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J ' I
STUDY OF THE NEED FOR SOCIAL WORK

1 SERVICES FOR THE TUBERCULOUS AND THEIR
FAMILIES IN BATTLE CREEK, MICHIGAN

Roberta R. Greene
May 1962

 

 

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A STUDY OF THE NEED FOR SOCIAL WORK SERVICES FOR THE TUBERCULOUS

AND THEIR FAMILIES IN BATTLE CREEK, MICHIGAN

Roberta R. Greene

A PROJECT REPORT

Submitted to the School of Social WOrk
Michigan State University
in Partial Fulfillment of the
Requirements for the Degree
of

MASTER OF SOCIAL WORK

May 1952

Apyroved: E J\rV\J£S$JEEV§HNEBJJ\K7“1)L_'
__ 'fi _—" ‘

Chairman, Research Committee

 

THESIS

 

TABLE OF CONTENTS

PAGE
PREFACE I
LISTS OF TABLES II
INTRODUCTION 1-2

Chapter
I. HISTORICAL BACKGROUND AND CURRENT OPINION . . . . . 3-7

II 0 METHODS AND PROCEDUES o o o o o o o o o o o o o o 0 8-10
III. PRESENTATION AND ANALYSIS OF DATA . . . . . . . . . 11-27

Description of Caseload

Social and Psychological Data

Use of Community Agencies

Health Problems in Addition to Tuberculosis
Identification of Social WOrk Needs

IV. CONCLUSIONS AND RECOMMENDATIONS . . . . . . . . . . 28-30
BIBLIOGMPIN O O O O O O C 0 . O O C O O O O O O O O O O 0 31-33
APPENDIX

Schedule . . . . . . . . . . . . . . . . . . . . . . 34-35

TABLE
1.

LIST OF TABLES

Age of Patient at Opening of Case . . . . . . .
Marital Status . . . . . . .. . . . . . . . . .
Classification of Occupation . . . . . . . . .
Number of Social and Psychological Problems . .
Number of Agencies Contacted by Number of Cases

Public and Private Agencies Connected with the
Tuberculosis Case . . . . . . . . . . . . .

Number of Health Problems . . . . . . . . . .

Relation of Ease of Hospitalization to Against
Medical Advice Discharges . . . . . . . . .

.12

.12

.12

.17-18

.19-20

. 20-21

PREFACE

The data for this study was collected under the auspices
of the Michigan Department of Health and the Calhoun County Health
Department. I would like to thank them for the use of the data
and the wonderful c00peration of their staffs. I would particularly
like to thank Mr. Robert Shipman of the Michigan Department of Health for
his help and guidance in this undertaking.

A Special word of thanks to my husband, David, for making the

statistical work involved in this study almost bearable.

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INTRODUCTION

it has long been recognized that in addition to medical needs the
tuberculous patient may have a multitude of problems. It is only recently
that widespread efforts have been made to evaluate and meet these needs.

It was in the recognition of the necessity for objective evaluation of the
needs of the tuberculous that this study was undertaken.

The purpose of this study was to determine whether or not the tuber-
culosis patients of Battle Creek, Michigan had social and/or psychological
problems of such a nature as might warrant social work services. It was
h0ped that the extent to which such problems existed, as well as what forms
these problems took might be determined. In this way, the question as to
whether or not there were unmet needs for social work services among Battle
Creek tuberculosis patients and their families might be answered.

It was not the purpose of this study to try to prove that tuberculosis
is a psychophysiological illness nor to investigate the medical care
received by these patients. The sole purpose was to show that social and
psychological problems, which could require social work services, existed among
tuberculosis patients of Battle Creek. It was not directly determined if
these problems interfered with medical treatment. In all instances medical care
was assumed to be adequate. The problem was one of evaluating the need for
medical social work services in that it was assumed that where tuberculosis
was aggravated by the strain of social and psychological problems and
vice versa, the individuals affected coul not function in a society to
the utmost of their ability.

There has been much published already on the socio-cultural factors
associated with tuberculosis. The case for social services for the tuber-
culous has been established in several instances. The focus of this study
was to objectively evaluate the need for such social work services in the
city of Battle Creek, Michigan. in this reSpect the problem was also one in
community organization.

The goals of the study were stated as quettions rather than in hypo-
thetical form, as the study aimed at description and analysis rather than

at the determination of causal relationship. The study attempted to -

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answer five major questions:

I. What was the pattern of residency, age, sex, ocCUpation, family
composition, and general socio-economic status of the tuberculos
in Battle Creek, Michigan? Do studies of other areas show these
patterns to be representative

2. What social, psychol09ical, and health problems do the tuberculous
of Battle Creek reveal in their relationship with the public health
nurse

3. What community resources are available for the use of the tuber-
cdous in Battle Creek, Michigan? (What do some other communities
provide?) To what extent are the available resources used?

b. What are the unmet social work needs?

5. How could these unmet needs be met by the community? How would
the role of the social worker differ from that of the public
health nurse in meeting unmet needs? How might these roles
overlap?

The study was done under the auspices of the Michigan Department of
Health. The Department was interested in evaluating Michigan's need for
social work services in the general field of public health, and in the case
of this study, for the tuberculous. The investigator served as a medical
social work extern for the Department during the summer of l96l, and was
assigned to a local health department for purposes of conducting this
study. The Calhoun County Health Department, located in Battle Creek,
Michigan was selected for this study because of its receptive attitude toward
the field and phil050phy of social work.

Officials at the Calhoun County Health Department, through previous
studies, were aware that there were many "multi-probleM'families on their
general caseload. They were particularly interested in knowing the
extent to which multi-problem families could be found on their tuberculosis
caseload. The obtaining of this information was still another goal of the
study. It was h0ped that this question could be ansered objectivelyvdlle
investigating social and psychological problems, in general.

It was hOped that the study would result in a more effective use of

social services in the field of public health in Michigan, particularly for

the tubercdbus.

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CHAPTER I
HISTORICAL BACKGROUND AND CURRENT OPINION

Tuberculosis was very prevalent in society in the seventeenth and
eighteenth centuries when wave after wave of fatal epidemics periodically
Spread through large segments of the population. In those days, tubercu-
losis was always with the people and nobody paid any particdar attention
to it, at least not any more than any other disease.

