease. An individual with a pgwerful others health locus of control believes that the probability he will acquire heart disease lies with the behaviors and actions of significant others, whether it be family members, friends, or health professionals. An individual with a Engage health locus of control believes that the probability he will acquire heart disease is a matter of fate, luck, or chance. For individuals who have a powerful others locus of control and a chance locus of control the underlying belief is that there is nothing that can be done by them to alter the likelihood of acquiring heart disease. For this study, health locus of control is operationally defined by the Multidimensional Health Locus of Control scales. In the following paragraphs the relationship between ethnically influenced health behavior and health locus of control will be drawn. 57 From the examination of the health beliefs and practices of Mexican-Americans and Black-Americans, it is apparent that health behavior is ethnically defined or at least greatly influenced by ethnic perceptions and behavioral norms. Health behavior is only one area of normative behavior learned in the socialization process of childhood. Its influence persists in adult life and continues to affect health practices. Health behavior by Mexican-Americans is greatly influenced by the belief that VGood health is a blessing from God". This belief parallels the powerful others locus of con- trol orientation, which states that the factors which control health are beyond individual control, and lie instead with someone who is perceived as an authority figure. The divine power of God is an example. It would be expected then, that Mexican-Americans would possess a powerful others locus of control orientation. However, good health is also seen as a "matter of chance, with little that one can do about it". This supposition falls into the pattern of thinking consistent with a chance locus of control orientation, where the control for one's health also lies with factors outside of individual control, as for example luck, chance, or fate. Thus, Mexican-Americans appear to portray both dimensions of externality in regard to perceived control for good health. Health behavior by Black-Americans is greatly influenced by the perception that the world is a dangerous place and man must manipulate events in order to survive. Good health is largely a matter of ”looking after your- self". This conviction is congruent with an internal locus of control orientation, where personal control for one's health is 58 assumed. It is expected then, that as a group Black-Americans would possess an internal locus of control orientation. From these assumptions, the relationship between health belief systems and health locus of control can be drawn. The health belief systems of Mexican-Americans and Black-Americans are influenced by ethnically determined norms. These health beliefs parallel the health locus of control dimensions. The logical conclusion, then, is that the same ethnically determined norms that influence health beliefs also have an impact on health locus of control orientation. Similar to health behavior, health locus of control orientation may be ethnically defined or at least greatly influenced by ethnic percep- tions and behavioral norms. It may additionally be a perception that is learned in the socialization process of childhood, and its influence on health behavior may persist into adulthood. This study will examine the relationship between these two concepts and their separate and combined effects on health behavior to ascertain whether the above proposal is valid. Studies that have addressed themselves to locus of control and ethnic background do provide evidence of a relationship between the two concepts. The evidence is contradictory. For example, Blacks have been reported to be more externally oriented than Whites by Battle and Rotter (1963) and Lefcourt and Ladwig (1966) in situations that are not health-related. Brunswick (1969) found the opposite attitude in Black adolescents who "indicated a high degree of conviction about the avoidability of illness" in comparison with White and Spanish adolescents. Brunswick also reports that for 59 four-fifths of the Black and Spanish adolescents being healthy was of value to them (1969). However, the Spanish adolescents demon- strated "considerable fatalism" concerning the avoidability of ill- ness. This finding is shared by Graves (1961) who reports that Indians and Spanish-Americans are more externally oriented than Whites. Based on the examination of the Mexican-American's health belief system and supporting research, an external health locus of control orientation (significant others and/or chance) may be expected for this group. It remains to be seen which orientation for Black- Americans will emerge: an internal orientation as supported by the examination of the Black-American health belief system and research, or an external orientation as supported by research alone. Socio-economic class in relation to ethnicity also has an influence on locus of control orientation (Battle 8 Rotter, 1963; Lefcourt & Ladwig, 1966). In all of the reported ethnic studies, "groups whose social position is one of minimal power either by class or race tend to score higher in the external control direction" (Lefcourt, 1966). In addition to the studies by Battle and Rotter (1963) and Lefcourt and Ladwig (1966), supporting evidence for this contention is provided by Strodtbeck (1958). The construct of "mastery", similar to the locus of control dimension of effectance belief (i.e. "I can do something about it . . ."), was measured. Strodtbeck found Jewish middle and upper-class subjects more mastery believing than lower-class Italians, a difference he attributed to social class. 60 The relationship between social class and health locus of con- trol has not been documented. However, this researcher contends that ethnically influenced health beliefs have a greater influence over health behavior than do other barriers commonly associated with lower socio-economic status. In spite of the poverty status of a large percentage of Mexican-Americans and Black-Americans, the exam- ination of their health belief systems show that they do value health and engage in health behavior designed to maintain health and prevent illness. Their socio-economic status is comparable; the difference in the health cultures of these two ethnic groups lies with their perceptions of who has the control for their health. That is, it is their ethnically influenced health beliefs that have a bearing on their health locus of control orientation, not social class. Therefore, this researcher contends that Lefcourt's (1966) position on social class and externality will not apply to health locus of control. By holding social class constant this study may provide evidence that it is ethnicity only and not social class that effects health locus of control. The relationship between an ethnically influenced health belief system and health locus of control has been presented. The lack of literature concerning health locus of control and social class has been noted. The particular health behavior that this study is con— cerned with will now be discussed. First, the risk factors of heart disease will be established. Then the health maintenance practices that are designed to prevent the development of heart disease will 61 be presented. Lastly, the impact that the Mexican-American and Black-American health belief systems and health locus of control may have on health maintenance practices related to the risk factors of heart disease will be discussed. Thus, the three concepts that are the foundation of this study will be drawn together to develop the conceptual framework. Health Maintenance Practices Related to the RiSk Factors Of Heart Disease Health maintenance practices related to the risk factors of heart disease have been selected to study because of the morbidity and mortality associated with heart disease (see Figure 1). Heart disease is statistically an epidemic, and it is the chief cause of death and morbidity in the United States (McIntosh, Stamler, & Jackson, 1978). Over 600,000 Americans die each year from coronary artery disease; of these deaths, 170,000 occur in people less than 65 years old (McIntosh, et al., 1978). Seventy percent of deaths occur outside the hospital. For survivors the likelihood of dying in the subsequent five years is increased five-fold, and 90 percent of the subsequent deaths will result from recurrent cardiovascular catastrophies (McIntosh, et al.,l978). Personal habits and patterns of daily life are the major contributing factors toward the develop- ment of heart disease. The following paragraphs will establish the risk factors of heart disease. They are: smoking, hypertension, hypercholesterolemia, obesity, and lack of physical exercise. The variable health main- tenance practices will then be examined. 62 The United States has the highest smoking rate in the world. Smoking contributes to the development of atherosclerosis and risk of heart attack (McIntosh et al., 1978). Stamler (1978) cites a study in which autopsied subjects disclosed evidence that the "find- ing of atherosclerosis correlated with the smoking pattern during a lifetime" (p. 128). The incidence of atherosclerosis was higher in those who smoked with a significant relationship to the amount of cigarettes smoked. In another study comparing subjects over a period of 20 to 40 years it was found that those who smoked 10 cigarettes or more per day 20 to 40 years previously presented with a mortality rate for coronary artery disease that was 1.6 times higher than those subjects who smoked less than 10 cigarettes per day (McIntosh et al., 1978). Hypertension is the second identified risk factor of heart disease. Stamler (1978) states that "as one goes up the scale of optimal pressures to levels of 85 millimeters of mercury diastolic or higher for persons aged 30 years or older, the risk of coronary artery disease increases" (p. 128). This relationship is also illustrated in the same previously documented study where subjects with systolic blood pressures of 130 millimeters of mercury or higher were correlated with a mortality rate of coronary heart disease that was 1.6 times higher than those without increased systolic blood pressure over a time period of 20 to 40 years (McIntosh et al., 1978). Particularly relevant to this study is the morbidity and mortality associated with hypertension for the Black- American. Hypertension is twice as prevalent among this population 63 as it is among the white population. For Black women, the morbidity rate is seven times greater in any age group. For Black men, the morbidity rate is 15 times greater between the ages of 15 to 40. The development of hypertension in this age group make Black men more likely to develop heart disease when they are in the 40-60 year age group. Of the 13 million Black-Americans with hypertension, only 50 percent are aware of it. Of this, 20 percent receive adequate treatment. The mortality rate is consequently 3 to 12 times greater (Martin, 1976; Sams, 1978). The documentation of a relationship between serum cholesterol levels and coronary artery disease is "as substantial as the body of evidence relating hypertension and cigarette smoking to athero- sclerosis" (Stamler, 1978, p. 128). The amount of saturated fats in the diet is directly associated with the serum cholesterol level. Stamler (1978) cites a study where "Finns obtain 22 percent of their calories from saturated fat and had the highest five year incidence of coronary artery disease of any population" (p. 129). Hyper- cholesterolemia is thus the third risk factor of heart disease. There is a direct correlation between obesity and the cardio- vascular risk factors of hypertension and hypercholesterolemia (Gotto et al., 1978). Obesity is the result of an increase in caloric intake of all foods in general, and those that are high in saturated fats in particular. Adipose cells may be hyperplastic and/or hypertrophic. It is the hyperplastic cell that is found in obese children, with a three to five-fold increase in the number of lipid cells than that present in non-obese children. The hypertrophic 64 form of obesity is most often found in middle-aged adults, at that time period where the risk of cardiovascular disease is greatest. By the age of 50, 50 percent of Black women are obese (Gotto et al., 1978). Nichols (1978) states that the hypertrophied adipose cells contribute to health problems. Because obesity has such a great influence on the cardiovascular risk factors of hypertension and hypercholesterolemia, and because the hypertrophic form of obesity is most prevalent in that age group most prone to cardiovascular disease, it is, for the purposes of this study, the fourth contrib- uting factor associated with the incidence of heart disease. Fred (1978) states that exercise affects atherosclerotic blood vessels by producing an enlargement of the vessels which thereby decreases the amount of lumen obstruction. Evidence is provided in studies by Mann et a1. (1972) and Paffenbarger et a1. (1970). Mann and associates studied a group in East Africa who consume about 300 grams of fat and 600 milligrams of cholesterol daily, with an intake of animal fat which exceeds that of American men. This population is also reported to be "exceptionally active and physically fit". The investigators studied the hearts and aortas of 50 men at autopsy, and found that even though extensive atherosclerosis with lipid infiltration and fibrous changes was present, there were few obstruct- ing lesions. Coronary arteries, with the intimal thickening of atherosclerosis evident, had enlarged to compensate for the degree of atherosclerosis present. Paffenbarger and associates (1970) studied longshoremen over a period of 16 years. They found that cargo handlers, who expend 1000 calories more than the other 65 longshoremen, had a death rate that was 25 percent lower than that of their sedentary fellow workers. Thus, even though exercise does not prevent the atherosclerotic process, it overcomes its effects by producing enlargement of the blood vessels, thereby decreasing the amount of lumen obstruction and contributing to a decrease in the incidence of heart disease. Fairly strenuous exercise, such as jogging, tennis, or swimming, that is engaged in for at least 30 minutes three times a week is required to impact health (Alexander et al., 1978). Therefore, lack of exercise and/or physical activity present in sedentary lifestyles is the fifth risk factor of heart disease (Stamler, 1978). In summary, the risk factors of heart disease are defined as: smoking, hypertension, hypercholesterolemia, obesity, and lack of physical activity. The health maintenance practices related to these risk factors will now be discussed. Health behavior is defined as: any activity undertaken by an individual who believes he is healthy in order to prevent disease or to detect it in an asymptomatic state (Kasl & Cobb, 1966)- Health maintenance practices related to the risk factors of heart disease is a health behavior directed toward prevention and/or early detec- tion of heart disease. Specifically, the identified practices are: (1) smoke 10 or less cigarettes per day; (2) obtain a blood pressure check once a year; (3) monitor weight weekly; (4) participate regularly in an exercise program or physical activity, i.e. stren- uous exercise for 30 minutes at least three times a week; (5) limit 66 dietary intake of salt; and (6) control dietary intake of cholesterol and saturated fats. In summary, there is a need for health professionals to direct their efforts toward the identified health maintenance practices and establish a health maintenance and promotion care plan for every patient. This health care plan should reflect individual differ- ences in beliefs about health if it is to be effective. Two vari- ables which contribute to individual differences are an ethnically influenced health belief system and a health locus of control orien- tation. For example, for the Black-American with a conceptual con- fusion of "high blood" for high blood pressure, the recommendation to decrease his dietary intake of salt as a health maintenance practice designed to prevent high blood pressure will not be understood or acted upon. Rather he may believe that the health professional does not know what he is talking about since it is