A suggested program for consumer health education for the health services delivery centers in the San Luis Valley

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Content A SUGGESTED PROGRAM FOR CONSUMER HEALTH EDUCATION
FOR THE HEALTH SERVICES DELIVERY CENTERS
IN THÉ SAN LUIS VALLEY
by
Demetrio Richard Lovato
A Thesis Presented to the
FACULTY OF THE SCHOOL OF PUBLIC ADMINISTRATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
Master of Public Administration
June 19 7 9
UMI Number: EP64912
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
Dissartaiiort AwMisNng
UMI EP64912
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
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/"I
This thesis, w ritten by
Demetri p.. R.... Lpy a t p..................................................
under the direction o f the undersigned Guidance
Committee, and approved by a ll its members, has
been presented to and accepted by the F aculty of
the School of P u b lic A d m in istra tio n in p a rtia l f u l
fillm e n t of the requirements fo r the degree of
MASTER OF
PUBLIC ADMINISTRATION
?
D ate.
Guidance Committee :\
C hair mm
TABLE OF CONTENTS
! lIST of t a b l e s ....................................... . iii
{Chapter
INTRODUCTION
Purpose of the Stüdy
Definitions of Terms
Organization of Thesis
II. HEALTH EDUCATION IN RELATION TO PAST
EXPERIENCE................................... 12
III. PROBLEMS OF HEALTH-CARE CONSUMERS............. 19
I
IV. SOCIAL, ECONOMIC, AND CULTURAL ASPECTS OF
HEALTH-CARE PROBLEMS IN SURVEY AREA.......... 34
Communication Problems |
Economic Problems
i Conflicts with Folk Beliefs
! Problems Related to Definitions of Disease
Problems Related to Modesty
Problems Related to Medical Roles
Problems of Social Distance
The Problem of Hospitalization
I Preliminary List of Spanish Health Words
i
V. CONCLUSIONS AND RECOMMENDATIONS................. 55
j Conclusions
Recommendations
I i
I APPENDIXES............................................... 75
, A. Questionnaire. . ................................ 76,
! B. Consumer Interview............................. 81
! C. Problem-Solving Recommendations................ 84
j D. A Self-Training Handbook ....................... 9 8
! SOURCES CONSULTED........................................ 128
! ii
^ - - - - - - - - - - - - - — - - - - - - - - - - - - - - - - - - — — - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -— — - - - - - - I
LIST OF TABLES
Table
1. Sample Population's Identification of
Specialty Health Services by Title ........... 31
2. Questionnaire Summary............................. 3 3 ;
3. Location and Number of Consumer Interviews . . . 35
CHAPTER I
INTRODUCTION
Health care in the United States is allegedly in a
state of crisis. High and rising costs, insufficient medi
cal and paramedical personnel, a higher infant mortality
rate in 1969 than those in thirteen other countries, a lower
life expectancy for males than in seventeen other countries
in 1965, and poor emergency room and ambulatory care are
among the diverse facts or allegations that have justified a
wide variety of proposed reforms. Yet the number of health
personnel, the proportion of the gross national product
spent on health care, and the sheer quantity of services
rendered have grown considerably faster than the economy as
a whole.^ Health education is a must if we are to make our
populace aware of these crises.
Health education has been defined as "the sum of
experiences which favorably influence habits, attitudes.
U.S. Congress, Committee on Ways and Means, Basic
Facts on the Health Industry (Washington, D.C.: Government
Printing Office, 1971).
and knowledge relating to individual, community, cultural,
2
and racial health." In order to provide people in the
community with such experiences, it is necessary to make
them aware of individual and community health needs and
problems, to secure the facts, to disseminate the informa
tion, and to motivate them to act.
As pointed out in the above definition, the habits,
attitudes, and knowledge of the people must be considered
in planning any educational program. In our modern society
the senses of the average citizen are constantly bombarded
by publicity, propaganda, advertising, and promotional and
educational forces. Some of these forces are subtle; others
are not. The community health educator must recognize this
competition and must devise and employ techniques that will
obtain a fair share of public attention. The community
health educator must continually consider and utilize two
important factors in planning and conducting his program:
motivation and communication.
This study was concerned specifically with those
health services provided in the San Luis Valley, which is
2
Jack Smolensky and Franklin B. Haar, Principles of
Community Health (Philadelphia: W. B. Saunders Co., 1961),
p. 72.
located in southern Colorado and northern New Mexico
between the San Juan Mountains to the west and the Sangre
de Cristo Mountains to the east. It is divided into six
counties in Colorado (Alamosa, Saguache, Mineral, Rio
Grande, Conejos, and Costilla) and half of Taos County in
northern New Mexico. All references made to the San Luis
Valley in this thesis are made to Conejos, Costilla, and
Taos Counties.
Purpose of the Study
Health services in the San Luis Valley have been
limited to those of private physicians and private dentists
Very . few community, or neighborhood: health center, types
of health delivery systems have been used.
«
Because the economic status of the Valley popula
tion is relatively low, many of its members have no knowl
edge of preventive health care. The development of a well-
controlled, comprehensive health delivery system is essen
tial for Valley inhabitants and, prior to its introduction,
consumer education is a must. The Department of Health,
Education, and Welfare-funded health programs in the Valley
have been delivering services by using the private physi
cian’s or private dentist's methods of delivery. Education
of the health consumer and the health provider should
3
eliminate many of the problems now existing.
Often the real purpose of consumer involvement in
decision-making processes is not well understood by either
the providers or consumers. On one hand, providers who do
not understand tend to view participation as interference
or as consumer control over professional decisions. This
is often caused by the confusion between quality of service
and quality of care, and who should be concerned with which.
The following definitions are provided to help eliminate
this confusion:
Quality of service is concerned more with the effi
ciency of the general operation of the facility— the manner
in which care is delivered, which by implication includes
the preservation of personal dignity and privacy in the
implementation of intimate procedures.
Quality of care is directly concerned with the
nature, value, and effectiveness of medical/dental proce
dures provided by the medical/dental professionals.
One purpose of this study was to present information
about the Spanish-speaking people of the San Luis Valley
that may be useful to medical and related professional
people who work with members of that population group.
Another purpose was to describe the situation of the
Spanish-speaking people and their relationships with the
English-speaking population among whom they live to illus
trate a few simple but highly important generalizations
about medicine and culture and the interrelationships
between them.
Professional and subprofessional workers in the
fields of health, medicine, welfare, and education whose
occupations involve them in considerable interaction with
Spanish-speaking people in the Valley have had opportuni
ties to observe that their patients, clients, or students
at times behave in ways that are thoroughly puzzling. A
mother who obviously loves her child waits until he is
critically ill and almost beyond help before seeking medi
cal aid. A patient seriously ill with cancer leaves a
hospital against medical advice to attend the wedding of
his brother. Children who are already much retarded are
enrolled in schools months after the opening date and leave
long before the term ends. A family on public assistance,
without enough money for food, makes a down payment on an
expensive television set. A child dying of leukemia is
taken from a hospital and placed under the care of a curan-
dera, a Mexican folk healer. These and similar examples of
behavior that could be listed are difficult for profes-
sional people to understand because they derive in part
from somewhat different notions about the meanings and rela
tive values of health, education, welfare, family relation
ships, time, work, and personal and professional responsi
bility than those generally shared by persons who have
received professional training. These behavioral differ
ences are manifestations of a conditioning in and by a cul
tural group that includes among its beliefs, practices, and
patterns of relationship many that are different from those
of the predominant English-speaking population of the
Valley.