The true medical nature of tuberculosis was not understood until
fairly late in the nineteenth century. During this century many medical
and social conditions greatly favored the spread of thie disease. It
was the chief cause of death in all ranks of society. At this time the
standard of living was comparatively low, and the gap between the rich and
the poor was far greater than it is today. Doctors who have tried to trace
tuberculosis back to its source have said that the poor environmental con-
ditions under which such a large portion of society lived, must have been res-
pnsible for a great deal of the spreadand prOpagation of the disease.2
Facilities for treatment were poor and the peOple had very little know-
ledge of the mode of transmission of tuberculosis, and therefore took few
measures to prevent the disease from spreading.

With the twentieth century has come a gradual and steady rise in the stan-
dard of living. There has been much progress in the public health field and
in private health measures. According to Dr. Esmond R. Long, “the twentieth
century has seen a perfectly extraordinary improvement in the methods of

medical treatment.“ The death rate due to tuberculosis has dr0pped enormous-

 

lDr. Esmond R. Long,“The Field of Tuberculosis, A Multi-Discifline

Approach to It", Social Work Practice in the Field of Tuberculosis,
ed. Eleanor E. Cockerill, (Pittsburgh: University of Pittsburgh Press,

1958), p.llb.

2mm” pp.lla-llb.

3Ibido, ppolla‘IIbo

ly, yet many feel that the case loads have not been reduced correspondingly,'

Dr. Long has stated that there must be a medical and a social attack
against the spread of tuberculosis. Among the social factors which could be
attacked are ignorance, poverty, and lack of community responsibility. The
continued existence of tuberculosis was seen by Dr. Long as being partly
linked to the fact that some groups of people are ignorant of prOper hygienic
and nutritional procedures. Poverty also stands out conspicuously among the
social conditions responsible for tubersulosis. Today the poorer peOple
have the highest rate of tuberculosis, while the economically more favored
are much better off.

Today tuberculosis is understood as a disease which must be conquered
by many disciplines working tOgether. Educators, community planners, social
workers, nutritionists, legislators, vocational counselors, and technical
experts of all kinds are necessary for the job.

Just where the services of the social worker fit in this multi-
discipline approach, can be more preperly understood if one first underé
stands some of the social, economic and psychological problems associated
with tuberculosis. A. Frances Berry discusses several factors inherent in
tuberculosis and its treatment, each of which may cause emotional difficulties,
strains in family relationships, and the need for environmental adjustments.”

The first factor discussed is chronicity. All that can be said about
the emotional components of a chronic illness can be applied to tuberculosis.
In addition to environmental problems, such as financial care, care of
children, or a need for housing, tuberculosis entails emotional adjustments
because of the long-term treatment and convalescence involved. Ambitions
and future plans must often be postponed or abandoned. During months and

5

years of treatment, economic and social status may be changed.

 

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A. Frances Berry,“Social Work In Tuberculosis Control", Reprinted from
the TTansactions of the Forty-third Annual Meeting of the National
Tuberculosis Association, l9i-I7. p.2.

lbid.

vi

————'7

A second factor which has been a source of difficulty for individuals
with tuberculosis is the need to be isolated for treatment. The separation
of the patient from his family over a long period of time may change the
whole family constellation. Certainly, the patient and his family have to
readjust to each other at the time the patient returns to the home.l

The “unpredictability“ of the tuberculosis is a third factor affecting
the tuberculosis patient. Tuberculosis is a recurrent disease. It may
be reactivated without apparent reason, despite the best medical care.

The anxiety this can cause the patient and his family can often make
adjustment to a normal way of life extremely difficult. The whole family
of the tuberculosis patient often needs help in handling its fears about
the disease.2

The symptoms of tuberculosis are often unrecognizable until the disease is
discovered. This can pose yet another problem for the tuberculosis victim.
It is often a freat shock for the unsuspecting individual to learn he has
tuberculosis

Thus, there are four factors inherent in the nature of tuberculosis,
namely chronicity, isolation for treatment, unpredictability of the
disease, and unrecognizable symptoms, each of which in itself can cause
or precipitate serious casework problems. According to Berry, one needs
only to take into account the above mentioned factors to realize that
tuberculosis is an illness which necessitates the best casework services
and community c00peration which can be offered--from the beginning of
diagnosis through the patient's adjustment following hospitalization.

SOphia Bloom, a medical social worker formerly with the Tuberculosis
Control Division of the United States Public Health Service, has stated
that it is not commonly accepted that all persons suffering from tuberculosis

have economic and social problems which are an inherent part of the illness.5

 

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Sophia Bloom, “Some Economic and Emotional Problems of the
Tuberculosis Patient and his Family," Public Health Reports, Vol.

LXIII, No. lh (April 2, l948), p. 4&8.

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To begin with, she points out, tuberculosis is a chronic and expensive disease.
Few people are able, alone, to meet the cost of medical care.I General relief
and categorical assistance are the usual sources of support. The sum given

in many areas is insufficient to maintain a minimum standard of living.
Although a patient may be eligible for relief, it may be a severe blow to the
breadwinner's pride that he can no longer care for his family. Economic in-
security may also intensify any existing emotional problems as well as cause
additional anxiety.

Problems other than economic insecurity are of great significance to
the tuberculosis patient. These are many reasons for the emotional difficulties
experienced by almost all patients. Among these are the shock of the diag-
nosis, fears, anxieties, superstitions, sense of shame, anddespair. The
tuberculosis victim is suddenly faced with the necessity of an immediate
adjustment to a new and terrifying situation. The emotionally insecure
person will find it even more difficult to meet this new and frightening sit-
uation.5 Some studies have even concluded that an abrupt rise in frequency
of both economic and personal stress occurs in the year preceding the onset
of tuberculosis. The frequency of“life creses" was found by one investigator
to clearly distinguish the tuberculous group studied from the nontuberculous.
However, this takes us into the field of psychosomatic medicine, which is not
within the province of this study.

It is clear from the literature that tubechbsis is both a physiological
and a social disease--social in its causes and its consequences. Certainly,
from a theoretical standpoint it seems clear that social workers can help
effectively to combat the psycho-social problems assockted with tuberculosis.

The next two sections will be devoted to an objective evaluation and

discussion of the make-Up of an actual tuberculosis caseload. It is hoped that

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6Thomas H. Holmes et. al, “Psychosocial and PsychOphysiologic

Studies of Tuberculosis,"Psychosomatic Mediciqg, Vol. XIX, No. 2
(MarcheApril, l957). p. 139-

this evaluation will lead to a deeper understanding of thesncial work
needs of the tuberculous. ’

The following sections will deal with conclusions and recommendations
including a discussion of the various ways communities have met or can

meet the need for social work services for the tuberculous.