common knowledge in the Black-American community that to lower "high blood" one should drink the brine of olives. He then may be more likely to engage in this health practice which in the long run will have an adverse effect on his health. For the Mexican-American who believes that "good health is a blessing from God", that is, who exhibits a power- ful others health locus of control orientation, the suggestion to regulate dietary sources of cholesterol and saturated fats as a means to prevent the development of hypercholesterolemia and main- tain health may not be comprehended, and/or followed. It is clear, then, that these two variables contribute to the development of 67 individual beliefs and perceptions concerning health maintenance practices related to the risk factors of heart disease. Therefore, knowledge of the impact of ethnically influenced health beliefs and practices and health locus of control orientation on health behavior will enable health professionals to provide more realistic and individualistic health promotion care, and should contribute to the decline of the incidence of heart disease, or at least alter the long term effects of the disease. The three major concepts in this study: ethnic background, health locus of control, and health maintenance practices related to the risk factors of heart disease have been developed and inter- related to form the conceptual framework for this study. The fol- lowing paragraphs will apply the framework to nursing theory and discuss the relevance of this study for nursing. NursinggTheer Man's perceptions and behavior is based on how he views himself as an individual, as a partner in interpersonal relationships, and as a member of his society. Nursing interfaces with man at all three levels. For man as an individual, nursing needs to strive to deliver health care that is individualistic for "holistic man". That is, nursing should recognize that man responds and adapts to forces in his environment, and that his adaptations are a reflection of his self-care ability (Leininger, 1970). Beliefs and values about attaining and maintaining health is one reflection of man's adapta- tions and self-care abilities. Because ethnicity and health locus 68 of control orientation influence health beliefs and practices, they also have an impact on man's adaptations and self-care abilities. Therefore, nursing must have knowledge of ethnically-influenced health beliefs and practices if health care is to be delivered to holistic man that will promote his self-care abilities. For man as a partner in an interpersonal relationship, the nurse plays a role in the dyad at the point of contact with man. The nurse responds and relates to man based on perceptions and knowledge. The fact that the nurse is a nurse implies that perceptions and interactions are a product of the professionalization process which adheres to the middle-class values and norms of the dominant society (Dorsey & Jackson, 1976). Thus, the framework within which the nurse functions is that of the dominant society. The nurse has been taught to utilize this framework as a gauge against which man is measured. However, when the nurse encounters man who is from a different ethnic background, who has a distinct health culture that is at odds with that of the dominant society, "cultural dissonance" follows. The final result is inadequate health care (Dorsey & Jackson, 1976). The implication for nursing then, is to take action to reduce cultural dissonance. A good beginning point is to recog- nize the existence of and have knowledge about alternative health belief systems. Nursing also interfaces with man as a member of society. Smith (1976) states that nursing must be aware of the fact that "cultural pluralism is the order of the day" (p. 1). Smith (1976) 69 goes on to say that "inherent in this awareness is the knowledge that nursing intervention, which seeks to promote a positive self- concept and self-actualization, must be based on an understanding and tolerance of different systems of beliefs and values that arise out of a pluralistic society" (p. 1). It is clear that differences related to an ethnic health belief system and health locus orienta- tion are examples of the products of a pluralistic society. Thus, for holistic man, who has a distinct health culture, and who is a member of a pluralistic society, nursing's goal is to maximize his adaptation and self—care abilities in order to promote and maintain health. The concept of self-care is the basis of Orem's (1971) theory for nursing. It is defined as “the practice of activities that individuals personally initiate and perform on their own behalf in maintaining life, health, and well-being" (Orem, 1971, p. 13). Self-care behavior is learned and guided by cultural norms and expectations. It is therapeutic if it "contributes . . . (to the) prevention, control, or cure of disease process and injuries" (Orem, 1971, p. 20). Orem (1971) distinguishes two types of self-care: universal self-care which is required by everyone at all times, and health deviation self-care which is required in those instances of injury, disease, or exposure to disease producing agents. Universal self- care is further divided into six categories: (1) air, water, food; (2) excrements; (3) activity and rest; (4) solitude and social interaction; (5) hazards to life and well—being; and (6) being 70 normal. Health maintenance practices related to the risk factors of heart disease fall into several of these categories. Dietary control of foods that are high in sodium, cholesterol and saturated fats is a self-care behavior related to (1) air, water and food. Participation in regular exercise falls into the category (3) activity and rest. Self-care behavior related to (5) hazards to life and well-being encompasses all of the health maintenance practices since each risk factor is either a chronic illness and a hazard to life and well-being, or a precursor to heart disease, also a hazard to life and well-being. In summary, nursing's goal is to promote the attainment of the highest level of self-care possible. Because of the influence of ethnic background on health behavior, and variations in health locus of control orientation, nursing interventions need to be selective and individualized. Knowledge of ethnic health belief systems and the relationship between ethnic background and health locus of control orientation as it affects health maintenance practices related to the risk factors of heart disease will enable nursing to individualize interventions and impact the health status of the Mexican-American and Black-American. Teaching, counseling, and supportive services should reflect individual variations and con- tribute to the promotion of positive self-care abilities. Educative services concerning the risk factors of heart disease, identification 71 of existing risk factors, and development of a mutually formulated plan of health maintenance for the patient contributes to this goal. Therefore, knowledge of the effect of ethnic background and health locus of control on health maintenance practices related to the risk factors of heart disease is important and necessary for nursing to study. Summary In this chapter, the concepts of an ethnically influenced health belief system, health locus of control, and health mainten- ance practices related to the risk factors of heart disease were developed into a conceptual framework that showed their inter- relationship and how they each contributed to self-care (Orem, 1971). In this way, the foundation and rationale for this study was documented. In Chapter III, a literature pertaining to each of the major variables is reviewed. The literature review will further substantiate the rationale and need for this study. CHAPTER III REVIEW OF THE LITERATURE Overview The review of the literature synthesizes research relevant to the three major study variables. Specifically, in this chapter a review of the studies relevant to the following areas is presented: ethnic background and health behavior, health locus of control and health behavior, and ethnic background and health locus of control. Research studies pertaining to the interaction effect of the vari- ables ethnic background, health locus of control, and health behavior are also discussed. Within each category that discusses health behavior, studies addressing health maintenance practices related to the risk factors of heart disease are presented. Research directed toward attitudinal and social factors and their influence on each of the major variables is discussed. Nursing's research contributions to the literature are integrated throughout the chapter. In this way the interrelationship of the study variables as developed in the conceptual framework is further substantiated. The rationale for the problem statement and the hypotheses is documented, and the need for this study further established. 72 73 Ethnic Background and Health Behavior Knowledge about health and illness is acquired during the socialization process of childhood. Health behavior throughout adulthood is a reflection of this knowledge. Spector (1979) states that "meanings attached to the notions of health and illness are related to the basic, culture—bound values by which we define a given experience and perception" (p. 75). Cultural and ethnic influences impact personal experiences and perceptions and are two factors impacting knowledge about health and illness. This study is concerned with ethnic influences on health behavior. Suchman (1964) states that "ethnic group labels are . . . indicative of socio-cultural differences" (p. 321). Cultural varia- tions are "universal and exist in all human races" (Lee, 1976, p. 88). One's cultural background is a component of one's ethnic background (Spector, 1979). An ethnic group thus has its own cultural identity (Saunders, 1954, p. 107). Therefore, even though cultural influences are broad in the sense of universality, they are a specific attribute of an ethnic group. An ethnic group "refers to any continuing group or division of mankind" (Saunders, 1954, p. 107). The group shares social experiences, values, norms, attitudes and a cultural identity (Suchman, 1964; Saunders, 1954), all of which influence health beliefs and practices. Suchman (1964) states that as shared values and common experiences change, the individual's behavioral response to health and illness will also change. 74 In the following paragraphs health behavior particular to each ethnic background is examined. Specifically, the research findings that are presented discuss the Mexican-American and Black-American in health, health maintenance practices related to the risk factors of heart disease, and the influence of attitudinal and social factors on health behavior. The Mexican-American in Health The concept of "health" to the Mexican-American reflects sur- vival strategies derived from Spanish, Indian, and Anglo influences. Schulman and Smith (1963) were members of an interdisciplinary research team who studied the meaning of health for Spanish-speaking villagers in northern New Mexico and southern Colorado. The authors identified the isolation of these particular communities as con- tributing to the retention of the folk health belief system. They also noted that the system is undergoing a gradual modification due to a greater exposure to the Anglo health culture. A fundamental difference between the folk health culture and the Anglo health culture is the concept of "health" and the definitives of a "normal" healthy state. Knowledge of this difference is required to impact the health status of the Mexican-American. In the Mexican culture, health is an important value orientation (Baca, 1969; Samora, 1978; Schulman & Smith, 1963). Its scope is present oriented because the struggle for survival is present oriented. There is, therefore, little thought given to the 75 relationship between past events and a current health state or present events and a future health state (Schulman & Smith, 1963). The survival of the family is dependent upon the health status of the Mexican-American male. He therefore has to be healthy. The characteristics of a healthy male adult are a high level of physical activity, a well-fleshed body, and the absence of pain. A demon- strable vitality reflects an ability to perform familial and communal roles. A man who is physically active has "sangre fuerte" (strong blood) and strength. He is "robusto" (big). There is no differen- tiation between muscle tone and size. An obese man who "carries his weight well" is considered healthy. Size is also associated with strength and an ability to work harder. Any sign indicative of a lack of strength may mean a lack of wellness, which is a threat to the survival of the family (Schulman & Smith, 1963, p. 229). Thus a villager goes to great lengths to demonstrate his vitality and wellness. The absence of pain means that a man is able to perform his role expectations. One of Schulman and Smith's (1963) informants, a well-educated man who maintained his folk health beliefs, differ- entiated between the "absence of disease" as the Anglo concept of health, and the "absence of pain" as the Mexican-American concept of health. An individual with a chronic disease thus may consider himself healthy as long as he is free of pain and able to fulfill his role expectations. The possession of health is perceived as always "subject to attack," where calamity is not unexpected. Schulman and Smith (1963) 76 assert that this view of health is a realistic one in view of the Mexican-American's perception of life as a struggle to survive. They state that the folk health belief system "depends upon this basic realistic acceptance of disease and an undesired but not unexpected interruption to a healthy state" (p. 228). Samora (1978), a member of Schulman and Smith's research team, and Baca (1969) sub- stantiate these basic attributes of "health." The literature addressing the Mexican-American folk health belief system has been developed in Chapter II, and it will not be repeated. In a review of this literature, Weaver (1973) stated there was ”reason to believe that the oft-claimed significance of traditional folk health culture is overdrawn" (p. 97). Studies which deal with such variables as age, socio-economic class, familial ties, and cultural acculturation, and their influence on belief in the folk health culture and attainment of medical care, inject a degree of uncertainty regarding the universality of the folk health belief system. Findings also differ depending on the geographic location of the study. Studies which address the effect of atti- tudinal and social variables on belief in and utilization of the folk health belief system are presented in the following section. Attitudinal and Social Variables: Health Beliefs. Holland (1978) described a process of "assimilative integration" of tradi- tional and modern medicine within the Mexican-American community. He stated that "in the process of change the latter tends to replace the former in predictable and uniform patterns of change determined 77 by the overall similarities and differences of the original systems" (p. 113-114). The sample population studied by Holland (1978) was 250 Mexican-American families in Tucson, Arizona, who were representa- tive of the city's Mexican-American population. The majority of the families were first or second generation Americans, with origins of isolated villages and towns in northwestern Mexico. Their socio- economic class position was lower than that of the general Tucson population but higher than the poor peasant Mexican class. The structured interview was designed to elicit information concerning length of residence, family composition, ethnic origin of spouses, income, language, material culture, living conditions, cultural preferences, and strength of belief in traditional disease concepts. Holland (1978) identified the three phases of assimilative integration as conservative, transitional, and highly assimilated. Within the total sample Holland (1978) found that 25 percent were in the conservative phase of the assimilative process. The Mexican- Americans in this group expressed strong belief in the three major disease classifications of the folk health belief system and high skepticism of the ability of Anglo physicians to treat such diseases. They preferred herbal remedies and the services of the curandero. They sought help from the modern health care system with apprehension and uncertainty only after other health measures had failed. Holland described those in the conservative phase as belonging to the culture of poverty, having a low income, little education, and an unskilled job. Close social and cultural ties with relatives and friends in 78 Mexico were maintained and lifestyle was similar to that in Mexico. There was a dependence on kinship ties, a preference for highly- populated Mexican-American communities and the Spanish language, and a value placed on magic and religion. Mexican-Americans in the transitional phase of the assimilative process continued to perceive illness from the traditional perspec- tive but they had adopted enough concepts from modern medicine so that the two systems were closely intertwined. The 50 percent of the study sample in this phase still believed in diseases of dis- location and emotional disease but attempted to substantiate them with concepts from the modern health care system. They therefore perceived illness in both terminologies, sought out both alternatives for treatment, and attributed success to the one with which relief was more closely associated. Belief in the existence of magico- religious disease significantly declined to the point of doubt or complete denial. Members of this group were semi-skilled or skilled laborers who were usually first and second generation Americans. The remaining 25 percent of Holland's (1978) sample was described as highly assimilative, where belief in diseases of dis- location and those with an emotional etiology was weak or non- existent. Traditional terminology was known to members of this group, but they used the modern disease classifications and preferred to receive health care from the modern health care system. However, they utilized herbal remedies and curanderos when they were not satisfied with the results of scientific treatment. Members of the highly assimilated group had more in common with Anglo-Americans. 