The Problem
Although much has been written describing the devel
opment of health education curriculum for traditional
schools, comparatively little has been written concerning
the principles and methods of community or consumer health
education and, to the writer's knowledge, nothing has been
written concerning the populace of the San Luis Valley.
Since there is so little literature describing or discussing
the principles and methods of community or consumer health
education, the investigator examined the available litera
ture on health education curriculum, inventoried the con
sumers of a given area, and developed a model of consumer
6
health education program for the health services delivery
centers in the San Luis Valley.
The population of the two Colorado counties included
in this study is as follows :^
Costilla County: 3,0 91 inhabitants; 100 per
cent rural; 20.8 percent Anglo, 78.5 percent
Spanish surname; .06 percent Black; and 1.6
percent other.
Conejos County : 7,846 inhabitants ; 100 percent
rural; 31.7 percent Anglo, 67.6 percent Spanish
surname; .01 percent Black; and .7 percent other.
The population of the northern half of Taos County included
4
in this study is as follows:
Northern half of Taos County, north of and in
cluding the community of San Cristobal: 3,134
inhabitants ; 100 percent rural, 27 percent Anglo,
70 percent Spanish surname, 3 percent other.
Spanish-speaking people in the San Luis Valley
share a distinctive culture that to some extent varies from
individual to individual and from situation to situation
and exhibits itself in behavior distinguishable from that
3
Colorado Department of Health, Records and Statis
tics Section, Colorado Counties and Planning Regions,
August 30, 1972, Planning Region No. 18 (Denver: Colorado
Department of Health, 1972).
^New Mexico Department of Social Services, Division
of Public Welfare, Taos County Department Welfare Statis
tics, February 1971 (Taos : New Mexico Department of Social
Services, 1971),
of other cultural groups. As mentioned previously, one pur
pose of this study was to provide enough information about
that culture and its historical antecedents to enable health
professional people who work with members of the Spanish
speaking group to gain some insights into factors that may
underlie some of the group's behavior. The discussion is
not intended to constitute a complete account of the culture
of Spanish-speaking people. Rather, it is hoped that it may
serve as an introduction to that culture and sensitize
people in the health professions to some of its implica
tions .
Definitions of Terms
Many of the terms used in this thesis are in com
mon usage. The exact meaning attached to these words
depends largely on the training and experiences of the per
son using them. The following definitions and discussions
are offered, therefore, to provide a common understanding
of the terms as used in this thesis and to provide a basis
for discussion or criticism.
Consumer.— A consumer is an individual who uses
health services to satisfy his and his family's health needs
rather than attempting to provide them himself.
8
Health Services Delivery Centers.— Health services
delivery centers are defined as any outpatient health
clinic, whether it is partially or totally financed by the
federal government or not.
Provider.— The provider is the physician or dentist
or any person directly assisting the physician or dentist
in rendering health services.
Spanish-speaking.— For convenience, "Spanish
speaking" includes all members of the Spanish and Mexican
cultures in the area studied. "Spanish," "Chicano,"
"Spanish surname," "Mexican," "Mexican American," and "Mexi-
cano" are also commonly used in the area, and the educa
tional strategy must be sensitive to the impact the use of
these terms will have, upon the particular group.
Organization of Thesis
This thesis is not intended to provide a technical
discussion of health and disease, nor of the various forms
of treatment and care. Its purpose is to help the health
consumer and the health professional plan and conduct a
program in health education for prevention as well as for
better understanding of health.
The developed program may contain material that is
9
irrelevant to the user, depending on the amount of time
allotted or the circumstances at hand. Therefore, the user
is urged to select and adapt the experiences that best meet
the capabilities and interests of the recipient.
The chapters of this thesis reflect this plan of
study. In order to achieve these objectives, a review of
health education literature is given in Chapter II. Al
though this literature deals with health education in the
typical school setting, the program suggested in this thesis
illustrates how such material may be adapted for consumer
education in the San Luis Valley, particularly for the
Spanish-speaking populace.
Health consumer problems encountered by the populace
of the San Luis Valley are described in Chapter III. Under
standing the demands for citizen involvement in the health
field must be built on a foundation of understanding why
"consumer education" is an issue to begin with. This, in
turn, requires some familiarity with the sociopolitical
environment that produced the issue. Demands for accounta
bility to the community remain abstract from the social con
ditions characterizing communities from which these cries
are made most vocal.
Chapter IV illustrates the problems of the health
10
providers as they try to understand the consumer and attempt
to deliver good quality care. The discussion summarizes and
recommends ways to overcome the major barriers encountered
by health professionals in delivering better .health care.
The social and economic characteristics that affect prob
lems of health and illness in the San Luis Valley are also
discussed. Health professionals should seek a better under
standing of these characteristics. Perhaps, through better
understanding, health workers will be able to find solutions
to the continuing serious problems of health.
Chapter V is based on the final conclusions derived
from the study. A determination is made as to the type of
health education training needed and the content of such
training.
The questionnaire used in this study is contained
in Appendix A. Appendix B contains a copy of the form used
for the personal consumer interviews. Problem-solving
recommendations are offered in Appendix C. Appendix D is
a self-training handbook for use in solving the health
problems discussed in this thesis.
11
CHAPTER II
HEALTH EDUCATION IN RELATION
TO PAST EXPERIENCE
Research for this study began in the summer of 1974.
Once the topics for each section were outlined, an attempt
was made to find all written materials available on them—
journal articles, books, pamphlets, manuals, government
reports, memoranda, transcripts, and newspaper clippings.
The libraries of the University of Southern California in
Los Angeles and Adams State College in Alamosa, Colorado,
were used.
Although there is a substantial amount of written
material available on health education, it is related to
other settings, not to the culture or people of the San Luis
Valley. This material represents the most thorough, cogent
literature presently available. To keep informed on all
issues, it is suggested that health education personnel con
sult the following publications:
Federal Register
Health Law Newsletter
Clearinghouse Review
12
American Journal of Public Health
Health Rights News
The Nation's Health Journal
HSMHA Health Reports
National Association of Secondary School
Principals Bulletin
Comprehensive Health Services Career Development-
Technical Assistance Bulletin
Senior Scholastics
The four books listed below were most pertinent to
the problems discussed in this thesis.
Health in the Mexican-American. Culture by Margaret
Clark is not a systematic sociological analysis, but a pow
erful essay on Mexican Americans in a California community
and the health problems they face because health profes-
1
sionals do not understand their culture.
The Other America by Michael Harrington is an excel
lent capsulization of the dimensions of poverty in the
United States. Its portrayal of poverty is no't^ limited to
2
considerations of minority group conditions.
Citizen Participation; The Local Perspective by
Melvin B. Mogulof gives examples of citizen participation
^Margaret Clark, Health in the Mexican-American Cul
ture (Los Angeles: University of California Press, 1970).