CHAPTER II
METHODS AND PROCEDURES

The data for this study were obtained under the authority Of
the Michigan Department of Health and the Calhoun County Health
Department. They were collected from the records of the public health
nurses of Calhoun County.

Under the present organization of the Michigan Department of
Health and its county departments, the public health nurse has a
great deal of professional contact with the tuberculosis patient
and his family. The amount of contact depends upon such factors
as the duration of the illness, whether or not the patient is hos-
pitalized, and if so, on the length of confinement, the need of the
family in terms of health supervision, etc.

All doctors must report diagnosed and suspected cases of tuberculosis
to their county health department. Mass tuberculin testing and a follow
up of patient's contacts also helps to discover those with the disease.

Once the cases become known to local health departments, it then be-
comes the function of the public health nurse to help the family to follow
the recommended course of medical treatment.

Each nurse has a district within the county in which she visits
all persons on the public health case loads, including tuberculosis
patients and their families. The nurse will help the patient and his
family plan for medical treatment in a sanitarium. Where medically
possible, the nurse may help the patient continue his treatment at home,
after a brief stay in a sanitarium. In either case, the family must be
instructed in the pr0per procedures they must follow. Periodic visits are
made to be sure the patient and/or his family are following proper medical
procedures. In cases where the patient is hospitalized his case will still
remain Open. During this time, the nurse may call on individuals who could
have been infected by the patient, and encourage them to be tested. Members

of the patient's family must be checked routinely over a period‘EFf time

~11

to see if they have been infected. After the patient's return to the home,
his case will remain Open until the medical officer has said it may be
closed. Until their case is closed, the nurse continues to call on the
patients to encourage them to follow the necessary routine to prevent
relapse, and to encourage them to take the required follow-up x-rays.

During all the time the nursehas had contacts with the patient
and his family, she has gathered much important medical, social and
psychological information. Records were kept in which the nurse recorded a brief
account of each visit or interview. These records serve as a means of
recalling pertinent information, Of making case revias, and as a source of
reference when there is a change of nurses. These records include, in some
instances, the accounts of several nurses who might have worked on a case
over the years. This gave the investigator a fuller picture of the patient
and his family from more than one point of view.

The reliability of the data obtained by the investigator depended, of
course, upon the assumption that the nurses had recorded all pertinent social
and psychological information accurately. Public health nurses have
received some education in the psychological and sociological disciplines;
therefore they probably observed and recorded with a sufficient degree of
competency for purposes of this study.

A schedule was used by the investigator in extracting the pertinent
data from the records. The Social and Psychological Profile, which serves as
the first page of the schedule, was a slightly modified version of a form
used by the Family Service Association of America to summarize case material.
In addition to the profile, general socio-cultural data, such as age, sex and
family composition, were extracted. Questions were also included regarding
the use of community resources, health problems other than tuberculosis that
were faced by the families, and the disposition of the tuberculosis cases.

It was decided to limit the study to those individuals residing the the
Greater Battle Creek area. Greater Battle Creek includes the city of Battle
Creek and the four surrounding townships. Cases were also limited to those
that had been Open for at least a year, thus assuring a sufficient number of
recorded visits by the nurse. In the Greater Battle Creek area, there are
ISO individuals who either have tuberculosis or are still on the case load for
follow-ups, whose case had been Open for at least one year. One hundred

and thirty-six of these individuals are included in the study. The remaining

.—
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10

lb individuals' cases were omitted because their records were undergoing
Since the public

various clerical procedures and were not available.
there may be

health nurse records are in the form of family folders, and since

more than one case of tuberculosis in a family, this study deals with

I36 patients discussed in 120 family folders or case records.

CHAPTER II I
PRESENTATION AND ANALYSIS OF DATA
Description of the Caseload
Sex and Age

Of the l36 patients, discussed in l20 family folders, seventy-eight
were male (57.3%), and fifty-eight were female (h2.7%). The Greater Battle
Creek area, in general, had a strikingly different prOportion of males to
females, h9.9% and SO.P% reSpectively. However, this diffence was not
found to be statistically significant. For the United States as a whole,

the males case rate was found to be nearly twice that of the female case-

ra te.2

The ages of the patients are the ages at the time they first became
known to the health department. A majority of the female patients (55.2%)
learned Of their disease between the ages of twenty and thirty-nine. A
large prOportion, (h8.7%) of the male patients became known to the health
department between the ages of forty and fifty-nine. For the United States
in general, more cases were reported in the 25-4h age group than in any
other twenty-year age period, and two-thirds of the reported cases were
between the ages of 25 and 6h, inclusively. In other words, most of the
tuberculosis cases reported for the United States in general, including

Battle Creek, were in the most productive years of life.3

 

IUnited States Bureau of Census. United States Census of Population:

1260, “General POpulation Characteristics, Michigan", Washington B.C.:
(United States Government Printing Office, l96|),p.98.

2Stanley Glaser and Paul Roney, Reported Tuberculosis Data, Public
Health Service Publication No. .560 (Washington: United States Government
Printing Office, I955), p.

3lbi d. ., p.22.

‘_-

12

TABLE I
AGE OF PATIENT AT OPENING OF CASE ( Battle Creek)

 

 

Females Males Total

Number Percent Number ‘Percent Number
Under 20 3 5.2 2 2.6 1 5
20-29 16 27.6 9 11.5 25
30-39 16 27.6 13 16.7 29
h0-49 9 15.5 16 20.5 25
50-59 2 3.h 22 28.2 2h
60-69 3 5.2 8 10.2 11
70 and over 2 3.“ 2 2.6 h
Unknown 7 12.1 6 7.7 13
TOTAL 58 100.0 78 100.0 136

 

Marital Status and Family Composition
The marital status of the patients, as indicatedin Table 2, represented
the marital status at the time of the study. Therefore, those individuals
categorized as married may have at one time been widowed or divorced. The
single classification included lh children. Over eighty percent (83.8%) of
the patients have been married at one time or another. Those patients

presently married accounted for 62.2% of the total number of patients.

TABLE 2
MARITAL STATUS
MARITAL STATUS PERCENTAGE
Married 63-2
Single 16.2
Widowed 7.h
Divorced 606

Separated 6-6

Percent
3.7
18.4
21.3
18.h
17.6
8.1

2.9

9.6

100.0

13

In determining the number of children per family, a family was defined
as two or more related persons living togerther. 0f the 120 cases, 111 could
be defined as a family. These 111 families were found to have 2h2 children
'or 2.18 children per family. This figure probably understates the average
number of children per family because families which were thought of as
having no children included older couples whose children were out of the
home and not mentioned in the record. At any rate, it is clear that due to
the large number of married patients, many of whom had children, tuberculosis could

very well be a disruptive force In the patients' family life.