79 Their educational and income levels were similar. Ties with the nuclear family were more important than extended kinship ties, and English was the preferred language. Faith in the traditional folk health care system was replaced by a greater reliance on modern medicine. Thus, Holland (1978) concluded that when the Mexican-American is ill, he will make use of traditional and modern treatments, often simultaneously. Holland believed that the Mexican-American's ulti- mate decision regarding the source of medical care is a reflection of the strength of his faith in either system. He further asserted that the traditional folk health belief system is undergoing a process of cultural change in which health beliefs and practices are being modified so that they are more congruent with those held by the modern health care system. Holland's (1978) findings were substantiated in part by Madsen (1973) who stated that the degree of reliance on the modern and traditional health care systems is correlated with class and educa- tion. His observations were that the lower class depended most heavily on the services of the curandero but utilized modern medicine. The lower middle class portrayed some skepticism toward folk medicine but utilized it along with modern medicine. The upper middle class visited a physician to gain prestige but concurrently relied on prayers as an essential element of cure. They preferred medical explanations for illness but resorted to folk explanations when scientific treatment failed. Those in the highest socio-economic class depended entirely on physicians and prayer, but consulted a 80 faith healer as a last resort and in an extreme situation such as chronic illness. The limitation with Madsen's study is that he did not specify what criteria he used to determine social class. Kay's (1977) informants appeared to display an age-related difference in knowledge and belief in folk health concepts. Her ethnographic study took place in a large southwestern city in a Mexican-American barrio. It focused on the health beliefs and prac- tices of women on whom, it is asserted by Kay (1977), falls the major responsibility for their family's health. The 60 women studied were members of four families whose familial generation extended from Mexican-born to third generation American. Their age range was 22 to 78 years, and years of education was zero to ten. Kay documented that it was the older women in the barrio who were most knowledgeable about fblk health beliefs. The belief that vulnerability to illness is influenced by age and events in the lifecycle lends support for cultural health prescriptions pertain- ing to menstruation, pregnancy, childbirth, and childcare. Kay (1977) described the beliefs concerning these health issues, including health maintenance practices undertaken to prevent the "marking" of an unborn infant, the "fixing" of the position of the unborn infant by the partera, and the guidelines of "1a dieta" which prescribes postpartum health behavior. Among Kay's informants only those women who were supervised by the female elders practiced the customs of "1a dieta" (p. 166). In summary, Holland (1978), Madsen (1973), and Kay (1977) all document that Mexican-Americans adhere to both health belief systems 81 simultaneously. The traditional Mexican-American health belief system is undergoing a cultural change process, an "assimilative integration," resulting in a cultural health belief system that encompasses both folk and scientific health beliefs and practices. These authors note a socio-economic status and age-related difference with regard to belief in and practice of folk medicine. There is a transference of concepts from one system to another, as for example, the equation of "fallen fontanelle" with dehydration (Holland, 1978; Kay, 1977). Belief in the magico-religious disease concept is not as strong as belief in the other traditional diseases, a finding Holland (1978) attributes to the lack of a parallel concept in the modern health care system and the revision of a religion which in the past espoused the "medieval beliefs“ that illness was a punish- ment of God or act of the devil (p. 114). Sixty percent of Holland's (1978) study population denied belief in magico-religious disease and stated that it was a "superstition contrary to Catholic doctrine to which only the older generations adhered" (Holland, 1978, p. 115). The women in Kay's (1977) sample denied that God sends illness as a punishment, asserting instead that "Help your- self, and God will help you" (p. 123). Thus it appears that Mexican-Americans are not fatalistic as has been documented by others. Studies by Snow and Johnson (1977) and Martinez and Martin (1978) document findings which do not support the conclusions of Holland (1978), Madsen (1973), and Kay (1977). Snow and Johnson (1977) did not find the same age-related difference in folk health 82 beliefs and practices regarding normal bodily functions that Kay (1977) did. Their study explored the Mexican-American female's understanding of menstruation and how it affects body image, per- ception of disease, diet, willingness to take medicine, and contra- ceptive use. Participants in Snow and Johnson's study were women enrolled in a public health clinic in Michigan. The clinic served a multi- ethnic, poorly educated, low income population, where social and cultural influences contributed to an already existing communication barrier. The researchers interviewed 40 women who were attending the prenatal and medical care clinics. The age range was 17 to 41, with a mean of 29.2 years. The majority of the women believed they should change their behavior whenever vaginal bleeding is present. The basis for the prescribed health behavior is the hot-cold theory of disease, where blood is seen as a hot and dry substance, opposed or clotted by any food, herb, medication, or environmental element that is cold and wet. Cultural health prescriptions thus reflect beliefs that women who are bleeding should avoid water, cold air, and cold foods. Foods which are classified as cold are important vitamin sources, as for example citrus fruits, tomatoes, and green leafy vegetables (Snow & Johnson, 1977, p. 2738). An examination of the age range of the respondents revealed the absence of an age-related difference concerning these folk health beliefs and practices. Snow and Johnson (1977) asserted that differences in nutritional beliefs and practices among Mexican-American women who are in the 83 child-bearing years have particular implications for health care professionals. This assertion is substantiated by Cardenas, Gibbs and Young (1978) who documented the need for early prenatal education. These researchers found that among primigravid Mexican-American women between the ages of 13 and 35, lack of knowledge about food and nutrition during pregnancy had an adverse effect on their nutri- tional status. The women exhibited nutritional deficiencies in iron, vitamin A, and calcium (Cardenas, Gibbs, & Young, 1978, p. 264). Johnston (1977) is a nurse researcher who studied expectations held by Anglo, English-speaking Mexican-American, Spanish-speaking Mexican-American, and Black mothers regarding the perceived efficacy of vitamins. Her sample was 200 women who had a mean age of 28 years. She found that for Spanish-speaking Mexican-American and Black-American mothers the value of taking vitamins was greater than for English-speaking Mexican-American or Anglo mothers. How- ever, the former group of women also exhibited a greater tendency to believe in "magic" explanations regarding the intended effect of vitamin supplements. Thus, research findings by Snow and Johnson (1977), Cardenas, Gibbs, and Young (1976), and Johnston (1977) do not substantiate an age-related differencein folk health beliefs and practices. Rather these authors assert that health professionals should not assume their younger Mexican-American clients do not still retain ethnically influenced health beliefs and practices, a.finding echoed by Martinez and Martin (1978). 84 The purpose of Martinez and Martin's (1978) exploratory study was to determine the extent of knowledge about the disease concepts in the folk health belief system and to obtain an account of beliefs concerning etiology, symptomatology, and modes of treatment. Similar to Holland (1978), they addressed the acculturation process but documented findings that conflicted with his. Martinez and Martin state that "acculturation and assimilation of persons of Mexican origin . . . has been slowed by social mechanisms of the larger society which tend to keep these people separate" (p. 276). The result is sociocultural isolation and a preservation of folk beliefs, which the authors found to be unrelated to age, education, or place of birth. Their sample consisted of 75 Mexican-American housewives living in a southwestern city. The age range of the respondents was 18 to 84, with a median age of 39. The median years of schooling was six; eight had no formal education. The majority of the women were born in the United States (51); the rest were born in Mexico. The design for the study was a structured interview. Results indicated that belief in five folk diseases was wide- spread. More than 97 percent of the women interviewed knew about them. Ninety-five percent reported occurrences of these illnesses in their own families. There was no relationship between reports of occurrences and age, education, or place of birth. Eighty-five percent of the women identified symptoms, etiology, and health measures specific to evil eye, empacho, susto, and fallen fontanelle. The belief in "mal puesto" or witchcraft was also strongly 85 represented in these women. Knowledge regarding its etiology and symptoms was revealed by two-thirds of the study sample, and one- third knew about its treatment. Of the eight reports of mal puesto among immediate family members, six were from women under the median age. Respondents in the study by Martinez and Martin (1978) indi- cated that the curandero is the healer consulted for treatment of folk diseases. However, four-fifths of the respondents reported that they also sought health care from physicians for medical reasons. Thus both types of curers are utilized simultaneously, a finding documented by others. The role of the curandero in the Mexican-American health belief system has been documented in studies which took place in Arizona, northern California, New Mexico, and south Texas (Clark, 1959; Holland, 1978; Madsen, 1973; Rubel, 1966, 1960; and Saunders, 1954). Edgerton, Karno, and Fernandez (1978) did not find the same promi- nance of the curandero in East Los Angeles. A household interview designed to assess folk psychiatric practices was administered to a sample of 500 Mexican-Americans and 200 Anglo-Americans. The authors found that few curanderos practiced in East Los Angeles. Those who did practice did not possess the fame accorded curanderos in other parts of the country. The curandero was mentioned as a potential health care provider by less than one percent of the study partici- pants. Kay's (1977) findings substantiate in part those of Edgarton, Karno, and Fernandez (1978). The role of the curandero and the 86 validity of his treatments was the area of greatest disagreement among Kay's informants. The young women had no knowledge of folk treatments and expressed a disdain for folk healers. Thus, there appears to be a difference in extent of belief in the curandero related to age and geographical area of the community. Nursing has had an impact on the literature pertaining to the Mexican-American in health by acknowledging the survival of the folk health belief system and documenting the responsibility it has to provide health care that meets the needs of the Mexican-American patient. Dorsey and Jackson (1976) discussed beliefs concerning the etiology and treatment fer folk disease, and the role of spirit- ualism and the curandero in healing. Evidence of health behavior undertaken to maintain health and prevent illness was presented by a discussion of herbal remedies and health prescriptions which serve to keep the body in balance and in a state of health. Baca (1969), Gonzales (1976), Hautman (1979), Johnson (1978), Spector (1979), and White (1977) are other nurses who have documented in varying degrees folk health beliefs and practices of the Mexican-American which co- exist with belief and practice in the professional health care system. The purpose of reviewing these multiple studies is not to argue whether a folk health belief system does or does not exist, but rather it is to describe the many social and attitudinal variables which impact the Mexican-Ameriomfs health culture. The researchers attempt to determine the extent of belief in the health culture, and to examine some of the variables which may influence the strength of 87 belief. Specifically, the research findings reviewed have addressed the effect of cultural acculturation, age, and socio-economic class on folk health beliefs. Conflicting findings and Opinions can only lead to the conclusion that belief in all of the concepts which have been documented as comprising the Mexican-American health belief system are not generalizable to every Mexican-American at all times and in all places. Variations in health beliefs contribute to variations in health behavior. It is the responsibility of nursing to assess for ethnically influenced health beliefs and to design interventions which reflect individual variations. The present study collects data related to age, socio-economic status, and familial generation. The data are used to describe the study sample. In this way this study builds on the research of others and contributes to the knowledge base regarding the Mexican- American health belief system. The review of the literature on Mexican-Americans and health behavior will now focus on the effect of attitudinal and socio- cultural factors on the Mexican-American's health practices and his seeking of medical care. Attitudinal and Social Variables: Health Practices. A study by Nall and Speilberg (1967) examined the cultural and social factors related to the acceptance or rejection of the recommended treatment regime for tuberculosis. Their study participants were 88 from the Rio Grande River valley of southern Texas. The authors do not contest the importance of the folk health belief system in this part of the country as documented by Madsen (1973) and Rubel (1960). However, they do contest the opinion that belief in the folk health belief system is a