2
Michael Harrington, The Other America (New York;
Macmillan, 1952).
13
in seven settings, one of which is a neighborhood health
center, and one a community mental health center.^
Citizen Participation; A Review and Commentary of
Federal Policies and Practices by Melvin B. Mogulof ana
lyzes the meanings of "citizen," "participation," "neigh
borhood," and "representation," and describes programs hav
ing legislative or administrative requirements for citizen
participation, by federal agency, with policy implications.
Community control became an issue during the push
for minority group rights in the 1960s. Civil rights de
mands— enfranchisement, equal access to public institutions
and accommodations— progressed to demands for economic and
social program "remedies"— better housing, health, educa
tion, child care, job training--which in turn progressed to
demands for determination of how those programs were to
operate and for self-determination in a political sense.
During this period, social program remedies proliferated.
All avowed to be aimed at changing the conditions of the
poor, especially those in minority groups.
^Melvin B. Mogulof, Citizen Participation: The
Local Perspective (New York: Urban Institute, 1970).
^Melvin B. Mogulof, Citizen Participation: A Review
and Commentary of Federal Policies and Practices (New York :
Prior "social programming" had been characterized
by professional dominance— services were dispensed by the
credentialed in a manner ranging from the paternalistic to
the humiliating, and administration and policy were con
trolled by these professionals. Probably the most flagrant
example was welfare administration, in which the social
worker's chief function was to certify needs, rather than
to direct recipients to resources or opportunities. Case
work, rather than community participation, was the predomi
nant model.
Casework addressed the individual problem; commu
nity education addresses conditions common to a whole cate
gory of people (the elderly, drug addicts, tenants, health
clinic users, and so on) or to a geographic entity (a neigh
borhood where garbage collection or crime or lack of trans
portation are major issues).
Two major new emphases thus entered the social pro
gramming picture. There was a shift from individual to
community needs. The necessity for involving the people
being served in the planning and implementation of social
programs purporting to change their lives was recognized.
The Economic Opportunity Act of 1964, which gen
erated an overabundance of social action programs called
_______________________ 15
"The War on Poverty," contained language on the need to seek
"maximum feasible participation" of the poor. The original :
intent of this language was and continues to be much dis
puted, but the fact remains that the Office of Economic
Opportunity began to generate administrative policies and
guidelines requiring community participation. Programs of
community action agencies have mechanisms for participation
of the poor on committees and boards at every level. Again,
how real and active such participation has been is a much-
disputed subject. The point is that community participation
in the direction of social programs was legitimized and
formalized, which resulted in requirements for community and
consumer involvement. These requirements, though still
largely in an advisory capacity, are now part of innumerable
programs of such agencies as Housing and Urban Development,
Labor, and Health, Education and Welfare. Examples are the
parent committees of Title I Elementary and Secondary Edu
cation Act programs and Comprehensive Health Planning Coun
cils of HEW, and the Model Cities boards of HUD.
This oversimplified, fragmented history is not meant
to suggest that community participation/control demands were
welcomed or readily heeded by professional program planners,
purveyors of services, or politicians. The process was one
16
of struggle by poor people who saw these new programs,
though inadequate and often inept, as a beginning wedge for
full economic and political participation.
The importance of a community voice in running one
small day-care center or a rural neighborhood health center
may seem an anathema, given the conflicts, program delays,
and mismanagement that can be generated in the process.
"Why," the professional or politician may ask, "can't 'they'
be satisfied with the fact that a service is being provided
in the first place?" The answer goes back to that phrase
"social-political environment." The antipoverty programs,
despite their deficiencies, often came into virtual
economic-political wastelands. A Head Start program in
Conejos County or a quilting cooperative in the community of
Costilla may seem but pittances to deal with past and pres
ent deprivations, but they are something, and people iden
tified them as theirs. They brought jobs, services, and a
symbolic (if not often actual) base for organizing to attack
broader community problems. For the first time, something
existed in which they were supposed to have a say. To
people who were often newly enfranchised, who literally
could risk death in efforts to assert their rights, commu
nity participation in planning and operating a program was
revolutionary.
17
If community control demands came out of the move- 1
ment for minority group rights and opportunities, they have
not been limited to either the poor or the minorities, as
f
large segments of the population come the question the
capacity of institutions to respond and to be accountable at
any level.
Health care problems are a good example of those
that cut across economic, social, political, and racial
lines. Increasing costs, fragmentation, inaccessibility,
and poor quality of care may soon reach the point where
middle-class Blue Cross subscribers may be as ready for
organization and as demanding of consumer control as bean,
farmers in Costilla County and welfare mothers in Taos
County.
18
CHAPTER III
PROBLEMS OF HEALTH-CARE' CONSUMERS
Everyone, at one time or another, feels "just miser
able" and some really suffer severely--that is the picture
of our health today. The countless good days that happen to
most of us most of the time are quickly forgotten when we
are sick. There is no greater concern to more people than
the state of their health. It is the usual form of greeting
'a friend: "How have you been?" Local newspapers devote
much space to obituaries, one of the most-read pages in any
paper, for people are naturally concerned with life and its
end— death.
What are your chances to live a normal, illness-free
life? And when you become ill, what are your chances of
getting well again quickly, without losing your savings and
going into debt, without losing your job? Or if it is a
member of your family about whom you are anxious, what
chance has he or she?
Statistics on illness usually make no impression on
us until we become one of the ciphers— then it is too late.
19
However, increasingly more people are learning that they can
I
prevent things happening to put them in the "sick" statis
tics. They are learning what to do when they become ill,
in order to get well as quickly as possible without any con-I
tinuing disability— what to do for their families.
There are a number of diseases that make chronic
sufferers or invalids of those who are stricken. These
diseases are no respecters of wealth or of age. It does not
matter who we are, where we live, or what our income may be.
Some of these diseases strike the young. Infantile paraly
sis usually strikes children, but does not spare adults, for
example, the late Franklin Roosevelt. Arthritis, cancer,
ulcers, diabetes, and arteriosclerosis, to name a few of the
more prevalent diseases, may not occur until people are at
the peak of their earning power and responsibilities, then
render them helpless, and a burden on others. Heart disease
seems to single out a man when he is at the zenith of his
career, with heavy duties and pressures weighing upon him,
as in President Eisenhower's case.
No other disease affects more people more persis
tently from babyhood to old age than bad teeth. Disfigured
mouths and teeth, with their harmful effects on personality
and earning power, and the cleft palate, with its harelip
20
and impaired speech, are not uncommon but are curable.
Tooth decay, with its secondary effects on general health,
is almost universal. Most people go through life with bad
I
teeth, either through ignorance or because treating them
costs too much in terms of pain, time, and money.
No one pays much attention to the little ills. Yet
it is the cold that hits when we least expect it, does not
exactly put us to bed, but makes us "drag around" for days,
that is so general that it is classed as one of the most
costly in individual discomfort, lost working time, and lost
earnings. A small accident, sprain, or cut can also inca
pacitate us.