OCCUPATION
OCCUpations of the head of the household were classified according

to the United States Bureau of the Census' Classified Index of Occupations

 

and Industries. In general, the vast majority of principal wage earners
fell into the grOUp that would be considered unskilled or semi-skilled.
Only a small percentage (7.5%) could be called professional or mana-
gerial. Twenty-five percent of the heads of households were engaged'

in service OccUpations, including janitorial, maintenance, and hospital
work. The fact that so many of the patients were unskilled laborees was

of significance for purposes of this study for several reasons. First, the
patient's income prior to his illness could have been relatively low and

irregular. There would usually not be much money set aside for an unan-

TABLE 3

CLASSIFICATION OF OCCUPATIONS
of the head of household

OccUpationaI Classification Incidence

Professional, technical and kindred h
Farmers and farm managers 1
Managers, officials and proprietors 4
Clerical and kindred A
Sales 7
Craftsmen, foremen and kindred 12
Operatives 24
Private household 1
Service, except private household 30

Farm Laborers and foremen 2
Laborers, except farm and mine 7
Other* 2
Reported as retired only 7
Reported as unemployed only A
Not reported ll
TOTAL 120

*Both in US Army

15

ticipated serious illness such as tuberculosis. Thus, if the principal wage
earner was removed from the home, many financial problems could arise. If a
wife and mother was hospitalized, there could be insufficient funds to hire a
Vmother substitute.“ Then there was the problem of the patient's employ-
ment after recovery. Manual labor, especially where long hours would be invol-
ved would no longer be possible, at least for quite some time. During the
many months of treatment, and recuperation, the patient's family often must
go on relief. In any case, there is certainly a great possibility that
tuberculosis patients and their families would experience financial
difficulty and the anxiety this difficulty could cause. Later in the study,
the data surrounding these possibilities will be presented.

Length of Time Case Open

The average length of time cases were poen was 7.8 years. This amount
of time included the entire time the case was known to the health department,
from the diagnosis of the disease, through treatment, and finally, follow-
up. This does not mean to imply that tuberculosis always necessitates many
years of treatment. Many patients return to the community after a relatively
short period of hospitalization. Most tuberculosis beds are no longer being
held by patients who occupy them for years on end. About half the patients
in the United States occupying beds on June 30, l960,had been hospitalized
less than 6 months. Only about 8% of the patients had been continuously in
the hospital for 3 years or more.1

Residence '

The places in which tuberculosis patients and their families lived
were plotted on a map of Greater Battle Creek. It could easily be stated
that a great number of these people resided in the areas closest to the
center of the city. These areas have traditionally been known among so-
ciologists as being occupied by families of relatively low socio-economic
status.2 These areas were also considered to be areas of high mobility and
social disorganization. Fewere patients were found to reside in the“higher

class" neighborhoods further removed from the center of the city.

 

‘shaw and Glaser, Tuberculosis Chart Series, Public Health Service
Publication No. 639 (Washington:United States Government Printing Office,
1961), p.13.

2
Ronald Freeman et.al. Principles of Sociology (New York: Henry Holt

and Company, 1952), p.363.

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Social and Psychological Data

There has been much written on the social and the psychological
problems associated with tuberculosis. One body of literature deals with
trying to define the relationship of psychosocial factors to the natural
history of tuberculosis. Most of these studies attempt to isolate various
psychological and social characteristics which tend to predispose individuals
to tuberculosis. Such was the orientation of the study headed by Dr. Holmes,
"Psychosocial and PsychOphysiologic Studies of Tuberculosis.“ In this study
it was found that the tuberculous subjects were sensitive, anxious, rigid
and emotionally labile. It was also found that disintegration of the
patient's psychosocial adjustment almost invariably occurred in the two
year period preceding the onset or the relapse of the disease. Such dis-
integration took the form of high frequencies of broken marriages, and
changes in residential and occupational status. The following quote from
the study gives a clear picture of the author's point of view:

These patients, when compared with the cultural norms, were

in many ways marginal peOple at the time of the onset of

tuberculosis. They started life with an unfavorable social

status and grew up in an environment that was for them

crippling. They were, in essence, strangers attempting to

find a place for themselves in the contemporary American

scene. As perceived by the individuals with tuberculosis,

the poorly understood world in which they lived was a

source Of perennial danger and the threat of being 'walled

off' and rendered 'helpless' was always imminent. The

nature of their attitudes and life experiences made it unusually
;¥i;diifficult for them to what was eXpected of them or what they

expected of themselves. As a consequence their attempts at

adjustment were characterized by unrealistic striving which

was not only unrewarding but also productive of cumulative

conflict, anxiety, and depression. It was in this setting of

increasing life stress acting on individuals whose limited

capacities were no longer adequate for resolving problems

or achieving satisfaction that tuberculosis developed.

Another body of literature deals with the social, economic, and
psychological impact Of tuberculosis. This view stress the problems inherent
in the nature of the disease. In this case, the emphasis was on such things
as the strain and anxiety which may result when there is constant worry over
finances, when family members are separated, or when family plans are dis-
rupted. This approach gives recognition to the fact that individuals may
have had social and eimotional problems prior to the illness; however, the
emphasis is on existing emotional and social problems whether or not inten-

sified by tuberculosis. This view is represented by Sophia Bloom:

 

IHolmes, op.cit. p.lhl.
2_..

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17

It is not so frequently recognized that all persons suffering
from tuberculosis have economic and wocial problems which are
an inherent part of the illness...Emotional adjuctments of a
profound and complex nature have to be mdde by the stable as
well as by the unstable, and the difference is merely one of
degree of intensity.

The above two points of view are not seen as conflicting, but are,

rather, a differnce in emphasis of areas for study and concern. Both are
important from a social work standpoint. The first point of view, which
deals with the social and psychological etiology of tuberculosis, is con-
sidered an area of concern for preventive social work. The second approach
points Up the fact that there are social and emotional problems which are
an inherent part of tuberculosis, and need social work attention. This
social work service would be needed regardless of the fact that the
problem originated before the onset of the disease.

In this study it was not poséble to ascertain whether or not
problems noted were in existence prior to the onset of of tuberculosis.
The study was aimed at determining the number and types of problems ex-
erienced by the tuberculous of Battle Creek during the time they were
known to the health department. The behavior of patients as described by
the nurse was categorized by the investigator according to her understanding

of the Family Service Association.