barrier to health care services as asserted by Madsen (1973), Rubel (1960), and Saunders (1954). This study attempted to provide empirical evidence that belief and participation in one system does not preclude belief and partici- pation in the other. The researchers examined three prominent traits of the Mexican-American health culture which are viewed by some as major barriers to the utilization of the modern health care system. These traits are (l) a set of traditional folk medical beliefs and practices; (2) the use of the curandero; and (3) a "set of ritualistic acts" believed to have favorable effects on health. Statistical analysis revealed no relationship between any of these variables and the acceptance or rejection of the modern treatment regime for tuberculosis. Nall and Speilberg (1967) then examined the social integration of the respondents and its relationship to the acceptance of medical care. The indices which measured social integration were integra- tion into the family group, integration into the ethnic locality group, language usage outside the home, and subjective expressions of social integration-alienation. An examination and analysis of these variables provide a description of demographic and social characteristics associated with accepting the treatment regime. As expected, those individuals 89 demonstrating high integration into their ethnic culture were more likely to reject treatment. They were older, usually married, had relatives present in their neighborhood, and knew their neighbors. Spanish was the only language spoken. These individuals expressed a subjective expression of low anomie, that is, they did not feel alienated from their Mexican-American culture. Those individuals who were more likely to accept the treatment were not married, had no relatives in their neighborhood, did not know their neighbors, and spoke either just English or both English and Spanish. While exhibiting objective characteristics of decreased integration into their ethnic background, they subjectively expressed feelings of high anomie, that is, high alienation from and low integration into the Mexican-American culture. It is interesting to note that these respondents were not assimilated into the dominant Anglo society, yet they did accept the treatment, a statistically significant find- ing. Hall and Speilberg (1967) believe that these data reflect a process of socio-cultural change in which "movement out of the tra- ditional ethnic system begins through the diminution of the indi- vidual's social linkages to it" (p. 307). The disengagement appears to be either preceded or accompanied by a subjective experience of alienation. Nall and Speilberg's observations are similar to those of Holland (1978) who identified a change process where traditional and modern medicine is undergoing an "assimilative integration." The study participants who rejected the treatment 90 possess social and cultural characteristics similar to Holland's (1978) conservative group members. Nall and Speilberg (1967) concluded that the Mexican-American health culture has a "milieu" effect which is "unfavorable" to the acceptance of the medical treatment regime for tuberculosos (p. 306). The milieu effect does not reinforce the demands of the treatment but neither does it appear to be a barrier to treatment. Thus, findings support the assertion that belief in the folk health belief system is not a barrier to the seeking of health care services. Welch, Comer and Steinman (1973) also examined variables which have an impact on the relationship between attitudes toward modern medicine, closeness to the Mexican health culture, and assimilation into the dominant Anglo society. "Hostility toward doctors" and "traditional attitudes toward medicine" were measured by four ques- tions each. The social indicators that measured degree of closeness to the Mexican culture were (1) taking the interview in Spanish; (2) number of years living in the United States; (3) parents' birthplace; and (4) size of the Mexican-American community. Social and economic status in the community were measured by education, income, age, sex, and the number of years of community residence. Results indicated that social characteristics did not explain much variance in health care attitudes within different social groups in the Mexican-American community. The relationships of the variables were in the expected direction, but were statistically weak. Closeness to the community appeared to have the most 91 influence on fostering a negative attitude toward the modern health care system and a positive attitude toward the folk health care system. These attitudes were not confined to that segment of the population that was older, Spanish-speaking, or little educated as the authors originally proposed. Welch et a1. (1973) then examined the effect of attitudes and social characteristics on utilization of health care services. The health services examined were health maintenance behaviors such as immunizations, dental health check-ups, and vision testing. The statistical analysis indicated that those who had a greater distrust of doctors and a traditional perception of health care were just as likely to have engaged in the health maintenance behaviors as those who were not untrusting. The authors stated that the mistrust felt by the Mexican-Americans must originate within the modern health care system rather than being shaped by the folk health care system. Belief in the traditional system is therefore not a barrier to the utilization of medical services. Overall, the social factors explained more of the variance in health care behavior than did the attitudinal variables. Age, sex, and socio-economic status were more influential than the character- istics that measured attachment to the Mexican-American culture. Welch et a1. (1973) stated that this pattern of responses might be "echoed by any moderate to low income group in society" (p. 208). However, the authors also noted that even these correlations were not strong enough to explain all the variance in health behavior. Thus, this study generally substantiated the findings of Nall and Speilberg 92 (1967). Assimilation into the dominate society and closeness to the Mexican-American culture does not fully explain individual variations in health behavior. Rather socio-economic class and age were found to be related more to utilization than either attitudes toward modern medicine or closeness to the Mexican-American culture. Lee's (1976) research provided contrasting evidence regarding the role of socio-cultural attributes and socio-economic status on patterns of seeking medical care. His six month field research gathered data on 416 Mexican-American families in a California community served by a federally funded neighborhood health center. The families were identified as either American—born English- speaking or Mexican-born Spanish-speaking. Findings disclosed there was no relationship between the socio-economic status of the family and the utilization of health care services. The pattern of health care use was influenced more by the socio-cultural attributes of the family. American-born patients were more liberal about health issues related to family planning, abortion, and birth control for teenagers. In summary, research studies which examine the effect of social and attitudinal variables on utilization of health care services document conflicting results. This should come as no surprise in view of the variations in health beliefs noted earlier. In the following section, studies addressing health behavior related to the risk factors of heart disease are discussed. 93 Health Behavior Related to the Risk Factors of Heart Disease. The review of the literature on health behavior concerned specifi- cally with the Mexican-American's health maintenance practices related to the risk factors of heart disease discloses few research studies in this area. The studies that are in the literature do not deal with health maintenance practices per se, but rather document data regarding some of the risk factors of heart disease. Yanochik-Owen and White (1977) examined the nutritional status of Mexican-American children in Arizona. The Mexican-American popu- lation comprised 48 percent of the population seen in county health department clinics in 1974. The clinic population tended to be a lower-income, higher-risk group than the total population. Ninety percent were under six years old. The study sample was not randomly selected and thus results of their study are not generalizable to all Mexican-Americans in Arizona. The findings revealed that a weight-for-height greater than the 95th percentile was the greatest health problem for these Mexican- American children. In the two to five year old age group, 13.3 percent were overweight, compared with 8.9 percent of the other ethnic groups who were overweight. This difference was statistically signi- ficant (p. 153). High cholesterol blood levels were also a health problem among the Mexican-American children, though not as great a problem compared with the other ethnic groups. Of the 294 Mexican- American children tested for serum cholesterol levels, 56 percent had a level greater than 160 milligrams percent, and 12 percent had a level greater than 200 milligrams percent (p. 154). Although the 94 percentages were not as great for the Mexican-American children as fer children of other ethnic backgrounds (16 percent and 61 percent, respectively), the results are still alarming in view of the number of children who, at the age of six or younger, have high serum cholesterol levels. The results of this study suggest that if obesity and hyper- cholesterolemia are health problems for Mexican-American children, they will also be health problems for Mexican-American adults. Nutritional beliefs and practices is one area of health behavior learned and shaped by cultural influences during the socialization process of childhood. Their effects persist into adulthood. Mexican-Americans appear to be susceptible to an early onset in the development of two risk factors of heart disease: obesity and hypercholesterolemia. Yanochik-Owens and White (1977) state that the traditional perceptions of a Mexican-American diet of beans three times a day has not been found to be true. The availability of food stamps probably contributes to an increased dietary intake of eggs, lard, and sweets, which in turn contribute to the develop- ment of obesity and hypercholesterolemia. The authors additionally suggest that the increased dietary intake of beans and other vege- table proteins may explain the lower level of elevated serum cholesterol exhibited by Mexican-American children as compared with the children of other ethnic groups. Evidence supporting the early onset of hypercholesterolemia for Mexican-American men was provided by Shields et a1. (1967). They measured serum fatty acids, triglycerides, cholesterol and 95 phospholipids for a large sample (n = 1094) of Spanish-American and Anglo men from New Mexico. Measurements were done on an overnight fasting serum and a postprandial serum drawn three hours after a high-fat test meal. The results indicated that fasting serum lipids in Spanish- American men reach maximum concentrations 10 to 30 years before the coresponding maximum concentrations in Anglo-American men (p. 485). Postprandial curves paralleled the fasting curves. The authors also noted the relationship between cardiovascular mortality statistics and lipid concentrations for the two ethnic groups. Corresponding to high serum lipid levels for Spanish-American men through the age of 39, the incidence of cardiovascular deaths is higher for Spanish- American men before age 30. Cardiovascular deaths for Anglo-American men between the ages of 40 and 79 are approximately one-third higher than for Spanish-American men. Shields et al. (1967) attempted to explain their paradoxical findings, specifically the findings that Spanish-American men, in Spite of an early onset of hypercholesterolemia and an increased sus- ceptibility to heart disease, actually exhibit a lower mortality rate for heart disease. The authors noted that death rates from all causes have been found to vary directly with the degree of urbanization (p. 496). Variationsirnlifestyle based on geographical areas reflect differences in physical activity, dietary practices, and stresses. For the Mexican-American, life in a predominantly rural area such as New Mexico may give rise to behaviors which in the long run con- tribute to a decline in the incidence of heart disease. 96 The review of the literature emphasized that the Mexican- American's concept of health encompassed the ability to work, to perform one's daily activities. A high level of physical activity is valued because to work hard is valued. Mexican-American men may therefore exhibit a higher level of physical activity than Anglo men. Studies by Mann et a1. (1972) and Paffenbarger et a1. (1970) have shown that even though physical activity does not prevent the atherosclerotic process, it overcomes its effects by enlarging the blood vessels, which decreases the amount of lumen obstruction and contributes to a decrease in the incidence of heart disease. Thus, it is possible that the high level of physical activity inherent in the Mexican-American's lifestyle and emphasized in the cultural meaning of health is the factor which overcomes the increased sus- ceptibility to heart disease imposed by hypercholesterolemia. This is just one aspect of Mexican-American health behavior deserving further study. It is especially relevant to nursing who has a responsibility to impact the morbidity and mortality associated with heart disease. Knowledge of the relationship between the Mexican- American's values of hard work and high physical activity levels and susceptibility to heart disease can provide nursing with a solid foundation upon which to plan and implement nursing interventions designed to impact the health status of the Mexican American. This study will contribute to the literature in this area by measuring physical activity as one health maintenance practice related to the risk factors of heart disease. 97 In summary, several studies have examined the Mexican-American's vulnerability to heart disease. The lack of documentation regarding the Mexican-American's actual health behavior related to the risk fac- tors of heart disease has been noted. The present study will add to the knowledge base of Mexican-American health behavior by measuring health maintenance practices related to the risk factors of heart disease. The review of the literature will now present studies which document the Black-American's health behavior. The Black-American in Health The concept of health in the Black-Amercian culture reflects African, Native Indian American, and Anglo-American influence. Its origins are “grounded in the African's beliefs about life and the nature of living,“ where life is perceived as a process rather than a state (Jacques, 1976, p. 115). Health is one aspect of this process. It encompasses the physical, emotional, and spiritual needs of the individual. The belief that life is a process and not a state is a fundamental different between the folk health culture and the Anglo health culture. Health beliefs and practices reflect strategies the Black- American learned during slavery, where good health was necessary to survive. Jacques states that "for many, the concept of wellness remains related to being able to labor productively" (p. 119). A healthy person exhibits a high level of physical activity, endurance, agility, and stamina. He is able to resist illness and work. He lives in a clean environment, has a good appetite and eats a balanced diet (Brunswick & Josephson, 1972, p. 30). Good health is important 98 to the Black-American, a value that is conducive to positive health behavior (Brunswick & Josephson, 1972; Cornely & Bigman, 1963). In the following section research studies addressing the effect of attitudinal and social variables on health beliefs are discussed. Attitudinal and Social Variables: Health Beliefs. Brunswick and Josephson (1972) found positive attitudes about health, health concerns, and health practices among Black adolescents in Washington Heights (Brunswick, 1969) and Harlem (Brunswick & Josephson, 1972). Their findings lend credibility to the premise that positive health attitudes and beliefs in the adolescent years are conducive to positive health behavior in adulthood. Adolescents showed concern for their health through their ability to evaluate their health needs. Forty-four percent of Brunswick's (1969) pretest study population identified cigarette smoking as a major health problem for young people; one-fifth of the respondents in Brunswick and Josephson's (1972) large-scale survey agreed. Drugs, drinking, air pollution and unsanitary living condi— tions were other social health problems mentioned by respondents (Brunswick, 1969). Almost one-third thought they did not receive adequate heat, and one-quarter reported an insufficient hot water supply (Brunswick & Josephson, 1972). The identification of "good" and "bad" health habits reflected the same themes which were present in the group's conception of a healthy person and the perceived health problems of the group. Physical activity was the most frequently reported personal health habit, identified by 80 percent of the interviewed adolescents. 