While we are concerned directly with what happens to
us and our families, our health needs cannot be handled sep
arately from the health of all American people, for so much
of health is a matter of surroundings, laws, long-range
plans, and efforts of both the public bodies and private
groups. Good health depends on such problems as the sani
tation laws and their enforcement, which prevent illnesses
ranging from food poisoning to typhoid epidemics; pure water
for drinking purposes; good housing; adequate sewage dis
posal; proper heating; pastimes and recreation; ready access
to hospitals; and the presence in the community of proper
21
health facilities and an adequate number of trained health
personnel.
An attempt was made to address the above problems
through the use of questionnaires (Appendix A) and inter
views (Appendix B). Questionnaires were mailed to 150 fam
ilies to ensure a coverage of at least 1 percent of the pop
ulation of the three counties included in this study.
The names of the families for the survey were ran
domly selected. A computer list of all registered families
in the three counties was obtained, then the middle name on
every other page was selected. To assure an equal repre
sentation, 22 percent (33) of the 150 questionnaires were
mailed to Costilla County residents; 56 percent (84) were
mailed to Conejos County residents, and 22 percent (33) were
mailed to residents of northern Taos County. Of these, 68
questionnaires (4 5 percent) were returned. This represented
a total of 394 individuals (2.8 percent of the total popula
tion). Only 72.7 percent (24) of the questionnaires were
returned from Costilla County; 21 percent (26) were returned
from Conejos County; and 54.5 percent (18) were returned from
Taos County. The low number of questionnaires returned from
Conejos County is attributed to the fact that the investi
gator was not as well known in that county as in the other
two.
22
1
The average size of a family in all three counties '
was found to be large--5.8 members per family. In Costilla
County, the average family has 5.2 members, in Conejos
County there are 6.7 members per family, and in Taos County
there are 5.5 members per family.
As defined in the New Mexico Food Stamp Program, any
family of four earning less than $5,0 00 per year is living
in poverty. The mean income in Costilla County is $7,523
per year, and the median income is $5,384 per year, with
57 percent of the families earning $7,523 or more, while
6 3 percent earned $5,384 or more. The highest income re
ported was $13,000 per year for a family of four; the lowest
was $2,232 per year for a family of five.
The mean income in Conejos County is $5,97 0 per
year, with 54 percent earning more. The median income is
$4,500 per year, with 64 percent earning more. The highest
income reported was $11,000 per year for a family of seven;
the lowest was $2,000 per year for a family of four.
Taos County has a mean income of $6,7 33 per year per
family, with 43 percent earning that amount or less. The
median income is $3,750 per year, with 14 percent earning
that amount or less. The highest income reported was
$10,000 per year for a family of five and the lowest was
$2,500 per year for a family of three.
23
The mean income for all three counties is $6,618 per
annum, with 44 percent of the families earning less than
that amount. The median income is $5,500, with 36 percent
earning less.
The average level of education of the head of the
household in Costilla County is one year of college, with
the highest being a master's degree and the lowest being
the tenth grade.
In Conejos County, the average level of education
for the head of the household is the tenth grade, with the
highest being a master's degree plus one year's post
graduate work, and the lowest being the second grade.
In Taos County, the ave'rage level of education of
Ithe head of the household is the twelfth grade. The highest
is a master's degree in mining engineering, with the lowest
being the eleventh grade.
The average level of education of the head of the
household in all three counties is the twelfth grade.
It was found that there is a direct correlation
between the average income of the family and family size
in the three counties and the average income of the head of
the household— Costilla County having the highest correla
tion and Conejos having the lowest.
24
In Costilla County, 95 percent of the families own
their own homes. The average size of the home is 6.8 rooms,
with 3 bedrooms; 9 2 percent have hot and cold running water
with 1.25 baths, and 8 percent have cold running water only
with no bath.
In Conejos County, only 7 5 percent of the families
own their own homes. The average size is 5.3 rooms with
3 bedrooms; 95 percent have hot and cold running water with
1 bathroom, while 5 percent have no water at all.
In Taos County, 9 6 percent of the families own
their homes and 4 percent rent. The average size is 6.5
rooms per home, with 3 bedrooms; all have hot and cold run
ning water, with an average of 2 bathrooms per family.
In total, 89 percent of all families surveyed own
their homes with 6.2 rooms and 3 bedrooms; 96 percent have
hot and cold running water, 2.6 percent have cold water
only, and 1.4 percent have no running water at all; 9 6 per
cent have 1.25 bathrooms, while 4 percent have no bathroom.
The ethnic background in Costilla County is 92 per
cent Spanish surname, 7 percent Anglo, and 1 percent Ori
ental. Of the Spanish-surname families, 8 percent speak
only English at home, 50 percent speak English and Spanish,
and 42 percent speak only Spanish.
25
The population of Conejos County is comprised of
83 percent Spanish-surname and 17 percent Anglo families.
Of the Spanish-surname families, 33 percent speak only
English in the home, 3 3 percent speak both Spanish and
English, and 33 percent speak only Spanish.
The population in Taos County is comprised of , ;
78 percent Spanish-surname and 22 percent Anglo families.
In the Spanish-surname homes, 55 percent speak only English
and 4 5 speak only Spanish.
The population makeup of all three counties is
84.4 percent Spanish surname, 15.3 percent Anglo, and
.3 percent Oriental. In the Spanish-surname homes, 32 per
cent speak only English, 2 8 percent speak both English and
Spanish, and 40 percent speak only Spanish..
The people in Costilla County must travel 21 miles
for primary medical care, 18 miles for dental care, and
42 miles to the nearest hospital. In Conejos County, the
average distance traveled for primary medical care is 6.5
miles, 7.8 miles for dental care, and 16 miles to the near
est hospital. In the northern half of Taos County, the
people must travel 13 miles to the nearest physician,
11 miles to the nearest dentist, and 33 miles to the near
est hospital. The average distance people must travel for
26
primary medical care in all three counties is 13.5 miles,
12 miles to get dental care, and 30 miles to the nearest
hospital.
In Costilla County, 42 percent of the population
have regular medical checkups and 58 percent do not; 50 per
cent have regular dental checkups. Only 25 percent of
Conejos County residents have regular medical checkups,
while 75 percent wait until they become ill. As in Costilla
County, 50 percent have regular dental checkups. In Taos
County, 3 3 percent of the residents have regular medical
checkups and 44 percent have regular dental checkups. On
the average, only 33 percent of all residents in the three
counties have regular medical checkups, while 48 percent
have regular dental checkups.
In Costilla County, only 8 percent of the residents
have a local physician as their regular family physician;
the remaining 9 2 percent go out of the county for a doctor.
Fifty percent of the residents have a local family dentist,
33 percent have an out-of-county dentist and 17 percent
have no family dentist.
In Conejos County, 7 5 percent of the residents go
to a local physician for regular care, 17 percent go out of
the county, and 8 percent have no family physician. Also,
27
75 percent have a local family dentist. None travel out of
the county for regular dental care.
Only 11 percent of the residents of Taos County
have a local family doctor, 67 percent go out of the area
for regular medical care, and 22 percent have no family
doctor; 22 percent have a local family dentist, 56 percent
have an out-of-the-area dentist, and the remaining 22 per
cent do not have a family dentist.
