A family’s genetic contribution to health is mediated through socialization and environ- mental infl uences. Family mediates sanitation, housing, diet, physical activities, smoking and drinking, and risk exposures. Family is the context in which the sick role is learned and primary care is given. It is also the context for decision making about health care. Family values and norms infl uence basic health care behavior, including which resources to access (see Chapter Five on health care sectors) and when or whether to seek biomedical services. Family may also impede the utilization of health care. For instance, the shame associated with mental illness makes many Asian American families reluctant to seek care for family members.
Family mediates cultural and social infl uences on health through the transmission of gender roles, values, emotional behaviors, and identity. Families are universal, but their structures, roles, and infl uences vary. In all cultures, men and women form conjugal pairs;
however, although some of these marriages form new families, other marriages are into existing families, such as when a woman marries into her husband’s patrilineal extended family and lives with his relatives. Universal biosocial care roles of the family (Leininger, 1995) are complemented by culturally varying roles and activities of family members in providing care. An assessment of both cultural (group-specifi c) and social (universal) infl uences of the family is vital to culturally responsive health care. A knowledge of family health behaviors, preventive practices, and decision making regarding access to care is a basic foundation for understanding patient needs. Knowledge of the family health culture helps providers decide on priorities for intervention, necessary support, and education.
Addressing clients’ needs through family systems perspectives helps overcome the dominant biomedical and cultural tendencies to address problems in the reductive per- spective of an individual. The particular dynamics of family health behavior are crucial to various aspects of accessing care needs, such as determining the acceptability of proposed care to the patient and other family members, such as grandmothers, and family members’
participation in discharge planning and home treatment of the patient.
Family Structures. Family structures are variable. The European American family ideal, the nuclear family of parents (husband and wife) and their children, is not typical in most cultures. Indeed, the nuclear family no longer characterizes the living situation of most Americans; more Americans live in a single-parent family, which is typically a female-headed household. The extended family , consisting of a three-generational fam- ily structure (grandparents, parents, and children), is the more common ideal pattern of family organization found worldwide. The most typical form of the extended family has been the patrilineal extended family , where father-son obedience provides the authority structure, and brother loyalty reinforces the male power structure. Some extended family systems may also include other kin: aunts, uncles, cousins, and fi ctive kin. A matrilocal family is an extended family based on women’s kinship ties and residence and may con- sist of all descendants of a woman, including her sons and daughters and the daughters’
offspring. Generally neither the daughters’ husbands nor the sons’ wives and children are considered to be part of the family. In today’s world with widespread divorce and remarriage, other family structures have emerged such as the blended family , which
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combines the members of two families united through marriage. A variety of other nontra- ditional and alternative family structures are also created by gay and lesbian marriages.
Gender and Health
Family is the primary context where biologically determined sex characteristics are formed by culturally ascribed and socialized conditions of gender identity and behavior.
The culturally varying ways of managing the differences between men and women have many implications for health status. Helman (2001) suggests four elements of gender:
Genetic gender
Somatic gender based on phenotype, physical appearance, and secondary sex characteristics
Psychological gender based on self-perception
Social gender based on cultural defi nitions that defi ne perceptions and behavior.
Social gender is the most susceptible to sociocultural infl uences, but all aspects of gender are infl uenced by culture and have health implications. Cultural expectations regarding appropriate gender behaviors often create health problems and barriers to effective care. The relative value of sexes may affect the way newborns are treated or health care provided: for instance, where preference for males may lead to the neglect of female infants. Cultural rules about women’s modesty and exposure of her body affect health care interactions. This applies to men as well, affecting examination, bath- ing, and other procedures.
The expectation in some cultures that women should be subordinate to men can have a variety of effects in health care settings. In health examinations, a man may accompany his wife and answer the physician’s questions for her. For many nurses, this directly clashes with their professional expectations that women should be independent. This often produces anger and frustration in female providers, affecting patient care. Providers need to know cultural gender expectations and construct interactions that facilitate achieving health care goals.