99 Endurance, agility, and stamina in regard to physical activity were cited as the predominant characteristics of a healthy person (Brunswick & Josephson, 1972). Other health practices emphasized maintaining a good weight and eating a balanced diet. Thirty-four percent of the Black adolescents believed that eating the right kind of food was important in maintaining health. One in eight reported cleanliness, and one in five mentioned the proper amount of sleep as contributing to good health. Almost half of the Black adolescents (44 percent) mentioned their smoking habits when asked about bad health practices. Twenty-two percent thought they should eat fewer sweets (Brunswick, 1969). Eighty-one percent of the Black adolescents stated that being healthy "mattered a lot" to them (Brunswick, 1969). Nine out of ten believed that being healthy was largely "a matter of taking proper care of oneself" (Brunswick & Josephson, 1972, p. 30). Of the three ethnic groups represented in Brunswick's study, Blacks were most likely to believe in the avoidability of illness. Several reasearchers provide evidence that the same positive attitudes about health found among Black adolescents persist into adulthood. A study by Suchman (1964) conducted in the same setting as Brunswick's (1969), revealed that within the six ethnic groups represented in New York City, Blacks scored second highest on a preventive medical behavior index. Over 85 percent of the Black sample reported that they participated in health behaviors related to eating a balanced diet, obtaining polio immunizations, and seek- ing out medical check-ups in the absence of disease. 100 Cornely and Bigman (1963) found that among Black families in Washington, D.C. good health is important, an attitude "apparently not . . . affected by such personal or family characteristics as education, occupation, income or place of birth" (p. 24). Health practices engaged in to maintain good health included living moderately, eating the proper amount of food, and getting enough sleep, rest, and exercise. Cowles, Polgar, Simmons, and Switzer (1963) reported similar findings in their study which took place in South Berkeley, California. Respondents were asked the question "What are some of the things you have been doing to stay well?" Health behavior related to diet (44 percent), exercise (15 percent), and rest (15 percent) were the most frequently reported personal health habits. Seven percent identified such health measures as "avoiding exposure" and wearing proper clothing, beliefs which reflect the folk health culture. These physical measures were represented equally within high and low socio-economic groups. The authors reported that two-thirds of those in the higher socio-economic grOUp sought out health care professionals and used home remedies, while two-thirds of those in the lower socio-economic group indicated attitudinal and religious measures to protect and maintain health. Thus, evidence has been presented which demonstrates that Black-Americans do exhibit positive attitudes and beliefs about health. It is important to note that the health practices reported by these authors share the similarity of being health behaviors which can be engaged in without entering the modern health care 101 system. Perhaps this explains findings reported by Cornely and Bigman (1963), whose respondents rarely mentioned immunization, early diagnosis, or prompt treatment of illness as valuable in maintaining good health, and Cowles et a1. (1963), where only one percent of their study population obtained immunizations, and only 3 percent sought out pre- and post-natal care. Studies which report health behavior based on the services offered by the modern health care system may be overlooking an important aspect of the Black-American health belief system. These findings support the premise that "in the absence of any pain or apparent danger, to manipulate your diet, the amount of sleep you get, or the 'positive' character of your thoughts has a lower psychological and economic cost" than entering the modern health care system (Cowles et al., 1963, p. 234). In summary, the literature review reveals that Black-Americans portray health beliefs and attitudes which are conducive to positive health behavior. Studies which address the health behavior of the Black-American are reviewed next. These studies specifically address health behavior which necessitates entering the modern health care system, such as prenatal care, infant care, the seeking of health supervision regarding birth control, and the seeking of medical care in the absence of illness. The effect of socio- economic class and social cohesiveness as attitudinal and social factors influencing health behavior is discussed. 102 Attitudinal and Social Variables: Health Practices. Mindlin and Densen (1971) found that ethnicity was more important than socio-economic class in infant health supervision. These researchers conducted a household survey with random samples drawn from ethni- cally matched middle and low-income families in New York City. They found that White infants received more health visits and were better immunized than Black and Spanish infants. Education and family income was associated with health supervision, but not as strong as district of residence and ethnicity. A comparison of the three ethnic groups in the middle-income district revealed that Black and Spanish infants did not receive as much health supervision as did the White infants. The authors also measured the mother's attitudes toward medical care and doctors. Ninety percent of the White mothers indicated they had regular doctors who encouraged infant health supervision. Only 45 percent agreed that infants over one year old needed health supervision. In comparison, while only half of the Black and Spanish mothers reported that their doctors encouraged infant health supervision, 75 percent thought that it was important. Mindlin and Densen (1971) suggested that the manner in which health supervision is delivered may be responsible for their paradoxical findings where Blacks subjectively expressed positive health attitudes, but objectively exhibited negative health behavior. A study by Brinton (1972) revealed that nurses do not have a valid knowledge base regarding the perceived value of health to Black-American mothers. The nurses were asked to respond as they 103 thought their low-income, Black-American caseload would. In all areas except future orientation, there were major discrepancies between the nurses' perceptions of the mothers' values and the mothers' actual values. While 85 percent of the mothers ranked health in one of three top positions, only 48 percent of the nurses thought their clients valued health. Similarly, more families than nurses were found to be fatalistic, but not to the degree perceived by the nurses. Brinton (1972) commented that these misperceptions contributed to communication barriers and probably affected the mothers' care-seeking behavior. Nursing interventions based on incorrect assumptions are designed to fail. Brinton's (1972) study thus supported Mindlen and Densen's (1971) contention that it is the manner in which health care is delivered which impacts the Black- American's utilization of child health supervision. Strauss (1976) found that many factors associated with ethnic identity impacted dental health attitudes and behavior. The respondents in his study were 180 Black and White adults who sought dental care from a clinic. The randomly-selected sample tended to be well-educated, but Blacks had a lower income than Whites. There were differences between the ethnic groups in the structure of the nuclear family, with 24 percent of the Black respondents reporting they no longer had intact marriages compared with almost 7 percent of the White respondents. Strauss (1976) reported differences in utilization patterns. Black participants had a larger number of decayed and unfilled teeth and waited longer between visits. They initiated dental health 104 care later than Whites; one-fourth did not receive any dental health care until their teens. Thirty-six percent of the Black respondents did not know about dental floss. However, Black respondents placed a greater value on tooth appearance, and were more willing than White respondents to spend 15 minutes a night on dental care. This study thus provided evidence that Black respondents exhibited a high level of awareness and placed an importance on dental health. It is clear, however, that dental health information was not reaching this highly motivated segment of the Black community. Strauss (1976) suggested that manpower distribution and financial acces- sibility are two of the factors which affect utilization of dental health services. The findings reported by Mindlen and Densen (1971), Brinton (1972), and Strauss (1976) are similar in that their respondents expressed positive attitudes about health but exhibited negative health behavior. Many other researchers report findings which indicate that as a group, Black-Americans exhibit a range of health behavior. Watkins (1968) studied the pattern of prenatal care among 120 Black multigravidae women in Boston, Massachusetts. The women were selected from those seeking prenatal care at the city's public health clinic. The majority of the sample belonged to social class IV or V as defined by Hollingshead (p. 659). Results showed that early initators of prenatal care were younger, had a lower gravidity, carried fewer pregnancies to term, 105 and had fewer living children. Socio-economic class did not have an impact on early versus late initiation. By holding race and socio- economic status constant, Watkins (1968) demonstrated that the seeking of prenatal care was not associated with either variable. Cornely and Bigman's (1963) three year study addressed social and cultural factors which influence health behavior of low-income families. Their large scale study was conducted in Washington, D.C. The sample was drawn from two census tracts identified as almost all Black. Four hundred eight Black families and 98 White families chosen for comparative purposes were interviewed in their homes. The majority of the families were originally from the south,» but they had lived in Washington for 20 years or more. About half of the respondents had no more than eight years of education. Black respondents were more often employed in low-skilled jobs. Three- fourths of the Blacks and half the Whites had a family income of less than $4000 per year. Cornely and Bigman (1963) noted that "preventive health ser- vices are the key to the maintenance of the health of any community" (p. 26). Ninety-five percent of the respondents interviewed thought that obtaining a physical exam was important. However, their belief did not match their health behavior. Respondents from both races indicated their decision to seek medical care would depend upon the presence of early symptoms. The majority of the children in these families had received their immunizations, but the authors note that there was a "sizeable proportion" who had not been immunized. There were large percentages of families in which 106 none of the adults had ever been examined. They were, however, familiar with screening procedures. The chest x-ray was mentioned most frequently, a finding the authors attributed to the anti- tuberculosis campaigns. As the best indicator of a community's health, Cornely and Bigman (1963) evaluated infant and maternal care. Results indicated that health behavior related to the seeking of prenatal care either worsened from the first to the last pregnancy or demonstrated little positive change. In contrast health behavior related to infant care did improve between the first and the last birth. Specifically, positive health behavior was reflected in frequency of visits made during the first year of life, the age of the infant at the time of the first visit, and the mother's reason for seeking health care. The authors concluded that variations in the range of health knowledge, habits, attitudes, and utilization of health services exist among low-income groups within the same race. They asserted that "families living in low-income areas cannot be considered as a homogeneous group" (Cornely and Bigman, 1963, p. 28). This range of health behavior within the Black-American ethnic group is a fact that health professionals should account for in the delivery of health care services. Cowles, Polgar, Simmons and Switzer (1963) studied health behavior undertaken by Blacks in South Berkeley, California. They were specifically interested in evaluating the health measures of the study population when ill with a cold, and the utilization of preventive health care services. The study population was drawn by 107 a systematic random sampling of households in a census tract that was identified as having a high proportion (91.4 percent) of Black residents. Respondents were categorized as belonging to a relatively higher or lower socio-economic class based on their occupation, education, and home ownership. The authors believe these variables best measure social class because Blacks have more problems obtain- ing good jobs and decent housing (p. 229). Similar to Cornely and Bigman's (1963) study sample, the Blacks who participated in this study had lived in the city for some time. Study participants reported a range of health behavior they engaged in when they had a cold. Sixty-two percent went to the doctor. There was no relationship between socio-economic status and physician visit. Fifty percent utilized either home remedies or over-the-counter drugs alone. Home remedies were very frequently used whether a doctor was consulted or not. The authors note that all the home remedies identified were "medically acceptable" for relief of symptoms. Respondents identified rest, rubbing, anointing with oil, and prayer as health measures. In the absence of any illness there were 65 visits to the doctor. Of the 53 that were for check-ups, 34 were patient-initiated visits. There was a non-significant trend for patient-initiated visits to be made more frequently by those in the higher socio- economic class who had lived in Berkeley at least five years (p. 231). Cowles et a1. (1963) summarized their findings by noting there was "no overall resistance to scientific medicine" when Black- Americans considered themselves to be ill. The low percentage of 108 respondents who were immunized was a finding similar to that of Cornely and Bigman (1963). The widespread use of "physical measures" to maintain health also replicated the findings of Cornely and Bigman and again documented that Black-Americans do engage in health prac- tices to maintain their health. Suchman (1964) made an attempt to describe Black-American health behavior within a broader framework of sociocultural influences (Coe and Wessen, 1965). His results suggested that ethnicity leads to socio-cultural differences which in turn lead to sociomedical varia- tions (p. 329). Sociocultural differences fall along the "cosmopolitanism- parochialism" dimension. The dimensions were measured by ethnic exclusivity, friendship solidarity, and family orientation to tradi— tion and authority. The cosmopolitan orientation reflected hetero- geneous and loosely knit interpersonal relationships, while the parochial orientation reflected homogeneous and closely knit inter- personal relationships. Sociomedical responses were measured by knowledge about disease, skepticism of medical care, and dependency in illness. They defined a "scientific-popular" health orientation as a continuum which was objective, formal, professional and independent at one end, and subjective, informal, lay, and dependent at the other end (p. 355). Suchman (1964) measured the positions of six ethnic groups in New York City along the dimensions of (l) cosmopolitan-parochial social group orientation and (2) scientific-popular health orientation. 