In all three counties, 31 percent called a local
physician their family doctor, 59 go out of the county or
area for a physician, and 10 percent have no family doctor ;
49 percent have a local dentist as their family dentist,
30 percent go out of the county or area, and 21 percent have
no family dentist.
A large number of consumers are not aware of all
the medical and dental services that are available in their
area, or even know what services are available at the clinic
they most often visit. In Costilla County, 17 percent of
the people do not know what services are available in the
county, and 2 5 percent do not know what services are avail
able at the clinic they visit. In Conejos County, 23 per
cent of the consumers do not know what medical and dental
services are available in their own county or what services
28
are available in the clinic they visit. The percentages in
Costilla _ and Conejos Counties are not significantly greater
than those in Taos County. In Taos County, 55 percent do
not know what medical and dental services are available in
their own area, even though the clinic at Questa has been in
operation for seven years. The same percentage of people
do not know what services are available at the clinic they
most often visit.
In all three counties, 32 percent are not aware of
what medical and dental services are available in their
areas and 34 percent do not even know what services are
available in the clinic they visit.
The use of chiropractors is directly proportional
to the availability of the services within each area. In
Costilla County, where there is no chiropractic service,
no patients receive such services. In Conejos County,
8 percent to visit chiropractors, probably because there
are chiropractic services in Espanola, New Mexico— not far
from southern Conejos County. In Taos County, where chiro
practic services are available, 45 percent of the people
use such services. An average of only 17 percent of the
population in all three counties do use chiropractic
services.
29
since not all types of medical and dental services
are available in the San Luis Valley, a large number of
patients must travel out of the Valley for such services.
In Costilla County, 4 2 percent do leave the Valley for
health services, 50 percent do not, and 8 percent go only
when referred. In Conejos County, 23 percent do leave the
Valley, 69 percent do not, and 8 percent on referral only.
Although the northern half of Taos County is within the San
Luis Valley, a number of people in the area travel to Taos,
the county seat, for medical and dental services. Taos is
not within the Valley; therefore, the percentage of patients!
leaving the Valley for health services in this area is
high— 6 7 percent. Only 2 2 percent do not travel out of the
Valley for services, and 11 percent only on referral.
In the three counties, 44 percent of the patients
do go out of the Valley for health services, 47 percent do
not, and 9 percent only when referred.
Very few people in the Valley know how to identify
a specialty health service by its correct title. Table 1
shows the percentage of individuals knowing what each title
means.
Although respondents answered all the questions on
pages 1 and 2 of the questionnaire (general information),
30
TABLE 1
SAMPLE POPULATION'S IDENTIFICATION
OF SPECIALTY HEALTH SERVICES BY TITLE;
Percentage of Correct Replies
Conejos
County
All Three
Counties
Costilla
,County
Taos
County Specialty
89 75 62 75 General Surgeon
36 33
Psychiatrist 67
19 33
Internist 17
Obstetrician/
Gynecologist
46 33 38 67
74 67 62 92 Optometrist
48 56 31 58 Pediatrician
35 33 15 58 Neurologist
32 22
Ophthalmologist 67
32 22 23
Orthodontist 50
26 45 15
Cardiologist 17
35 56
42 Orthopedist
44.4
55. 5 Mean
32.7 15.0 58.0 Median
31
very few attempted to complete pages 3 and 4 (medical health
setting and dental health). Some attempted to change the
wording of the statement or add their own comments. There
fore, pages 3 and 4 of the instrument were found to be in
valid, and no attempt was made to analyze the results and
enter them as part of this thesis.
Examples of the statements made were: "I don't go
to the same doctor or dentist all the time." "I don't care
if he doesn't speak Spanish, I can understand English."
"We don't care how he dresses as long as he does his job
right." "Our doctor has no time to explain problems to us."
"My dentist is not from here, he is from Santa Fe." "We
don't qualify for free dental care, so we don't go to the
clinic here."
Many similar remarks were made, which gives the
impression that the instrument was misinterpreted and mis
leading. Since the intent was to measure the relationship
between the patient and the provider, information contained
in pages 3 and 4 of the questionnaire was eliminated. How
ever, judging from the remarks made and the few answers
given, it was assumed that the public in general is very
satisfied with the performances of the health providers in
the area. A summary of the information compiled from the
questionnaires returned is given in Table 2.
__________________ 32
T A B L E 2
Q U E S T IO N N A IR E SUMMARY
Item Costilla Conejos Taos Total
Number of questionnaires returned 24 26 18 68
Total family membership 124 172 98 394
Family members per family 5 .2 6 .7 5 .5 5.8
Number of families owning their home 23 20 17 60
Number of families renting their home 1 6 1 8
Number of homes with hot/cold
running water 22 24 18 64
Number of homes with cold running
water only 2 0 0 2
Number of homes with no running water 0 2 0 2
Ethnic background, total membership :
Anglo
9 29 22 60
Spanish (Chicano) 114 143 76 333
Black 0 0 0 0
Oriental 1 0 0 1
Indian 0 0 0 0
Other 0 0 0 0
Language spoken at home :
English only
2 8 10 20
Spanish only
10 8 8 26
English and Spanish 12 10 0 22
Number who have regular medical
checkups 10 6 6 22
Number who have regular dental
checkups 12 12 8 32
Number who are aware of the services
available in their area 20 20 8 48
Number who are aware of the services
available in the clinic the gen
erally visit
18 20 8 46
Number who use chiropractic services 0 2 8 10
33
CHAPTER IV
SOCIAL, ECONOMIC, AND CULTURAL ASPECTS
OF HEALTH-CARE PROBLEMS IN SURVEY AREA
The social, economic, and cultural characteristics
associated with health problems in a low-income, isolated
community, especially one with a Spanish-speaking popula
tion, are discussed in this chapter. Health providers are
seeking a better understanding of these characteristics,
with the hope that through this better understanding they
will be able to find some solutions to the high incidence
of infectious disease and high morbidity rate among low-
income Spanish-speaking people.
All the information for this chapter was derived
from 65 face-to-face interviews conducted by the investi
gator (see Appendix B for interview format). Table 3 shows
the date, place, town, number of interviews, and the total
family members in the homes of those interviewed.
During the interviews, the patients were asked to
state the most common problems they faced while receiving
medical or dental care. The eight most common problems
34
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35
stated were; communication, economics, conflicts with folk
beliefs, definitions of diseases, those related to medical
roles, social distance, and hospitalization (institution
alization) .
Following are some of the responses given to the
interview questions contained in Appendix B. Some of the
questions were not answered by all those interviewed; there
fore the total answers do not always equal the total number
of interviews shown in Table 3.
Question 1: In the past 12 months has any member of
your family had any sudden illness or injury? What
was the problem?
Of those answering "yes," 2 had appendicitis, 3 had
pneumonia, 7 had been injured in different types of acci
dents, and 52 answered "no."
Question 2: How many hours out of 24 would a car and
driver be immediately available if you had to go for
health care?
The replies' indicated that 12 had transportation
during the day only, 34 had transportation 24 hours a day,
9 said they had good neighbors, and 9 had no means of
transportation at all.