Table A
NUMBER OF SOCIAL AND PSYCHOLOGICAL PROBLEMS
Type of Problem Incidence

Family relationship g?
Marital difficulty

Parent-child relationship :2
Unmarried parenthoood
Individual personality adjustment #5
Children (l3 years or under) lO
Adolescents (lh to 20 years) 33
Adults (2| years or over) 32
Failure to accept community standards l6

--r

 

I
Bloom, op.cit. , p.1+’+8.

A

18

TABLE 3 (continued)

Planning substitute care of children 20
Old age 8
Mental illness 6
Diagnosed 5
Suspected l
Intellectual retardation l7
Diagnosed 8
Su5pected ' 9
Economic or employment 52
Educational and/or vocational Adjustment 12
Housing 20
Mobility l8
Other
Alcoholic lb

The study definitely pointed to noticeable disruption in individual
and family adjustment. (See Table h). Over one-half of the families
or individualshad difficulty in the economic or vocational areas. The
high cost of medical care and the financial strain and loss to families due
to tuberculosis has already been alluded to in various parts of this study.
All that need be drawn in here is the importance of the use of economic
assistance type agencies by the study group. (see Table 5).

Disruption of family life was noted in still other areas. Twenty out
of eighty-five families with children (23.5%) had difficulty with planning
substitute care of children while one or both parents received teeatment for
tuberculosis. This figure did not include the additional number of childfen
for whom relatives gladly cared outside the home, but never the less had to
be separated from parents and siblings. In extreme examples, as in the case
of family X, the entire family unit was idsorganized when the mother had to
leave the home for treatment. Mr. X. found the role of breadwinner and house-
keeper too mcuh of a burden. The family became known to the court and other
community agencies due to child neglect and mismanagement. These problems
soon cleared up when the mother returned to the home; however, the situation

still resulted in a sad drain on human and community resources.

19

The most serious problems in terms of incidence were in the areas of
family relationship and individual personality adjustment. Over one-third
of the tuberculosis patients were found to have experienced difficulty
in the area of family relationship. One-third of the families had at least
one individual who was considered to have a problem in the areas of personality
adjustment. The number was closer to one-half when alcoholics were included
in this group.

The number of alcoholics that are reported in this study does not in
any way reflect the magnitude of the problem of alcoholism among the
tuberculous. ”Alcoholism among tuberculosis patients has become a major
deterrent to effective tuberculosis control.”l The number of alcoholic
tuberculosis patients in sanatoriums throughout the nation has been
estimated at figures ranging from I5 to 85 per cent.

_g§e of Community Agencies

The study was designed to determine to what extent tuberculosis patients
and their families used the health and welfare resources of the Battle Creek
community. Table 5 illustrates the extent to which various agencies were used,
or at least the number of patients thought to have contacted particular
- agencies. Thable 6 gives a picture of the number of agencies contacted per
patients. Forty-three of the l20 families or individuals did not use any
public or private community resource other than the health department
itself. However, the remaining seventy-seven patients or their families used
an average of 3.6 agencies per case. The average number of contacts for all

the cases combined was 2.31 per case.

TABLE 5
NUMBER OF AGENCIES CONTACTED BY NUMBER OF CASES
Number of Agencies Number of Cases
0 1&3
l 22
2 ll
3 9

 

I

National Tuberculosis Association, “Fact-Finding in Alcoholism”,
Behabilitation Events, Vol. VII. No. 1 (Winter, I961).

lbid.

20

(table 5 continued),

1+ In
S 8
6 3
7 A
8 o
9 3
IO 1
II o
12 1
I3 0
1h 0
IS 0
16 I

Total contacts 278

Total cases 120

A total of 278 community contacts were made in all. The five agencies
with which families and/or public health nurses (in their behalf) had the
most frequent contacts were: 1) Local Branch of State Office ofVOcational
Rehabilitation, 2) Public Schools, 3) Service Clubs (for financial

assistance), A) Bureau of Social Aid and, 5) Department of Social Welfare.

TABLE 6

PUBLIC 8 PRIVATE AGENCIES KNOwN TO BE CONNECTED WITH THE T.B. CASES

Agency Number of Contacts
Office of Vocational Rehabilitation 24
Public Schools 22
Sercice Clubs 22
Bureau of Social Aid 20
Department of Social Welfare 20
Red Cross 20
Surplus Foods l3
Charitable Union 13
Medical Social worker l0
Andrew Kellogg School 10
Family Counseling l0

Cripple Children“s Commission

Volunteer Bureau

Police

Churches

Michigan Children's Aid

Veteran's Administration

Willard Trust Fund

Juvenile Court

Child Guidance Clinic
Salvation Army

W ‘_
“H

vac-w .P'U1U'I\I\l\l comm

2|

(TABLE6 continued)

 

Kalamazoo State Hospital A
Goodwill Industries 3
Probate Court 8
Needlework Guild 2
Legal Aid 2
Juvenile Home I
Girl's Training School I
US Immigration Service I
Ironwood Rehabilitation Center I
Coldwater State Home 3
Kalamazoo Children's Center I
Child Mental Health Consultant l'
Good Samaritan Home I
Private Firms (business) I
Easter Seals I
278 Total

Total of 36 Agencies

HEALIfl_PROBLEMS IN ADDITION TO TUBERCULOSIS

Tuberculosis patients and their families were found to have health
problems in addition to tuberculosis. These additional health problems were
those that were discussed with and recorded by the nurse. Only in twenty-two
cases were no additional health problems mentioned to the nurse. In fifty-six
cases, the families mentioned three or more illnesses to the nurse. Twenty-

six families discussed five or more health problems.

 

TABLE 7
NUMBER OF HEALTH PROBLEMS
Number of Health Problems Number of Families
0 22
l 27
2 l5
3 20
h IO
5 7
6 5
7 2
8 f3
9 3
IO 3
II 0
I2 0
l3 0
I! 0
l5 0
l6 3
W 120

average per family-3

22

It was also possible to ascertain information on the disposition of
the tuberculosis cases. An overwhilming majority of the patients had been
hospitalized at one time or another. Most of these were hospitalized with
relative ease and did not leave the hospital against medical advicd.
However, of the thirteen individuals who were hospitalized with some
difficulty, nine left the hospital against medical advice. It was important
to note that of the five individuals who were legflly admitted all were dis-

charged against medical advice.