Female status is associated with a number of socially induced health conditions and disorders. In European American culture, these include an increased tendency toward anorexia and bulimia, the use of a variety of cosmetic procedures and beautifying agents that prejudice health, stress from the cultural emphasis on appearance, and confl icts women face when professionalization puts them in confl ict with traditional norms. Male status is also associated with health risks. These include higher rates of death from most conditions, a shorter life expectancy, higher risks of disease from smoking and alcohol consumption, a greater tendency to a type A personality, and the associated higher rates of heart disease. Men are often less likely to avail themselves of medical care in a timely manner because of the cultural expectations that they should repress emotions and help- seeking behaviors, not complain about pain or discomfort, and downplay their distress and symptoms in ways that contribute to an underevaluation of the severity of their conditions.
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Family Roles in Care and Therapy
Different family realities cross-culturally constitute a source of problems in treatment and compliance. Family roles in primary care provision may include physical care, social and emotional support, and performance of a sick person’s ordinary responsibilities.
Family roles in this support differ from culture to culture and must be considered in the planning of care. Culturally based family expectations regarding care need to be known in order to include family members appropriately in making treatment decisions and sup- porting discharge plans. Cultural role expectations and norms about interpersonal inter- actions between different people, particularly in-laws, are relevant to home health care. A knowledge of family roles is essential in assisting a family in making decisions by know- ing who are considered to be the decision makers.
Decision-making processes are based in family but may involve certain members and not others or include others within an extended family and kinship system. Different kinship systems consider different family members to be the party responsible for a patient. In contrast to the European American system, where the obligations are with mother and father, matrilineal or patrilineal kinship structures may place legal, fi nancial, or moral responsibility for treatment within the kinship group of father or mother alone.
Although laws may require the parents’ authorization of medical procedures, understand- ing the key fi gures in the cultural patterns of decision making can facilitate providers’
efforts to obtain consent. If cultural practices are not understood and respected, relevant decision makers may be excluded, and legally responsible family members may feel that it is inappropriate for them to authorize treatment. The recognition of cultural authority enables health care providers to seek out culturally designated decision makers to ensure compliance with institutional requirements.
The cultural focus on groups supports new trends in the helping professions that focus on family systems and examining family culture (Helman, 2001). Family structure and relations may be protective or pathogenic and enhance or inhibit therapeutic pro- cesses. The family system may scapegoat a particular member, resulting in psychoso- matic disorders for the patient from disturbed family relations and their emotional effects. A resolution of problems for the patient may be inhibited by family processes, such as live-in grandparents refusing to accept the inevitability of acculturation for their children and grandchildren. Treatment needs to be directed at the family and its (dys)functions, rather than just the identifi ed patient.
A knowledge of the normative family relations within a culture helps determine if cer- tain behaviors are normative or deviant. Knowledge of what is normative in the culture is an important corrective to the tendency to evaluate client conditions from the dominant societal norms. The acculturation processes of the wider society are also important for iden- tifying the source of deviant or problematic behavior in outside social forces or the family system itself when its traditional patterns are maladaptive for a bicultural individual.
Kinship Extensions of family structures into broader networks of relations, such as grandparents, uncles and aunts, and cousins, are referred to as kinship or kin networks.
Kinship involves interpersonal ties that include both biological relationships and social ties produced by marriage and adoption. In contrast to the isolated family units and
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limited kinship networks typical of Euro-American middle-class families, many cultures have extended kinship structures that play an important role in everyday life. This extended kinship structure often constitutes the network within which health care and the associated social and economic support are provided during illness. Because of their fun- damental role in organizing human social systems, kinship expectations have important health functions. Functions of kinship that affect health care include responsibilities for the care of related children and the provision of material assistance and resources to kin.
The obligation of kin to support the ill may create institutional problems such as dozens of relatives visiting a patient in a hospital. Different concepts of family member can also cause problems in hospitals where visiting policies are largely structured on the assump- tions of the traditional middle-class American family: nuclear structure with few children.
The concept of fi ctive kin refers to unrelated individuals who assume kinship roles and terms: for example, a close female friend being called “sister” by another person, whose children refer to her as “auntie.” In today’s society where there are many families disrupted by divorce, fi ctive kin often play central roles in family systems. Culturally sensitive providers recognize these relations and extend to them the prerogatives allowed under narrower conceptions of the nuclear family.