Question 3 : From whom do you get advice first when
you or someone in your immediate family is sick?
Advice was first sought from grandparents by 8
__________ 3 6
of those interviewed, 2 mentioned neighbors, 2 said a close
friend, 3 9 said from the head of the household, and the
remainder reported none.
Question 4 ; As a man/woman, would you go to a doctor
of the opposite sex? If no, why not?
Of the men replying to this question, 10 said they
would go to a doctor of the opposite sex and 16 said they
would not because they would not undress in front of a
woman doctor. Of the women, 2 7 said they would go to a
male doctor and 2 said they would not. However, the 2 who
said "no" added that they would go if a woman was present.
Question 5: Do you prefer to be treated at a hospital
or at home? Why?
Five said that they preferred the hospital because
they felt they got better treatment there. However, 17
preferred to be treated at home, and gave the following
jreasons ; "At home you eat your own native food, you under-
I stand what's going on, you can have more visitors, you can
take medicine that will do you good, there are no gringas
(nurses) who do not understand what you want, and you can
go to the restroom when you want to."
Question 6 ; What first aid or medical supplies do
you have available in your home?
The following were mentioned: aspirin, mentholatum
37
and Vicks, Alka Seltzer, Aceite Mexicano, volcanic oil,
Epsom salts, Ex-Lax, castor oil, mineral oil, rubbing alco
hol, bandages, white tape, and iodine (tincture).
Question 7 ; What herbs or other home remedies do
you have available in your home and for what ailments?
The following were mentioned more than once; poleo
(pennyroyal) for colds, hierbabuena (peppermint) for stomach
aches, manzanilla (rosemary) for skin infection, alhucema
(lavender flower) for headaches, and Rosa de Castilla
(rosebud) for sore throat. Also mentioned were trementina
de pinon (turpentine) for injuries, artemisia (sagebrush)
for colds, aceite mexicano (mexican oil) for stomach dis
orders, piloncillo (sugar crust) for rash, and cascara
sagrada for laxatives.
Question 8: Have you or any member of your family
ever received prescriptions or medical advice from a
doctor that you couldn't understand?
Of the total interviewed, 39 mentioned prescrip
tions. One gave an example by saying, "How can one take i
the same pill three times a day?" Twenty-two said that at
one time or another they have not understood what the doc
tor had said and could not ask him to explain because he
"was too busy," and did not have help that could explain it
in Spanish.
38
Question 9 : Have you or any member of your household
ever become ill due to evil eye, fright, fallen fon
tanelle , empacho?
Five said that a member of their family, generally
a baby, had suffered from evil eye. Two said that one of
their children had suffered from fright. One said that he
knew of a neighbor who had suffered a fallen fontanelle, and
another said that his mother had told him that when he was
a child he had suffered a fallen fontanelle. Sixteen
mentioned suffering from empacho.
Question 10: Which ethnic or racial group does your
family identify with?
Of the total interviewed, 7 identified themselves
as Anglo, 2 as gringos, 36 as Spanish, 4 as Mexican
American, 3 as Chicano, and 12 as Spanish American.
Question 11: In the past, what has your physican
(dentist) said that you felt you did not understand?
Of all the 64 people asked, 4 0 said "nothing" and
9 said they did not remember. Fifteen said that at one
time or another they had been told something they did not
understand. Some of the things a physician of dentist had
said were : "Your boy has a concussion." ("How could he
have a concussion when he was unconscious?") "You need to
move to a lower altitude." ("I didn't understand why,
since I do not live up in the mountains, I live close to
39
La Jara.") ("I didn't know what he meant by double pneu
monia since I had only been sick once.") "Your gums are
infected." ("I didn't believe the dentist because I never
chew gum, I don't like it.") Other comments were: "I
didn't understand the eye doctor when he told me my daughter
had a lazy eye." "My oldest son had a rash caused by I
don't know what."
Question 12; In the past, what have you wanted to
to tell the physician (dentist) but did not know how?
Some of things mentioned were : "I think I have
rheumatism." "I have a hernia." "My wisdom tooth hurts."
"I think I have a cavity." "My dentures are loose." "I
have a rash by my genital organs."
All of the above were related to the author in
Spanish and he has translated them as accurately as possible;
without changing what the person intended to say.
In general, answers to most of the questions asked
during the interviews show that there .is a language commu
nication barrier. Although most of these people do under
stand English, their understanding is limited. A need for
more Spanish-speaking health personnel is shown, not only
for translating, but to help in understanding the cultural
differences.
40
Communication Problems
Conejos, Costilla, and Taos counties are communi
ties in which Spanish is the primary home language of the
greatest percentage of the population. Spanish is not only
the primary language of the people, but a symbol of their
cultural tradition and of their existence as a social group
Many of the people five years of age or older speak some
English, but most of these are children and young adults.
Even those who can communicate in English are frequently
hesitant to speak it and are much more comfortable using
their own language. They resent those who criticize them
for speaking Spanish.
A number of adolescents and young adults are sensi
tive about being ignorant of English. Children and ado
lescents have a dual language problem arising from an in
adequate command of both languages. For this reason they
seldom make very good interpreters; they sometimes fail to
understand English words or unable to think of Spanish
equivalents. There is usually no way for the monolingual
health worker to be sure that proper information has been
conveyed by a child translator because the child may try to
conceal the fact that he cannot translate adequately.
Spanish-speaking people often complain that they
41
cannot get information from hospitals or public health
departments by telephone because there is no one available
there who understands Spanish. Some complain that switch
board operators cannot understand them and simply break the
telephone connection.
A few local clinics have Spanish-speaking employees
in some capacity who can be called upon when necessary to
act as interpreters. At the present time, however, very
few medical agencies can provide this service.
The language barrier between medical workers and
Spanish-speaking people shows no sign of being resolved
promptly. Even though Spanish-speaking children are now
receiving more years of American schooling and are learning
jmore English than did their parents or grandparents, the
educational level is rising very slowly. An influx of new
[Mexican immigrants into the area each year also perpetuates
language differences. It is therefore safe to assume that
public health workers will continue for some time to face
communication problems in dealing with Spanish-speaking
groups.
Economic Problems
San Luis Valley people are a low-income group.
Those who are eligible for care at the government-funded
42
health clinics usually receive more medical service than
those who must go to private physicians. The most acute
problems in medical economics are among seasonal workers
and nonindigent families who are struggling to be finan
cially independent.
The median income of San Luis Valley residents is
$3,7 50 annually, with which he must support a family of five
to six. A major illness, a surgical operation, or a period
of hospitalization can be an economic disaster. Rather
than be faced with medical bills they cannot pay, many
Spanish-speaking families prefer to dispense with a phy
sician 's services as long as possible and rely instead on
home remedies, folk curers, and marginal practitioners.
It is important to remember that in the eyes of
medical specialists the world revolves around health, but
to the patient it is only one of many aspects of everyday
life. Time and money are limited for people with low
incomes and large families. Money is often the critical
factor that determines whether a patient will go to a doc
tor or do the best he can with the contents of the family
medicine chest. If money is desperately needed for other
things or if other desires are stronger than the wish to
feel a little better, money may be spent for something
other than medical care.