109 Suchman's (1964) results showed significant differences among the ethnic groups in social organization and health orientation. As a group, Blacks had a tendency to be more cosmopolitan than parochial which indicated the lack of a strong ethnic identity and weak interpersonal relationships, a finding supported by Snow (1974) and Rainwater (1970). Differences in health orientation paralleled differences in social organization. Only 27 percent of the Blacks exhibited a popular health culture. Within each ethnic group, those who belonged to a parochial social organization were more likely to exhibit a popular health orientation. Thus the relation- ship between social organization and health orientation was inde- pendent of ethnic background. Examining socio-economic class dif- ferences within each ethnic group revealed that socio-economic class impacted social organization and health orientation regardless of ethnic background. Additionally, when ethnic background, social class, and social organization were examined, it was the latter variable which had a greater impact on health orientation. Suchman (1964) concluded that "the form of social organization transcends the mere fact of ethnic group membership in determining sociomedical variations" (p. 328). Coe and Wessen (1965) evaluated Suchman's finding in terms of the effect of ethnicity on health behavior. Those individuals who were parochial, that is, who exhibited a strong sense of ethnic identity, were more skeptical of doctors and tended to delay or resist seeing a doctor. Parochial social group members were more 110 likely to turn to their ethnic group resources for advice and sup- port. For many ethnic groups, a lay referral system is an alterna- tive resource for health and illness care. Cowles et a1. (1963) identified the older woman of the Black-American population as influential in matters of health and illness. Twenty-one percent of their study population indicated they consulted a relative for advice when sick. Of the 32 relatives specified, more than half were mothers and aunts. Almost one-fourth of the respondents in Cornely and Bigman's (1963) study indicated they would turn to religion, family, or friends if medical care did not provide quick relief. Perhaps the major conclusion that can be drawn from the multiple studies reviewed is that within the Black-American health culture, the influence of many attitudinal and social variables lead to variations in health behavior. It is therefore difficult, if not impossible, to generalize the findings of any of the studies reported here. Thus it should not be assumed by health professionals that Black-Americans will always exhibit negative health behavior due to a "culture of poverty." Within the Black-American ethnic group there is a range of health behavior based on positive atti- tudes about health and sometimes negative attitudes toward the modern health care system. Literature addressing the Black-American's health behavior regarding the risk factors of heart disease will be presented next. It shonlbe remembered that the health behaviors defined by the 111 operational definitions of this study are all health maintenance practices which can be engaged in without entering the modern health care system. Health Behavior Related to the Risk Factors of Heart Disease. The literature addressing the Black-American's health behavior related to the risk factors of heart disease documents health maintenance practices dealing with nutrition and exercise. Cornely and Bigman (1963) reported many of the families in their study believed that citrus fruits cause acid in the blood and red meats have an effect on hypertension, beliefs which the authors stated were "food fallacies which were exploded years ago" (p. 24). They noted an association between educational level and prior residence in an urban area with a decline in these nutritional beliefs. YSnow documented the Black-American's conceptual confusion of "high blood" with high blood pressure (1977, 1976, 1974). She pro— vided a more accurate and justifiable explanation for beliefs labeled as "food fallacies" by Cornely and Bigman (1963). Black- Americans believe that the status of the blood is influenced by various internal and external stimuli. Diet is an example of an internal stimulus. Snow noted that "the notion that the volume of blood increases and decreases according to the diet is probably the most important folk belief in which clinicians should be aware" (1976, p. 54). The terms "low blood" and "high blood" are inter- changed for low and high blood pressure. High blood, that is, high blood pressure, results from eating too much rich food, in 112 particular red meat. Symptoms are dizziness, palpitations, head- aches, and vision problems- Folk treatment consists of eating foods which will decrease the volume of the blood, as for example, lemon juice, sour oranges, epsom salts, and the brine from pickles (Snow, 1976, p. 54). Thus, to be informed by a health practitioner that one will have to take medications to control high blood pressure for an extended period of time is perceived by the Black- American as a conspiracy between the practitioner and the pharmacist to make money. Home remedies are more "natural," cheaper, and take less time. As Snow observed, if a person can successfully lower his high blood (pressure) by drinking vinegar in hot water daily for nine days, why take medication (1976, p. 55)? Thus the health pro- fessional giving care to the Black-American needs to be aware of the concept of "high blood," its confusion with high blood pressure, and its folk treatment. Because the Black-American will not disclose these beliefs to the health care practitioner for fear of ridicule, it is important for the practitioner to assess for belief in "high blood," and to plan and implement appropriate treatment and educa- tional services. The adolescent respondents participating in Brunswick's (1969) survey revealed an awareness of their health and an ability to identify their good and bad health practices. As a group, Spanish, Black and White adolescents identified their health concerns as not getting enough exercise (35 percent); not eating the right kind of food (28 percent), the right amount of food (12 percent), not eating regularly (10 percent); smoking or smoking too much 113 (23 percent); not getting enough sleep (20 percent); and eating too many sweets (16 percent). Several of these health concerns contri- bute towards the development of the risk factors of heart disease. Of those who indicated they exercised regularly, Black adoles- cents exercised more than Spanish-speaking adolescents in all categories. Of the 78 percent Black adolescents who smoked regularly, 22 percent smoked less than ten cigarettes a day. These figures did not differ significantly from those for Spanish-speaking and White adolescents (Brunswick, 1969, p. 1738). They indicate that the onset of the risk factors of heart disease occurs early in the Black-American's adolescent years. However, their awareness of these "bad" health habits indicates an attitude about health which is conducive to teaching and shaping positive health behavior. Brunswick (1969) reported that the minority group adolescents in her sample pepulation valued good health more than the White adolescents. Eighty-one percent of the Black and 82 percent of the Spanish respondents indicated that it matters a lot to be healthy. Only 56 percent of the White respondents expressed the same feeling (p. 1741). It is clear that the positive attitudes about health expressed by Black adolescents and their awareness of "good“ and "bad" health practices provides a strong motivational base for health education. Attitudes about health learned during the socialization process of adolescence persist into adulthood. This is a worthwhile area for the health care professional to explore and develop when providing health care to the Black-American adult. It is especially important in view of the Black-American's 114 susceptibility to high morbidity and mortality rates associated with heart disease. The literature review has synthesized research studies des- cribing the Mexican-American and Black-American in health. The influence of attitudinal and social variables on health behavior has been described. Health behavior related to the risk factors of heart disease was discussed. This review will now present literature pertaining to the locus of control variable and its influence on health behavior. Specifically, the effect of health locus of control orientation on health behavior is discussed. Studies addressing health locus of control and health maintenance practices related to the risk factors of heart disease are reviewed. Locus of Control and Health Behavior The locus of control concept is derived from Rotter's social learning theory (1954), which says that the likelihood that any behavior or event will transpire is influenced and determined by (1) the individual's belief that his behavior will bring about a reinforcement, and (2) the value of the reinforcement to the indi- vidual. The reinforcement acts to fortify the expectancy that a particular behavior will ensure the same reinforcement in future situations. In a given situation, behavior is a function of specific expectancies relative to that situation rather than a function of generalized expectancies (Kaplan & Cowles, 1978; Lefcourt, 1966; Rotter, 1966). 115 Locus of control is thus the "degree to which the individual perceives that the reward follows from, or is contingent upon, his own behavior or attributes versus the degree to which he feels the reward is controlled by forces outside of himself and may occur independently of his own actions" (Rotter, 1966, p. 1). The dimen- sions~h~m¢m muz~hagmn 5:2 8238 8 p zoaezm>mmezH eszmaz 252 Orem's (l97l) nursing theory of self-care provides the frame- work by which the nursing implications of this study are discussed. Self-care is defined as "the practice of activities that individuals personally initiate and perform on their own behalf in maintaining life, health, and well-being" (Orem, 1971, p. 13). Self-care activities are based on two types of needs: universal and health deviation. Universal self-care needs are those required by everyone in the carrying out of activities of daily living. This type of need is related to basic human requirements for air, water and food, activity and rest, and protection from hazards to life and well- being (Orem, 1971). Health behaviors designed to fulfill universal self-care needs are therapeutic if they maintain health and prevent disease. Thus universal self-care is health care at the primary level where the emphasis is on health promotion and prevention of disease (Orem, 1971, p. 135). Health maintenance practices related to the risk factors of heart disease are universal self-care activities designed to maintain health and prevent heart disease. Self-care behavior is learned during the socialization process of childhood and is guided by cultural norms and expectations. The decision to engage in self-care activities thus reflects a cultural interpretation of health and illness and an individual perception of health care needs. A cultural interpretation of health and ill- ness is a component of an ethnic group, where the group shares common social experiences, values, norms, and attitudes which give it a distinct cultural identity (Saunders, 1954; Suchman, 1964). Thus 253 a cultural identity impacts perceptions of health and influences individual perceptions of health care needs and what self-care activities will fulfill these needs. Nursing interventions are initiated on the basis of the client's ability to perform self-care activities (Orem, 1971). In the supportive-educative system, nursing utilizes various combinations of support, guidance, and teaching to assist the client in overcoming self-care limitations (Orem, 1971, pp. 78- 79). The supportive-educative level of intervention is indicated for assistance with self-care activities related to universal self-care needs. It is therefore the appropriate level of intervention to assist the Black-American and Mexican-American male in meeting universal self-care needs related to the risk factors of heart disease. The findings of this study showed that engaging in health maintenance practices related to the risk factors of heart disease was independent of ethnicity. For these Black-American and Mexican-American respondents, self-care behavior related to the risk factors of heart disease reflect individual differences that are not necessarily related to their ethnicity. Thus, nurses should not mistakenly assume, as others have, that membership in an ethnic minority group automatically means negative health behavior and an inability to meet self-care needs at the primary level. Toward this end, nurses should gain insight into their own attitudes and beliefs which may perpetuate cultural 254 incongruence. Beliefs and values of the health care provider should not be forced onto the client. The assumption that ethnic minority group members do not engage in health maintenance behavior will impede the nursing process and hinder the ability of the nurse to assist the Black-American and Mexican-American client in self-care activities related to the risk factors of heart disease. Nurses should try to preserve client strengths that promote self-care abilities. An assessment of the Black-American's and Mexican-American's health beliefs and practices and familial and cultural resources will enable nurses to individualize supportive- educative interventions and make an impact on self-care abilities. This study did not measure ethnically influenced health beliefs, however the literature suggests that some of these beliefs may adversely affect the health status of the Black-American and Mexican-American male in regard to the risk factors of heart disease. The conceptual confusion of "high blood" for high blood pressure and its folk treatment has been documented in the conceptual frame- work chapter. However, the nurse should not assume that the Black- American client holds this belief. Rather, the finding that health maintenance practices related to the risk factors of heart disease was independent of ethnicity suggests that there are individual differences regarding such ethnically influenced health beliefs. Thus, the nurse needs to assess for ethnically influenced beliefs and implement appropriate interventions. For example, the nurse might approach the client by saying: Some people I know tell me 255 that eating too much red meat will make the blood go up. What do you think about this? In this way it is conveyed to the client that the nurse has an accepting attitude and knowledge of "high blood". The client may then be more willing to discuss beliefs which he knows are not shared by those in the dominant society. He may develop a greater trust of the nurse and be more amenable to nursing inter- ventions. When a client indicates a belief in "high blood", appropriate nursing interventions might include teaching about high blood pressure, its similarities and dissimilarities with high blood, and methods of prevention. The nurse should plan with the client for health maintenance and when possible incorporate folk treatments into the plan of care. For example, to discourage the drinking of brine from olives, the nurse would need to teach the client the principles behind sodium and fluid retention, and suggest that the client substitute some other acid food substances. Educative services to assist with control of dietary intake of high-sodium, high-cholesterol foods should reflect individual learning needs and provide experiences with problem-solving tech- niques and anticipatory guidance. For the male population of this study, educative services should include spouses and significant others to assist the client in behavioral changes related to nutri- tion practices. The health maintenance plan should reflect personal dietary preferences and consideration of culturally specific dietary habits. The development of a positive nurse-patient relationship 256 where the nurse