TABLE 8
RELATION OF EASE OF HOSPITALIZATION TO DISCHARGES AGAINST MEDICAL ADVICE

 

 

 

Ease of Hospitalization Number Number of Percentage
Hospitalized A.M.A.S of A.M.A.
E—asTIy 103 16 15.5%
With some difficulty l3 9 69.2%
Required legal action 5 5 lO0.0%
total I2I 3 0 2h.8%

 

The literature has shown that the diagnosis of tuberculosis is
received by the patient in a variety of ways. Some patients may view the
diagnosis as a sentence of doom. Others feel a great sense of relief because
they hear in the diagnosis of a serious illness means of getting away from
an unbearable home situation, or an escape from psychological conflict that
seemed insoluble. Certainly, cultural as well as psychological make-up plays
a large role in the reaction of the patient to the disease.

Perhaps the central issue for the patient with tuberculosis to resolve
is his acceptance of the passive role. For some this is easy; while for others

2
it is difficult. This depends on personality and cultural factors.

IEricwlttkower and R.A. Cleghorn (ed.), Recent Developments in Psychosomatic
Medicine (Philadelphia: J.B. Lippincott Company, I95h), p.282:

2
lbid., p.28h.

23

Identification of Social Work Needs

The foregoing findings shed considerable light on the characteristics
of tuberculosis cases in the aggregate. However, it was felt that in order
to arrive at an objective identification of social work needs, it was neces-
sary to arrive at some empirical way of analyzing the cases by family units,
or dase by case. It was found that in analyzing the data from this point of
view the cases could be placed rather meaningfully into four major categories.
These categories were arrived at by studying the relationship among three
factors from each case: (I) the number and type(s) of social and/or psycholog-
ical problems, (2) the number and type(s) of community resources used, and
(3) the number and types of health problems in addition to tuberculosis.

Both qualitative and quantitative factors were considered in placing
each case in the appr0priate category. These factors will be further
delineated at the time the category is discussed. A cigehexample will
also be given. The following are the four categories used to determine
social work need:

I. Multi-problem families
2. Casework prospects

3. Health problem families
h. Those with “no problems”

Multl-problem families have been characterized in the literature as
having more than their share of physical and emotional problems.I The
problems that can beset a multi-problem family are many, including such
things as poor housing, a long history of financial dependency, heavy
incidence of mental illness and retardation, periodic unemdoyment,
marietal discord, indebtedness, juvenile delinquency,etc. The multi-
problem family was also characterized as having a multiplicity of contacts
with manyu community agencies.

In accord with the above characteristics, the following criteriauere
arrived at for purposes of defining the term multi-problem family as used

in this study: I) There had to be two or more persons living in the Home.

 

e~"Helen Hallin, "Co-ordinating Agency Efforts in Behalf of the Hard-to-Reach
Family", Social Casework,¥X£I(, Janfiafyune, I959, 9-I6.

2
Kenneth Dick and Lydia J. Strnad, "The Multi-Problem Family and
Problem Service“, Social Casework, XXXIX, No.6 (June, I958) 3h9-355.
3

Hallin, loc.cit.

2h

2) Four or more social and/or psychological problems were experienced by the
family, one of which had to be in the area of individual personality adjust-
ment or family relationship. 3) The use of three or more community agencies
was considered to be an extensive use of community resourced. Agencies were
classified according to four functions, health, economic, legal, and social.
The multi-problem family had to use at least three of these four types.
A) The family had other health problems in addition to tuberculosis.

The X Family easily met the criteria for being classified a multi-problem
family, and serves as an interesting example:

The x Family was known to the community for their social and
psychological difficulties. The school often contacted various
community agencies, including the health department, concerning
the frequency of school absences among the X children. When
the children did report to school, they were reportedly dirty,
hungry and/or 5 ck. The older boys were known around school for
their “pick-a-fight attitude,’I and one was taken later to Boys'
Vocational School. The children were often left alone while the
parents worked, and a neglect charge was filed with the Probate
Court. One child of the five was diagnosed as intelbctually
retarded.

Mr.X and Mrs.x were both TB patients with a long history 0 AMA dis-
charges. Mr.x was known for his drunkenness and abusive attitude.
Many marital, economic, and housing difficulties were also
experienced by the family.

It was found that twenty-six of the l20 cases met the criteria for
classification as multi-problem families. This was 2l.7 per cent of the
cases. It was interesting that 36.6% of the patients that left the
hospital against medical advice fell into this category. It was also
found that ten out of twelve of the families that had more than one case
of tuberculosis in the family were also in this group.

Medical social workers in hospitals have been apprOpriately assigned
the responsibility of helping to alleviate the social, economic, and
emotional problems which were related to illness. The medical social
worker helps the patient and his family to make optimum use of medical
service when family or personal problems would otherwise interfere with

medical plans.l The role of a social worker in a public health department

I

 

l
AAthur Fink, Everett Wilson and Merill Conover, The Field of Social work
(New York: Henry Holt and Company, I956), p.32h.

r
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25

would be similar. This point will be elaborated upon further in the next
section of the study. The above definition served mainly as a guidepost in
arriving at the criteria for the category "casework prospect.'I

The following criteria were arrived at for defining the term casework
prospect as used in this study: l) Family units or individuals may be placed
in this category. Consequently, all single individuals, who would have other-
wise qualified for the category multi-problem family were placed in this
category. 2) Families included in this category were considered to have
experienced less severe damage to the family's ability to function than the
multi-probiem family. One through four social and/or psychological problems would
have qualified a family or an individual for this category depending upon
the nature of the problem. One problem was considered sufficient to qualify
a case for this category if an individual was alcoholic, had difficulty in
adjusting to his diagnosis, or staying in the samitarium, or had left the
sanitarium against medical advice. Problems of an economic nature were
not sufficient in themselves unless the individual was experiencing some
personal or familial conflict surrounding it. The term economic problem was
used broadly here to include such as vocational adjustment as well. 3) Most
cases in this category used some community resources, but not more than three
agencies or more than two of the types of agencies described before. All
cases were considred to have needed more effective social services. A) Some
cases had health problems in addition to tuberculosis. This criterion was
not considered as important as in the case of the muiti-problem families
where numerous health problems were necessary to meet the definitions
found in the literature.

The case of Miss Z could serve as a prototype of the casework pros-
pect category. The case of Miss 2 as well as #3 others fell into this
category. (36.6%)

Miss Z was a single woman of 52 who lived with her: mother
and aunt in a comfortable home. Her occupation was that of
an accountant. It was with great difficulty that Miss 2 was
finally hospitalized for TB. Both the health department and
sanatorium reported her refusal to accept herediagnosis or
treatment advice. She related to medical personnel in a
hostile fashion, and was called a “mama's girl.” Upon
release from the sanatorium, Miss Z felt a keen loss of
prestige and financial security in connection with her job.