43
Conflicts with Folk Beliefs
Nonscientific concepts of disease from their ances
tors are an important influence in the lives of the Spanish-
speaking people. Conflicts between folk beliefs and scien
tific medical practice can lead to fear and rejection of
American health services. Many of these folk beliefs are
persistent in second- and third-generation Spanish-speaking
people. One example is the persistence of beliefs about the
importance of dietary restrictions for postpartum mothers.
Some women resist hospital deliveries because they are
served foods in the hospital that they believe will impair
their own or their baby\s health in some way.
Religious beliefs, prayers, and spells of Mexican
origin are very important in the diagnosis and home treat
ment of disease.. For example, fragments of holy palm
blessed in the church on Palm Sunday are sometimes used to
ward off disease or in the magical curing of "evil eye."
Spanish-speaking people place considerable reliance
on Mexican folk-curing practices such as herbal remedies,
"cupping," topical applications of some sort, heat treat
ments, and massage. Patent medicines are also popular.
Spanish-speaking people are sometimes afraid of taking
strange medicines. One doctor reported that his Spanish
44
speaking patients frequently take less than the recommended
dose of a prescribed medicine--if the instructions are to
take three tablets daily, many patients will take only one
or two. A high percentage of Spanish-speaking patients con
sult some other type of curer--herbalist, curandero (medi
cine man), chiropractor, or homeopath--before consulting a
physician.
It should be emphasized that folk syndromes are very
real to the Spanish-speaking people. Health workers who
flatly deny the existence of "evil eye," mal aire, empacho,
"magical fright,: or disease caused by witchcraft may
expect to lose the confidence of many of their Spanish
speaking patients. Perhaps a greater tolerance and under
standing of folk beliefs may be fostered if health workers
recall that modern medical practice also has its remnants
of folklore.
Problems Related to Definitions of Disease
Spanish-speaking people and medical personnel some
times have different conceptions of normal and abnormal
physical states. There are, for example, differences in
what is considered "normal" growth and development. A
mother becomes indignant when a county nurse tells her that
her baby is not able to walk soon enough because he is too
45
fat. From the mother's point of view, the child is not too
fat but normal and healthy. She deeply resents the sug
gestion that her baby is abnormal or retarded in his motor
development.
To Spanish-speaking people, illness is generally
defined as a state of bodily discomfort. A person who has
no debilitating symptoms is usually held to be well and
healthy, even though the diagnostic tests of scientific
practitioners may reveal such serious pathological processes
as carcinoma, tuberculosis, or heart disease. It is diffi
cult for the people to understand how a sick person can
feel well and go about his normal tasks without discomfort.
To say to a patient without symptoms "you are sick" is to
invite confusion and disbelief.
Since the community defines disease as the presence
of symptoms, there is sometimes grave concern over the sig
nificance of unusual bodily states that medical specialists
view as "functional variations with the normal range." A
Spanish-speaking patient may consult a physician for symp
toms such as insomnia, anxiety, or "nervousness." A child
with "sad eyes" or one who "doesn't sleep enough" may be
taken for medical treatment, whereas one with diarrhea, a
common condition in the area, may not be considered
46
particularly ill. A thin man whose lack of abdominal fat
permits the palpation of the abdominal sorta may promptly
seek treatment for latido, a dread folk disease, but a per
son who has night sweats and a persistent cough is likely to
be treated with home remedies for "a little cold." Coughing
and sweating are everyday occurrences in the area, but a
"pounding stomach" is a strange and frightening phenomenon.
Physicians are sometimes annoyed with the simplicity
of the Spanish-speaking patients about what medical science
regards as "significant" symptoms. It may be of some con
solation to the harassed health worker to remember that he
makes a real contribution by assuring his patients that
their complaints, while disconcerting, have no ominous
meaning.
Problems Related to Modesty
One of the most frequent complaints that the
Spanish-speaking patients make about medical treatment is
that it is embarrassing. Girls and women in particular are
extremely modest— it is a pattern taught them from child
hood. One young woman reported that she had never undressed
in the presence of her sisters. She would not think of
removing even her outer garments unless she were alone.
This is a general attitude that makes it difficult for
47
Spanish-speaking patients to expose their bodies even to
medical workers.
Doctors and nurses in the fields of obstetrics,
gynecology, and venereal-disease control are made acutely
aware of the problems stemming from the Spanish-speaking
patients' concept of modesty. It is in these fields that
modesty problems most often arise, and special care must be
taken to avoid serious damage to medical relationships.
Problems Related to Medical Roles
Different cultures have different conceptions of
the proper roles played by participants in medical situa
tions. For example, many Anglos who have become increas
ingly aware of preventive medicine and hygiene accept the
idea that some diseases are the result of neglect or care
lessness on the part of the patient or those responsible
for his welfare. The Spanish-speaking people, on the other
hand, rarely blame patients for getting sick, or make the
patients feel guilty or responsible for an illness. A med
ical worker who implies that a sick person is at fault and
is somehow responsible for his condition may find his state
ments received with indignation or hostility. To the
patient and his family, such a view is unjust or even
malicious.
48
The medical practitioner is taught that an imper
sonal objectivity is a vital part of his role as an applied
scientist. He place a premium on efficiency--he tries to
"come directly to the point," dispense with "unnecessary"
formalities, and achieve maximum output in minimum time.
He also assumes that his status as a trained specialist
gives prestige and authority to his opinions and recom
mendations .
The people of the San Luis Valley, however, expect
quite different behavior from therapists. Their expecta
tions are based largely on the usual behavior patterns of
Mexican folk curers. People who expect a curer to be warm,
friendly, and interested in all aspects of the patient's
life find it difficult to trust a doctor who is impersonal
and "clinical" in his manner. Nor do they accept his au
thority to "give orders." He may suggest or counsel, but
an authoritarian or dictatorial approach on his part is
resented and rejected. His behavior, culturally sanctioned
in his own society, is often interpreted by Spanish-speakinc
patients as discourtesy if not outright boorishness.
Family members take a much more active role in med
ical care than they do in most Anglo communities. Two full
days' observation in the waiting rooms of the Conejos County
_____________ 49
Hospital at La Jara, Colorado, and the Holy Cross Hospital
at Taos, New Mexico, for example, disclosed not a single
Spanish-speaking patient unaccompanied by friends or rela
tives. In Spanish-speaking families, the patient alone
does not make medical decisions; his relatives and com-
padres (godparents) may be the ones to decide on courses
of action. Relatives expect to retain control over the
treatment of disease and resent relinquishing this control
to strangers who have no personal interest in the patient's
welfare. Patients, too, resent having their families ex
cluded from medical situations; they often resist hospitali
zation because it means isolation from the attentions and
moral support of their kinsmen and compadres.
Problems of Social Distance
Health providers who work with Spanish-speaking
communities are set apart socially from their clients.
Three factors of the public health worker's status maintain
social distance between him and the people with whom he
deals. First, he is a government employee and as such is
related to other government workers— law-enforcement offi
cers, tax assessors, immigration authorities, truant offi
cers, building inspectors, FBI agents, and public prose
cutors— all of whom are viewed as potential threats to
50
the security of poor people.