exhibits an acceptance of individual beliefs and a non-judgmental attitude will enhance patient reception to techniques designed to assist with behavioral changes. When providing health care to the Black-American male, the nurse should assess for the positive attitude about health that was documented in the conceptual framework and the review of the liter- ature chapters. If present, it should be exploited as much as pos- sible to assist in meeting self-care needs related to the risk factors of heart disease. If not present, the nurse could use the influences of significant others to motivate the Black-American client, including the religious leaders of the community. As docu- mented in the conceptual framework chapter and noted in the discus- sion of incidental findings, religious leaders have influence within the Black community. The nurse could also assess for beliefs about perceived susceptibility and threat of disease, and costs and benefits of the identified health maintenance practices, and plan appropriate interventions, as for example, behavior modification techniques for the client who finds the "costs" high in terms of willpower. When providing health care to the Mexican-American male, the nurse needs to assess for the low perception about how present behaviors impact future health states. Nursing interventions include teaching and counseling about the risk factors of heart disease and the long-term decrease in morbidity and mortality associated with health maintenance practices. The nurse could also promote the belief that good health is necessary to carry out the 257 activities of daily living as documented in the review of the literature chapter. The influence of significant others, including religious leaders in the community, might also be used to motivate the Mexican-American client. Nursing efforts should also be directed toward reaching those Black-Americans and Mexican-Americans at risk for heart disease who do not seek out health care from an established health care setting. Knowledge of familial and cultural resources will provide the nurse with avenues to reach those at risk. In the conceptual framework chapter it was noted that those in the lay referral system were con- sulted on issues of health maintenance and disease prevention. The nurse might become visible in the Black-American and Mexican-American community, get to know the healers in the lay referral system, and show a desire to collaborate with them as peers. By showing respect and exhibiting a non-judgmental attitude, the nurse will be able to further promote the health status of her clients. The nurse can additionally be visible to the Black-American and Mexican-American male by patronizing schools, work places, churches, and community centers, collaborating with community leaders, and planning and implementing educational public health programs. The main implications for nurses in education are to (1) help students identify their own beliefs and values which may perpetuate cultural incongruence and hinder the nursing process, and (2) include opportunities for students to learn about ethnically influenced health beliefs and practices. Nursing education programs need to integrate courses into their curriculums so that students have 258 a knowledge base that will enable them to provide health care to "holistic man" which meets his biopsychosocial health care needs. Students should also be given the opportunity to plan and implement nursing interventions based on the Black-American's and Mexican- American's health needs, beliefs, and practices. In summary, nursing interventions for Black-American and Mexican-American males already meeting self-care needs should be directed toward positive reinforcement and support of self-care activities. Nursing interventions for Black-American and Mexican- American males needing assistance with meeting self-care needs should be designed to assist with the implied behavioral and life- style changes present in several of the identified health maintenance practices. Other research findings in this pilot study documented that there was only a weak relationship between health locus of control and health maintenance practices related to the risk factors of heart disease for the total study sample and the Mexican-American ethnic group. The value of this weak relationship was limited in view of the apparent lack of validity of the health locus of control scale. There was no relationship for the Black-American ethnic group. There is a need to develop an instrument which accurately and reliably measures health locus of control beliefs for Black- American and Mexican-American men. Nursing research contributions in this area are indicated. In spite of the inadequacy of the health locus of control scale to measure three distinct orientations, the social learning 259 principles underlying the health locus of control concept suggest guidelines that might be useful in designing nursing interventions directed toward promotion of self-care abilities. Since individuals possess expectancies about the likelihood of behavior in bringing about a desired outcome, nursing assessment of expectancies in health-specific situations is warranted. Specific to self-care activities related to the prevention of heart disease, knowledge of individual expectancies regarding the efficacy of engaging in health maintenance practices will enable nursing to individualize health promotion plans. Behavior modification techniques may be useful in promoting positive health behavior related to smoking and dietary habits, and weight control. These techniques should reflect individual beliefs and needs by including combinations of assessment and control of environmental stimuli, recruiting assistance from significant others, and promoting individual strengths in self-monitoring and regulating of reinforcements. For example, an individual who believes that his own actions influence the likelihood of acquiring heart disease might achieve weight control with self-monitoring of dietary habits and self—reinforcement of positive health behavior. An individual who believes that his actions cannot alter the likelihood of acquiring heart disease may achieve success in losing weight by identifying factors in the environment which act as stimuli to over- eat. These factors could then be manipulated to control and rein- force positive dietary practices. Motivation to change dietary practices may be provided by social group pressures, and positive 260 health behavior reinforced by significant others in the individual's social network. Teaching someone who is not oriented to learning how he can prevent heart disease and maintain health would not be beneficial. Nursing intervention in this situation may be more productive if it were directed toward careful follow-up and develop- ment of an interpersonal relationship. The examination of the ethnically influenced health belief systems of Black-Americans and Mexican-Americans revealed beliefs which parallel the health locus of control orientations. The find- ings reported in this pilot study showed that it was not possible to state that Black-Americans exhibited an internal health locus of control orientation or that Mexican-Americans exhibited a chance health locus of control orientation. In view of the apparent lack of validity of the health locus of control scale, this finding was not surprising. In addition to further developing and validating the health locus of control scale for the general population, nursing research efforts should be directed toward assessment tools that reveal ethnically influenced beliefs about health. The health locus of control scale may be a valid measure of ethnically influ- enced health beliefs, however much research is required before this can be established. To promote the health status of Black- American and Mexican-American males, and to foster their self-' care abilities, nursing interventions should be directed toward assessment of self-care needs related to the risk factors of heart disease. Based on this assessment, the nurse should 261 develop and implement a mutually formulated plan of care for health maintenance and prevention of heart disease. Recommendations for Future Research From the findings of this pilot study, several recommendations for future research were identified. They are as follows: 1. This study should be replicated with several modifications. a. The criteria for admission to the study regarding the absence of a chronic illness should be met. If this is impossible because of the large number of men 40 to 60 years old with a chronic illness, there should be further statistical analysis to ascertain differences between those with a chronic illness and those without a chronic illness on mean health locus of control scores and health maintenance practices scores. Random sampling should be employed. There should be an established criteria for percentage of the questionnaire completed for inclusion in data analysis. For example, all questionnaires must be at least 75% completed. The researcher should also check for completion upon return of the questionnaire. There should be an established mechanism to obtain feedback from respondents who do not complete the ques- tionnaire totally to ascertain their difficulties with it and to modify it if necessary for future studies. 262 e. Further statistical analysis for differences in scores between those who are addressed personally by the researcher and those who are given the introductory letter and questionnaire by someone other than the researcher might be considered. In view of the high intercorrelatidn values for the three dimensions, the health locus of control scale needs to be further developed and validated for the general population, and specifically for the Black-American and Mexican- American population. It should be pretested on populations other than a young, middle-class, white population. It might include items which measure ethnically influenced beliefs about perceived control of health outcomes, in particular, beliefs in the powerful other dimension (God, lay referral system, folk healers). In view of the weak and non-significant relationships between health locus of control and health maintenance practices related to the risk factors of heart disease for respondents in this pilot study, the relationship between these two variables should be further studied. There is a need for further research regarding the effect of familial generation on health locus of control. The findings of this study showed that first-generation Mexican- Americans may possess expectancies about perceived control of health outcomes that are different from other Mexican- Americans. 263 The Black-American respondents in social class III appeared to exhibit a stronger internal health locus of control orientation than the Black-Americans in social classes IV and V. There is a need to statistically analyze differences in health locus of control orientation between social classes, including social class I and II. An assessment tool that will reflect ethnically influenced health beliefs might be a better predictor of health behavior than the health locus of control scale. There is a need to develop a scale that includes items to measure beliefs in high blood, the role of witchcraft in chronic illness, and the utilization of the lay referral system in maintaining health and preventing disease, in particular the utilization of folk treatments. The scale that measured health maintenance practices related to the risk factors of heart disease should be further developed. and reliability established. The food items which measured dietary intake of high sodium, high cholesterol foods may not have been valid items for the ethnic groups under study. They should be further studied and validated as to their relevance for Black- Americans and Mexican-Americans. More research studies are needed which document the Black- American's and Mexican-American's participation in health maintenance practices related to the risk factors of heart 264 disease. The review of the literature noted the lack of research studies in this area. 10. There is a need to identify other health behaviors not measured by the health maintenance practices scale engaged in by Black-Americans and Mexican-Americans. 11. The many factors that influence health behavior should con- tinue to be the focus of research studies. Some of these factors are: the effects of ethnicity, social class, and familial generation on health behavior; ethnic influences on the development of attitudes and values related to health; degree of adherence to ethnically influenced health belief systems; and variables which influence the decision to take health action, as for example, perceived suscepti- _ bility to disease, perceived severity of disease, and costs and benefits of health behavior. 12. There is a need for research studies which establish linkages between nursing interventions designed to promote the self-care abilities of the Black-American and Mexican- American and health outcomes related to the maintenance of health and prevention of heart disease. This is an impor- tant area for nursing to study in view of the high rates of morbidity and mortality associated with heart disease. In summary, this pilot study has raised several issues related to the relationship between ethnic background and health locus of control as it affects health maintenance practices related to the risk factors of heart disease. This study documented the independence 265 of ethnicity on health behavior where lower-class Black-Americans and Mexican-Americans exhibited a range of health behavior related to the risk factors of heart disease. Weak relationships between health locus of control and health maintenance practices were documented for the total study sample and for the Mexican-American ethnic group. There was no relationship for the Black-American ethnic group. It was noted that the weak relationships were not very significant in view of the apparent lack of validity of the health locus of control scale. The findings of this pilot study suggested nursing implications to assist the Black-American and Mexican-American male in self-care activities related to the main- tenance of health and prevention of heart disease. In this way, this study contributed to the knowledge base of nursing regarding the relationship between ethnic background and health locus of control as it affects health maintenance practices related to the risk factors of heart disease. APPENDICES 266 APPENDIX A LETTERS OF CONSENT 267 1+ / 3- 7-20 flea. Edua'zdo Iounzo PHONE (313) 787-570! OUR LADY OF GUADALUPE CHURCH 6-2316 WEST COLDWATER ROAD FLINT. MICHIGAN 48505 mama 538/ /‘x" 51 / 0 OJ 71,9149 4f: )7” Witty o' I r». I 7' _ z‘ a!) g (5C1 6:-cCLtl" \‘ flaw ' / M—E'z/ (9’ é'v‘ ‘ l ' , . l I} _ ‘_ y, ‘ 1’, ' , [’1 .,- , ‘ ( 4. )(‘ . ‘ (“Cl -xéLu'uC-a‘J—“74‘r q’m‘rcw aédzt. , ,4 7 ('_.z.mL.-L~Lu’mz_: Z’ )7“ - €595“sz A287,“... ’1 ,’ bid: I 76 1‘ f t azL/féi—CcL an? (My/we‘d (.49-gt, ((4.ch , (E(éWMfl/L 6L; “WLILCLLLL, a? \l/_/‘ , A“€.L"J-vé"7l ffiMJ/I fl I" ét-‘lia-("E ( fan I £¢'[?7 '. 268 269 L. Galvar'y ‘Bible G'urcb MAIL 2490 JOLLY ROAD REV CARLOS H DIAZ P 0 BOX 16277 OKEMOS MICHIGAN 48864 2712 ROSELAND LANSING Ml 48901 TELEPHONE 349-4980 EAST LANSING MI 48823 TEL (517) 351-7761 To Whom It May Concern: This is to inform you that Miss. Roberta Boyden has our authorization to conduct her research work among people form our church. This is specifically a voluntary help and we concent to participate in this study, and we give our permission tc present the answers, that are necessary. Sincerely: ” MT/cd “JRCUCIIITO I. II. IICHO AVII. HOV Y POI LO. .IOLO." "II. 18:. 270 CHURCH OF GOD aev.maIELcoezo-~m 2326 HIGH STREET —- LANSING — NICHIGAN —- PHONE: 482- 2597 v.1 Anna a. "so To WHOM IT MAY CONGIRN. Tm: LCT‘I'II is 1'0 Au'rwoaizt use: or 7w: Hum-m Foams 'rrwr was: TAKEN AT SPAM-H Crimea Or Goo on an N. Hum 51'. m LAwomo. M1 av Ma Bovotn. To usu- wta macaw: an "As-rants. THANK vou ron voun ATTINTION SINCIRILY [4% 4.... Rev. mute 271 amputees-mama" CDMI WDRIHIF WITH U. % 1am ILLINDII A? a. NORTH mama. MIDI-"BAN «one 402-3004 thrch 29, 1980 To Hhoa.it may concern: m. is to certify that Ha. Roberta Boyden, 3.11.; with re- aidence at 5715 Shaw St. Apt. 7; Haslett, nichigan, 48840; has been granted permission to carry out an investigation on "Health, belief and practice" along the lale pepulation of aexican-anerican, ages 40 - 60 at the Good Shepherd Riapanic Baptiat march. 