----- _‘The health problem family or individual appeared to have no social

26

and/or psychological problems, other than economic difficulties. For this
reason, when they used community agencies they were only economic or health
connected. Consequently, when establishing criteria for this category two

major health criteria were used: l) The family was troubled by numerous

(five or more) relatively minor illesses. 2) A member of the family suffered from
a major illness, such as cancer, heart disease, or diabetes, in addition to
tuberculosis. Fourteen cases (8.6%) met these criteria. The case of Family

Y served as an example of this category:

The Y Family lived in the rural Battle Creek area. There
were six children, one of which was the TB case. Mr. Y was

a steadily employed fireman, and his family appeared relative-
ly stable from a social-psychological point of view. However,
the family was troubled by the occurrence of numerofis minor
health problems (l6), among which were: measles, diarrhea,
vision complications, scarlet fever, anemia, poor nutrition,

3 slipped isc, chickenpox, intestinal flu, overweight indiv-
iduals, broken legs, etc. All of these problems came to

the attention the public health nurse.

It was felt that a case having only health problems could still benefit
from social work intervention. The rationale behind the use of this category
was the realizafion of the strain and anxiety which can be caused when
numerous illnesses are experienced in one family or by one individual.' It
would be expected that this continual strain would take its toll in psycho-
logical and/or social problems, at least in some instances. Cases of this
nature would be suitable for SUpportive help from the public health nurse and
refferal to a social worker if and when more serious problems develop.

Those cases classified as having “no problems“ did not fit into
any of the above categories. Any problemsthat were experienced by those
in this category where of an economic nature and were handled without
any apparent conflict either through appropriate agencies or within the
family itself. Thirty-six or 30% of the cases fell into this category.
in short, all indications given in the public health record seemed to
indicate the family or individual was able to cppe with the presence of
tuberculosis.

The above classification scheme was meant to be a rough way of
objectively determing what cases had unmet social work needs. About
58% of the cases wereoonsidered to have need of social work seriices.

Some of these cases were having this need met by taking advantage of ex-
isting community resources. Eight percent of the total caseload was

known to have been clients of the Family Service Agency. Three percent

27

of the cases were also known to the Child Guidance Clinic. But this does not
begin to meet the need. Some of the failures to help tuberculosis patients
and their families may result from inadequate utilization and coordination

of services which are already available in the community.I

The Michigan Department of Health has two social work consultant
positions. The Calhoun County Public Health Nurses found it necessary to
discuss eight percent of their caseload with a consultant. Social work
consultants have only incidental responsibility for idrect service. Their
major responsibility is that of evaluating individual and community
problems that interfere with the effectiveness of health problems.

In studying Table 6, it becomes clear that less than fifteen percent

of all the tuberculosis cases are evaluated or receive casework services.

CHAPTER IV
CONCLUSIONS 5 RECOMMENDATIONS

Tuberculosis is no longer the mass killer it once was. It is today an
even greater social problem, however -- a problem with which social work
should be concerned.

Tuberculosis is one of the serious illnesses which presents a wide range
of problems to patients and their families. Communicability, length of
treatment, often separation of the patient from his family, and the hazard of
its recurrence, all contribute to the disruption of individual and family
life. Every study of tuberculosis patients and their families reveals acute
needs to which these common phenomena contribute.I It would seem, then, that
tuberculosis patients and their families would be in need of social work
services on this basis alone.

Tuberculosis is a problem that should be of doncdrn to social work for
still another reason. This study of Battle Creek patients and their families
indicated, as did the literature, that a majority of tuberculosis victims
come from a segment of the p0pulation that is ill-prepared to cope with the
multiplicity of problems which are often associated with tuberculosis. Tuberculosis
hits a majority of patients during their most productive years. The male
patient often has to give up his job. When he recovers from tuberculosis,
jobs that are not physically taxing are nost difficult to find. Battle
Creek tuberculosis patients belong prinarily to the semi or unskilled labor
group, and, therefore, are probably in the lower income brackets. Con-
sequently, tuberculosis results in a great financial drain. The female
patient also has her problems. These usually involve being forced to leave
her home and young family.

The study definitely pointed to a noticeable disruption of family
life among Battle Creek tuberculosis patients and their families. For
example, over one-third of the families were found to have eXperienced

Mdifficulty in the area of family relationships. Over one-half of the

 

INational Tuberculosis Association, A Handbook on Social Services
for the Tuberculosis Patient (Washington, D.C. : National TUberaulosis
Association, l956) 6.3.

 

. J

K
. J
( l
is
I].
in
ll.
0\ In
A i

28

cases had difficulty in the economic/vocational areas.

The adjustment of individual family members was also found to be an
important factor in the cases under study. Sometime the individual con-
cerned might be the patient himself;other times, a member of the patient's
family. At least one-third of the families had at least one individual
who was thought to have a problem in the area of personality adjustment.
This group would be even larger if one wished to include alcoholics in this
group.

Tuberculosis patients and their families make considerable use of
community resources. The most widelyused agencies may be generally
termed economic assistance agencies.

There has been no conceeted effort in Battle Creek to co-ordimte the
efforts of the many agencies giving services to tuberculosis patients. Nor
has there been a plan for evaluating the need for casework services in
each individual case. In view of the fact that fifty-eight percent of the
cases were considered to have need of social work services, according to the
four category classification scheme, the lack of social work services is
a reason for concern.

The United States Public Health Service has come out in favor of
creating new services to meet the need for social work services. They
give two reasons for their position: First, they found they believe that
every tuberculosis patient and his family should have the opportunity
of good social planning and of continued casework service if the latter
is indicated. Second, they found in a study of numerous communities that
none of them wereable to assure complete social work coverage of all'
tuberculosis cases and their families through use of existing agencies.

In many large cities with relatively large incidences of tuberculosis a new
services have been started.2

The author agrees that ideal plan for social work services for the

 

lBerrY, 93. Cite, p05.

2
James Zeck, “Social Services in Tuberculosis”, Public Health Reports,
Vol.LX|V, No. #8 (December 2,]9h9), pp.l-2l.

29

tuberculous would be that of a comprehensive serivce such as suggested
by the United States Public Health Service. This could mean a social
worker in gxg£y_ county health department in Michigan, or Specialized
clinics in various locations throughout the state (as well as one or
two medical social work consultants in the state health department).

However, in making Specific recommendtions for the Calhoun County
Health Department, it is important to realize that shortages of trained
social workers as well as limited finances must be taken into account.