272 :‘o’gswmmt c" or CHURCH OF GOD IN CHRIST S'g‘g‘ifim' "E, mum“ or 4844235 1:: Street in"... 5.. ...... manor 3» 0. com was 31.38.18,...“ I. 8. GREENE. Asst. “mister 60] Hugh“ 1m. . Mg, ““31qu ELIIAH SANDERS. Asst. Minister SSE Gm. Secretary ALMA SMITH. Secretary MANUAL Pm, Dem m CID-7100 BOY IOPLIN. Deacon ”w” '1 "m: 'm‘" Prestdtnq Bishop at Northern Canada 3%?m'm'fio“. Treasurer State Sunday School Superintendent of Southwestern Michigan Secretary at National Finance Committee Mallet“ Board Member at the Interfaith Council and Treasurer Member of Board at Directors Urban Leaque April 18, 1980 Ms. Roberta Boyden 5715 Shaw St. Apt. 7 Haslett, Mi. 48840 Dear Ms. Boydent You have my pernission to address ay congregation and to administer a questionnaire concerning Health Beliefs and Practices, on Sunday, April 20, 1980. Participation will be voluntary. Sincerely, Rev. Bishop 5. C. Coles (fiemwwé mammmmrmstsmanswm 273 Urinal: A 331» It “limit liming, éflhhigan 439m CHURCH OFFICE REV. E. L. VANN, . 3500 WEST HOLMES ROAD 3440 WEST HOLMES ROAD PHONE (517) 882—5722 PHONE (517) 882-7068 Ms. Roberta Boyden, R.N. 5715 St. Apt. 7 Haslett, Hi. h88h0 February, 1D, 1980 Dear Ms. Boyden: In regards to the research you are doing to obtain your degree in nursing, you have my permission to visit our church on February 2hth to present your aspirations to the men of the church, and seek their help. I pray that you will obtain your degree in due time, and may God bless you in your vocation, and may you live long to serve your fellow-men. _Sincerely, Ed or L. Venn,Sr. dfinh nur,!hdhzr-fllhrhfi our aiahnnner -¢iflan our @Brnflher IN. J. I. oaavss. Paste! I“ fleet Hickman Awe. In. MO? 882-0196 Office: 05-9821 cmecu CL- he. Lola [the 1018 I Lenswee 886-183 CHAIRMAN 0' W60“. Lawns *‘IOIIC 2801 locate 335.0 CHAIM 0P rsusrus .1100" Lu tree I Kelsmroo 272-2872 mesa mean Isles MO Hume 02-1419 274 $1. Zion flissinnary Baptist Olhurrh 131‘) IALLAID IT. LANSING. MICHIGAN M The Church Across Town With A Downtown Program m7, 1979 it. Rberta Hayden 5715 Shaw St.-11pt. I7 malett, MI 48848 mark. m: IM.Jaeq1hE.&'aves.PastnrofflIeMt.Zimmesimazy Baptiatdnn'd'iherebyginis.RtertaBaydmpennissi addreestheaongregatimofthent.2im8aptistdnndianito Meters ' fliisdayOctnber‘l, 1979. milealthBeliefandPractiaesm 275 Galilrr Baptist Ollntrrh 1025 most Si. Jneepn 13m. “Box 10121 Innsinn. flirhignu 482101 Irv Ceca-Lt: q Y01.'f-Y uncro- teno w Mane .l'fi .Hf‘Nf AII.DIOI Cull-(a4 H~n~t ‘01 ‘HQt to thme It lay Concern: this is concerning a serrey that lies Roberta Boyden and I discussed In my office. The Servey she canted to tick among the men of our church eas'Health Beliefs and Parctices". I agreed that she could take the servcy and that it use not to be made publicly, only for her personal use in her work. 2he servey eas made on December 16th 1979, eith my App! 17131 e Rev. Charles S. rolbert pastor 276 REV. HERMAN GREEN, Pastor 1816 W. Kalamazoo - Phone 639-0727 fiamhisz @apiist (Chunk I29 NORTH PENNSYLVANIA AVENUE LANSING, MICHIGAN 48912 January 16, 1980 Roberts Boyden, R.N. 5715 Shaw St., Apt. 7 Haslett, HI 48840 Dear Ms. Boyden: RE: Michigan State University SchOol of Nursing As the pastor of Paradise Missionary Baptist Church, you have my consent to come in during our regular Sunday morning services on February 10, 1980 at 10:45 a.m. To acquire participation with the study, have the questionnaires completed on a voluntary basis. If you have any questions please call me at 489-0727. (0% 4'p«.z{é 4'30 (41 b '— ' e Yours in Christ, ..0 “714’“ efita "as, Rev. 8.8. Green, Pastor Paulin . Johnson, ch. clerk 886:? 277 Friendship Baptist Church 925 WEST MAIN STREET LANSING, MICHIGAN 48915 REV. E. C. HAWKINS December 17’ 1979 PHONE: 482-4264 CHURCH OFFICE: 372-9462 To Whom It Nay Concern: ks. Roberta Boyden was given permission by me, the pastor of Friendship Baptist Church, to address our congregation and administer a questionaire. She was received in a cordial way. and she gave a fine account of herself. Respectfully yours, (it 34.4 / 1 Rev. E. C. Hawkins 278 UNION BAPTIST CHURCH CHURCH .‘710. O 1020 W. HILGOALE STREET 0 LANSING. MICHIGAN WIS C 'AIIONAG! “24705 PASTOR luv. mamas J. uneasou March 3, 1980 TO WHOM IT MAY CONCERN: Miss Roberta Boyden, R.N. is given permission to speak at the Union Baptist Church on March 16, 1980 at the 11:15 worship service. We have allotted her five minutes to make her statement concerning her work. We trust it will be a benefit to all of us. Yours truly, ev. Charles J. Patter; n PASTOR Mrs. Barbara J. Davis CHURCH CLERK 279 :eryWW ‘ 1314 Ballard sum lamina, Mid-lean uses Phone: 482-1387 ANTONIO IENAVIOES Executive Director December 3, 1979 Roberta Boyden 5715 Shaw Street Apt. 7 Haslett, Hichigan 48840 Dear Ms. Boyden, This is to confirmed that you had my permission to address the patrons of Cristo Bey Health Program and administer a question- naire. I hope that the data collected will be of help to your work in your thesis. If I can be of farther assistance please let me know. Sincerely, . / ekhvn‘z'77UU£0Lz Connie Karin Health Coordinator 5% SUPPORTED av o 280 City of lANSING LANCINC. MICHIGAN “74870 “983 PARKS AND RICIMTION CITY HALL—4TH FLOOR August 1, 1979 Dear Miss Boyden: This letter is to confirm dates agreed upon for you to address the Kingsley Retirees and administer a questionnaire on Health Beliefs and Practices. Dates are as follows: Thursday, August 6, 1979 10:00 a.m. Thursday, December 13, 1979 9:00 a.m. We are looking forward to the interesting results of this study. Very sincerely, .é;);tzz¢4§ 72525t2‘29tz’ Irene Carter Agency Program Co-ordinator Kingsley Community Center 1C;cam APPENDIX B ENGLISH VERSION OF INSTRUMENT 281 Ethnic Background: The following items are to find out what the major ethnic or cultural influence is in your life, and which ethnic background you identify yourself with. Please check the box which best describes the ethnic background that you consider to be yours. Black-American [:1 Mexican or Mexican-American.[:] Caucasian [:3 Other If you have checked "other", please write here in the space provided what your ethnic background is: Education: Please place a checkmark next to the item which shows how much education you have. _____ 1) Under seven years of schooling 2) Seven to nine years of schooling .____ 3) Ten to eleven years of schooling 4) High school graduate ____ 5) One to three years college or business school 6) College graduate 7) Professionals (Masters, Doctorate, or Professional Degree) Occupation: Please write in the space provided exactly what you do fer work. Be specific, such as: "I work on the assembly line" or "I operate machines in a factory.” If you are currently not working, check this box 282 practices we have. you and your family have lived. Please answer each question and be as specific as you can. 283 The place where we are brought up influences the health beliefs and an answer, it is all right to leave the space blank. 1. these which you have. Where were you born? state country: How long did you live there? Mexico Therefbre, it would be helpful to know more about where This is the purpose of the fellowing questions. If you do not know U . S . ___Other How long have you lived in Michigan? Where were your parents born? mother: state country: father: state country: Where were your grandparents born? mother's mother: state country: mother's father: state country: father's mother: state country: father's father: state country: Below is a list of chronic illnesses. letter "3". CJ-P'DWN Him 900 0‘” high blood pressure (hypertension) overweight (obesity) chronic obstructive lung disease diabetes kidney disease (renal disease) liver disease cancer other (specify) Mexico Mexico Mexico Mexico Mexico Mexico none U.S. Other U.S. Other U.S. Other U.S. Other U.S. Other U.S. __Other Please place a checkmark next to If you do not have any chronic illness, check the too much cholesterol in the blood (hypercholesterolemia) Form A 284 MHLC This is a questionnaire designed to determine the way in which different people view certain important health-related issues. Each item is a belief statement with which you may agree or disagree. Beside each statement is a scale which ranges from strongly disagree (1) to strongly agree (6). For each item we would like you to circle the number that represents the extent to which you disagree or agree with the statement. The more strongly you agree with a statement, then the higher will be the number you circle. The more strongly you disagree with a statement, then the lower will be the number you circle. Please make sure that you answer every item and that you circle onl one number per item. This is a measure of your personal beliefs; obviously, tEeEE-are no right or wrong answers. Please answer these items carefully, but do not spend too much time on any one item. As much as you can, try to respond to each item.independently. When making your choice, do not be influenced by your previous choices. It is important that you respond according to your actual beliefs and not according to how you feel you should believe or how you think we want you to believe. e 3. Soon a u m u o as m a: o u o m «a m o u: e sess[:] Caucisico C] Otro [:J e ‘ R e ":0 ‘. I. I. a fi / ‘ / . '- 81 usted “a indicaoo otro , por facor CSCleL aqu1 e1 grtpo etnzco a] qpe oerteneoe: Eded: e A a e e I .4ucaoton: Por favor settle noted 01 owners gm: regs: descr1ba 1a ciLr:;:on qx‘ h: rr:2hi‘c. \ r W 1) Ionos do 7 ares » ”N ) -.ntre 7 y 9 c...’ 08 \ ~ 3) intro 10 y 11 anos A) Graduado do la escuola soooniaria (oolcgio ~ a e e 1 a e e s 5) artrc 1 v 3 anos do univer31 a: o lhEtltUtC profosolor"l 6) Graduado it ]a universidad n. I O In fl_ I O K O 7) alploma profeSional (licenoiado, doctorslo, maestria, inreolcro, etc. .‘ ‘ 0 O a / ) OF:C“ : Tonga 1a bondia do esoribir su oouoacicn cxactz, lo r"° ospsc":::- . : .. n n O . ea A n rr- . ~ -' manta p031bl.. Por edenplo, trabago in uni linCa do as; Lle'", o ".o, . .. .g .- , , \ ° .' . a v _ O Q a I m 1 lnaxtd er un Ts‘iica . Sl actualncui u‘ted no tlenc r" ac, Infillutlo 289 P \J viii For 0 “ a 290 htn v -ntos. n ndo fl. ‘.",] w + Jla \I(~ . g. E; (3 k .r 1a pr ta, bun .eto caia ‘ un a contee no W n. «I. my A... n I w. 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O 3 a w c a. ...... n. n ... a ..., .... ll ... 1i i. .1 ...o 1... .1 n... S r F. : Is... In... C r. T n. n n... ... S o E a. S n P. .1 \l;\.z\rz\;/)/\/\./\/)\./ IO .1 U n... I? 3 2. 5. U C I. a. Q ..,r. 3 n, .1. 1 n.. fl... 1». C A... G r. och .1 ...J D n... F v Na «4 j a “a 1.1.. 1., 1w. ..nJ. ...». ... e ... .o .L .- .L e e e m a . . r. o. .h flu. .i. flu e e o e e o... :1. .1 9a A.) b C ,. A U I MHLC 29] Esto es un cuestionario para determiner 1a mane ra en quo dive Hr as perso consideran ciertos asuntos relacionados con la salud. Cada pregunta C una oreonoia con la coal ustod punde o no estar de acuardo. A1 lads orcrjr+ hey una oscala que va entre disiento oompletamente (1) y concuerdo complctamente (6). Para oada pregunta, por favor ponga un cfroulo alredodor u indique olm nto difiere usted de la Opinion expresafla. Cuanto ed do aounr°o, mfs grande sari e1 numoro cuanto memos es-a do n C acuerdo, mgs p uefio se.a e1 numero. Por favor, con+este cada prcgunta, y - o- I A porfa un c1roulo alreded or do solamente ug numero rara cada pr egunt“ Este I , O O cuostzonarlo solo pldo las oreonoias persona he es obvio que no hay nlngnna rosouosta 'correcta' *1 'inoorroota'. Por favor, contestn la; praaurta: cor ouifla‘o, pero no ocuro so dema siaio en ninwmna or o: zata QHPCleiC'. Pasta doode spa potlblc trate dé cor+est€.r 0:6; trogunta sin paosar on 18‘ o‘raa, 3 no me dzge influenciar por Jas r9 puestm anteriores. ES imrort.ot; Pun ocotosto usted soyén lo quo realmento creO, y no sesfn lo one U: ad piensa es lo dobido, o lo gue netotro: quorenos cue uct crea. w o -p c # C +‘- C C.) C Q) E m E ('5’ E O H o m o o .- r— or-.' C) C . C) c- o L. L E $4 3: cf C‘ d c 2 a t) c. 2 C c c C O +4 +5 +" L {4 C C L: C). C) (D C3 C.) :1 :3 of-' or; or - O O L? L') U} C C "'1 0 r4 or-' C- O C: c: c: L) L) V l I 1. Cuanco me enfermo, la durac1on de la enferwedad es 1 2 3 u : doterminada por la manera en que yo me porto. J C I \ 2. No 1moorta lo q me haga, 81 me voy a enfermar, me 1 2 3 u 5 vo" a enformar 3. La major manera en que pm; Mo evxtar lag en’er- 1 2 a a a . . I ’7 J medados es vmsxtar a] meM 00 con freovenoia. I . a. La mayorla do las cosas que afoctan m1 salud 1 2 3 4 5 me sucedon por casualidad 5. Cuando no mo sionto bien, debo cor ojltar un 1 2 1 u q moiioo profosional. , 6. Yo mi. mo oontrolo mi Sc lu d. 1 P 7 U 9 7. Ni familia tiene mucho qua var con 81 mo 1 2 3 A : cnfermo o guardo buena salud. 8. Cuando me Pnfermo, yo mismo tengo la culpa. 1 2 q 4 5 .1 Concuerio comn1otamento 6 FOrmulario A 10. 11. 12. 13. 1h. 15. 16. 17. 18. La rapidez con que me recupere de una enfermedad se debe en gran parte a la suerte. Los profesionales encargados de la salud pfiblica controlan nd.salud. Mi buena salud se debe sobre todo a la buena fortuna. Lo qne mfis afecta mi salud es lo que hago yo mismo. Si me cuido bien, puedo evitar las enfermedades. Cuando me recupero de una enfermedad, generalmente es por- que otras personas (por ejemplo, médicos, enfermeras, familia, amigos) me han cuidado bien. Haga lo que haga, es may probable que me enferme. Si tiene que ser asi, guardaré buena salud. Si hago las cosas correctas, puedo mantener la buena salud En cuanto a mi salud, 3610 puedo hacer lo que me aconseja e1 médico. #4 Disiento completamente tu Disiento parcialmente I'D 292 l» Disiento un poco ‘t‘ Concuerdo un poco 4? 17:34? \h Concuerdo parcialmente 0“ Concuerdo completamente O\O\O\O\ 293 Las cinco preguntas siguientes tratan de determinar sus costumbres diaries. Por favor, ponga un circulo alrededor de la letra que mejor describa sus habitos. Indique 8610 una letra para cada pregunta. No hay respueatas correatas ni —7 ’ incorrectas. Solo me interesan sus habitos personales. 1. En un dia tipico, Lcuéntos cigarillos fuma usted? a. ninguno b. menos de media caJetilla c. entre media caJetilla y una caJetilla d. una caJetilla e. mas de una caJetilla 2. Durante los doce meses pasados,&ha ido usted para que le tomaran 1a presi6n arterial? . a. 31 b. no 3. LCon qné frecuencia se pesa usted? a. una vez a1 afio b. una vez a1 mes c. cada seis meses d. una vez a la aemana e. otro caso (especifiquelo) h. SCon qné frecuancia hace uated ejercicio o participa en una actividad fisica qne dnre por lo menos treinta.minutos? a. una vez cada semana b. tres veces cada semana c. diariamente d. nnnca e. otro case (eapecifiqnelo) 5. won qué frecuencia 1e ofrece d. trabajo de usted e1 ejercicio o la participa- ci6n en alguna actividad fisica que dare por lo menos treinta minutos? a. una vez cada semana b. tres veces cada semana c.‘ diariamente d. nunca e. otro caso (especifiquelo) 294 / ta es la ultina parte del Guest lonarlo. A continuacion se da una llsta ES de alime wt 08. Al lado de cada comida hay una escala que va entre muy a menudo (1) a nu nca o casi nnnca (3). Para ca 33 comida, Dongs un circulo alrededor del nfimw 0 one mejor describe la importancia de eso a1 inento en la dieta mated. Por favor indique solamente un nfimcro para caia pregun.a. Es impor- tante que net 91 conteste sezfln sus h5_itos veriaderoz, y no segfin lo qua ust d picnsa debe ser sus habitos. Bate alimento figura en mi dieta: muy a menuio do vex on nunca o cuando casi nunca 1. loche conjlota (eon Greta), crema, / hrlaio, requeson (sour oral") 1 2 j ?. co“"" “? morieria, por ejerjlo para? *1 4“ r‘ \, A ‘ , , H V + 2‘ ..31 PF} " fl ‘n ’ n-2pvntlo 0:333. ,Afivenfi P ...-lk ,,A 05-, toetada: d: “€12 (oJr: chips), fretzolt 1 2 j 3. comida fri t3 en Virtrc“ do ”rifle“ o I A prinzue o otra vrfica or arimfil 1 2 ‘ Z c / I i, garro de ccr:o, gawow, toolao, 911341110, pernil, salchict: 1 2 3 J. nesoedo salado o a*um m3 1 2 3 I a + ‘ . .1 “ 'x 3. / 3. Wu“ éiu1]-a o m r: “in“ comun es ‘ O O / oecur, glc no t are acei+e do matz, girasor, soya, 955310, sewilla dc / a algdioe, alazor) 1 2 J 7. Pantoca do cacahuote 1 2 j 9. queso 1 2 3 9. mis do 3 huevos cada somana 1 2 3 10. eepecia: y guises tales oor' concurido en polvo (:ouillon), e 133 do io:::fc alsa de Worcestershtr:, mostaza 1 2 j 11. perros calientes, fiambres como salchichdh de Bolonia (bologaa) 1 2 3 1?. chocolate 1 2 3 1° uso de Se] a la mean 1 ° ‘ J. - 4‘... * .\ -4 A. .7 J 1.”. hf,94(\ cofiqo y‘fi'knnnc C(‘V'mnorwchv .. . A 6.9;! ..., va 3-x), ‘ —