It certainly would not pay from a financial point of view for a relative-

ly low incidence area (county) to hire a social worker merely to serve the
tuberculous. However, if there was a sufficient number of trained social

workers available, a medical social workercould contribute a great deal to the goals
of any health department.

Perhaps the most serious roadblock to adequate social servicesfor the
tuberculous in Battle Creek is the lack of coordination of existing services.
It has been found in other localities that although comminity resources
do exist, there is often con coordination of them for rehabilitation purposes.
At times the patient and his family do not know that there are local sources
of help to which they may turn. Sometimes the patients are not clear about
what agencies are for or what they do--or for whom. Sometimes patients
are unwilling to ask for help or to use help offered them. lnsuch situations
patients' problems may persist and grow.I Most tuberculosis patients need the
assurance that there is an organized community program ready to help them face
their own problems. The author believes that if all health and velfare
agencies in Battle Creek, or in any othercity with a comparable tuberculosis
rate and with similar community resources, work together in a coordinated
fashionmmost of the need for social work services among the tuberculous
could be met. The council of social agencies would seem to be the appro-
priate body to meet this problem of coordination of services. The council
would serve as a means for promoting agency and community understanding
of the problems surrounding tuberculosis.

was.

National Tuberculosis Association, A Guide for the Development of
fighabilitation Programs in Tuberculosis Associations (Washington D.C.:
National Tuberculosis Association, I956), p.lO.

30

The task of coordinating services to multi-problem families is a
difficult and challenging one for social workers at this time. This tudy
indicates that a large number of multi-problem families may have a family
member with tuberculosis as well as various other illnesses which may bring
them to the attention of the health department. It is in coordinating
services to these families that social and health agencies may make a major
contribution to their community.

In short, the author recommends that a temporary committee be set
up to deal with the problem of coordinating sevices for the tubercuous of
Battle Creek. This committee might actually be set up as a sub-committee,
the main committee being a permanent one dealing with coordinating services
for multi-problem families.

Successful recovery from tuberculosis is a distinct medical possibil-
ity in this day and age. Restorationua a full and usefull life in the
community is also a possibility. Recovery from tuberculosis is more
than restoring the individual to physical health. It involves restoration
of the tuberculous to the fullest physical, mental, social, vocational, and
economic usefulness of which they are capable. But it should be remem-
bered that tuberculosis is still basically a public health problem.

The health department should certainly be the one to assume leadership
in coordinating the many disciplines that should be working together to
eliminate this disease. Social work is a field well-equipped to help in

meeting the challenge of this goal.

APPENDIX

 

BIBLIOGRAPHY
BOOKS
Fink, Arthur. The Field of Social Work. New York: Nenry Holt and Company,
I956.

Freeman, Ronald et.al. Principles of Sociology. New York: Henry Holt and
Company, I952.

Wittkower, Eric and Cleghorn, R. Recent Developments in Psychosomatic
Medicine. Philadelphia: J.B. Lippincott Company, I95“.

 

MAGAZINES AND ARTICLES
Bloom, Sophia. “Some Economic and Emotional Problems of the Tuberculosis
patient and his Family”, Public Health Reports-LXIII,lh. (April 2,
I948).hh8-h55.

Holmes, Thomas et. al. ”Psychosocial and PsychOphysiologic Studies of
Tuberculosis", Ppychosomatic Medicine, XIX,2. (March-April, I957),
I3h-Ih3.

Hallin, Helen. “Coordinating Agency Efforts for the Hard-to-Reach Famihfl,
Social Casework VXL (January, I959), 9-I6.

Long, Esmond. “The Field of Tuberculosis, a Multi-Discipline Approach to
its Problems", Social Work Practice in the Field of Tuberculosis.
Pittsburgh: University of Pittsburgh Press, I958.

Strnad, Lydia and Dick, Kenneth. “The Multi-Problem Family and Problem
Service“, Social Casewosk XXXIX, 6. (June, I958). 3H9-355.

Weber, Frances. "Tuberculosis and the Negro”, Public Health Reports LXIlI
(April 2, l9h8), #25-426.

Zeck, James. “Social Service in Tuberculosis“, Public Health Reports LXVIV,
#8. (December, I9hZ),I-2I.

PAMPHLETS
Glaser, Stanley and Roney, Paul. Rpported Tuberculosis Data,560. Washington:
United States Government Printing Office, I955.

National Tuberculosis Association. “Fact-Finding in Alcoholism", Rehabilitation
Event VIII,l (anter, I961).

A Guide for the Development of Rehabilitation Programs in Tuberculosis
Associations. Washington: National Tuberculosis Association, l956.

A Handbook on Social Services for Tuberculosis Patients. Washington:
National Tuberculosis Association, I956.

Shaw, L. and Glaser,S. Tuberculosis Chart Series, 639. Washington : United
States Government Printing Offie, l96l.

OTHER SOURCES
Berry, Frances. “Social Work in Tuberculosis Control “Reprinted from the
Transactions 33fthe Forty-Third Annual Meeting of the National Tuberculosis
Association, I957.

United States Bureau of the Census. United States Census of Popylationszl960,
"General P0pulation Characteristics of Michigan“. Washington:
United States Government Printing Office, I96l.

SCHEDULE

Check Problem Area

 

A Social and Psychological Profile of TB Cases
(Families)
Family Relationships

Marital difficulty

Parent-child relationship (indicate)

Unmarried Parentnood
Individual Personality Adjustment

Children (under 13 years)

Adolescents (13-20 years)

Adults (21 years & over)

Indicate which family member
Failure to Accept Community Standards
Planning Substitute Care of Children
Old Age

Mental Illness (wnich family member)

Diagnosed
Suspected

Intellectual Retardation (wnich family member)

Diagnosed
Suspected

Economic or Employment
Educational and/or Vocational Adjustment
Housing

Mobility

Other (indicate)

Referral Source

Date

 

 

 

 

 

 

 

 

 

 

 

 

1. List health problem(s) or disease(s) other than TB. Indicate
if the health problem occurred before or after the diagnosis
of TB. A=After B=Before

2. List other social and private agencies connected with this
case. C=Conference R=Referred by PEN

3. Fill in the following information about the patient.

Place of residence

OCCUpation (husband) (wife)‘
Income Source
Marital Status

Number of Children

Age

Education (husband (wife)

4. Disposition of Case:

Hospitalized: easily, some difficulty, legaly
Chemotherapy
Observation
Lost, moved, uncooperative
5. Did the patient leave the hospital against medical advice?

Yes No

 

 

 

 

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