The second factor that maintains the gulf between
medical workers and Spanish-speaking clients is that most
public health people are Anglos. Aside from the communica
tion barriers resulting from this difference, there are also
conflicts resulting from historic group tensions between
Anglos and the Spanish-speaking people in the San Luis Val
ley and other parts of the Southwest. Spanish-speaking
people are members of a minority group in the United States
Many of them have lived in localities where, in the past,
group tensions have been acute and have sometimes involved
open violence. For this reason, many Spanish-speaking peo
ple feel hostile toward Anglos. Those who are not actually
hostile may at least feel uncomfortable with English-
speaking persons, fear discriminatory treatment, and remain
acutely sensitive to Anglo criticism.
It has been suggested that Spanish-speaking commu
nities should be served by Spanish-speaking public health
workers. There is much merit in this recommendation; many
medical specialists of Spanish descent in Colorado and New
Mexico are working effectively and making significant con
tributions in public health fields. The use of Spanish
speaking personnel offers a ready solution to many problems
of communication and interethnic conflict.
51
However, employment of Spanish-speaking personnel is|
i
not a complete solution to the problem of social distance.
The third factor, that of socioeconomic class difference,
must also be considered.
Spanish-speaking doctors, nurses, and medical social
workers are professionals and thus, by definition, members of
"la alta sociedad" in the community. There is a great deal .
of resentment in the area toward some "successful" Spanish
speaking people who are thought to turn traitor to their own
people and identify themselves with the Anglo community.
Some Spanish-speaking professionals have success
fully bridged the class barrier and have achieved acceptance
in low-income neighborhoods. But unless Spanish-speaking
medical workers are extremely careful to avoid a super
cilious, overbearing, or patronizing attitude, they may
achieve less rapport with poor people than do those Anglos
who are able to overcome language and ethnic differences
with friendliness, courtesy, and an honest respect for the
dignity of their Spanish-speaking neighbors.
The. Problem of Hospitalization
Some of the reasons Spanish-speaking people gener
ally dread hospitalization are: lack of understanding of the
reasons for treatment or other hospital procedures, isolation
from family and friends, fear of the unknown, fear of inabil
ity to communicate their needs to hospital workers, fear of
discriminatory treatment, fear of affronts to modesty or
individual dignity, unaccustomed diet, and inability to meet'
family responsibilities while in the hospital. For many
Spanish-speaking patients, hospitalization represents the
synthesis of all the most objectionable aspects of Anglo
medical care.
Preliminary List of Spanish Health Words
The following list of English health words with
their closest Spanish translation that are likely to be the
most commonly used words in a health provider's office were
gathered through direct interviews of Spanish-speaking resi
dents of the San Luis Valley. It is not intended to be com
plete but rather a preliminary list that may help the pro
vider communicate with his Spanish-speaking patients.
English Spanish
accident accidente
adhesive tape
esperador
allergy alergia
ambulance
ambulancia
appointment
turno, cita, una hora
aspirin
aspirina
bandage venda
bleeding
sangrando
breathe
respirar
bruise
contusion
burn
quemadura
a cold
resfrio
constipated
estrenido
contact lenses
microlentillas
cough
tos
cut
un corte
dentist dentista
53
English Spanish
denture
diabetic
diet
dizzy
doctor (physician)
dysentery (diarrhea)
fainted
feel (sick)
fever
filling (tooth)
fracture
frame (glasses)
gauze
glasses (eye)
headache
hemorrhage
hurt
ill
indigestion
injured
lens (glasses)
medicine
novocaine
optometrist
pain
pharmacy
poisoning
sedative
sleeping pill
sprained
sore throat
stomachache
sunburn
surgeon
temperature
thermometer
toothache
ulcer
x-ray
dentadura
diabetico
dieta
mareado
medico
disenteria (diarrea)
desmayo
sintir mal
fiebre
empaste
fractura
armadura
gaza
gafas, lentes, ante ojos
dolor de cabeza
hemorragia
due le
enfermo
indigestion
herido
cristal
medicine
novocaina
optometrista
dolor
farmacia
intoxicacion
clamante
somnifero
torcidura
dolor de garganta
dolor de estomago
quemadura de sol
cirujano
temperature
termometro
dolor de muelo o diente
ulcera
radiografia
54
CHAPTER V
CONCLUSIONS AND RECOMMENDATIONS
Conclusions
Education and income are major factors in health
care. The incidence of some deficiency and communicable
diseases is highest among the least schooled, poorest
people living in congested city areas and rural isolation.
Some occupations are more hazardous or unhealthful than
others. The better trained people work in the better
paying, less hazardous jobs. Better educated, more well-
to-do people may pay more doctor bills than do people who
are less fortunate, thus appearing to be less healthy, but
the facts show that there is a considerably higher incidence
of disease and longer periods of illness among less edu-
lower-income people.
Health is not a private matter between the indi
vidual and his doctor. It is saturated with political con
siderations, for the practice of the healing arts is a mat
ter of law and public administration. Sickness and health
are big business, subject to numerous legal enactments and
55
their enforcement.
It is safe to conclude that in this richest nation
in the world, despite all the attention we have given to
our health, we are far from being as healthy as we should
or can be.
From the information gathered during this study, it
is concluded that a specific type of consumer health train
ing program needs to be developed. The findings indicate
that a conventional training program cannot be used in the
Valley, since the problems are unique to the area. We find
that even when the head of the household is educated, there
is no realization that preventive medicine is necessary.
This is evidenced by the number of families who do not :have
regular medical and dental checkups.
The large average size of the families in the
Valley indicates that a well-coordinated family program
should be developed. Although the questionnaire did not
ask for religious preference, it is the author's opinion
that the majority of the population is Catholic, which
means that a family-planning program that would be accept
able by that majority should be developed. Working closely
with the local priests and ministers would help encourage
those who would be reluctant to accept such a program be
cause of religious beliefs.
5'6
Very little can be done to increase the annual
income of the families in the area, which is said to be
agricultural although it has a very short growing season—
less than 100 days per year. However, a nutrition program
could be developed that would fit the needs of the Spanish
speaking people. They coiild be trained to make proper and
legal use of the USDA Food Stamp Program and supplement
their low incomes.
Brochures could be developed that would teach the
mothers or other food buyers to buy as much nutritious food
as possible- with their limited amount of money or food
stamps. Evening classes on nutrition could be regularly
scheduled through the Home Extension Program. High schools
in the area could be encouraged to teach in their cooking
classes various ways to use and prepare commonly used foods
such as beans, chile, tortillas, and so on, instead of
risottos. Creole pot roasts, fancy biscuits, and the like,
that the students probably will never cook again. Not only
could the young high school girls and boys teach their
parents, but would be better prepared to become the cooks
of tomorrow.
As previously stated, it was found that the educa
tional level of the head of the household is not low in
57
comparison to that in other areas. However, their educa
tion has been traditional, not health oriented, as shown
through their limited knowledge of the titles of medical
and dental specialists. Again, the local schools should
be encouraged to modify their health education curriculum
to meet local needs.
Since the population of the area consists of people
whose ancestors came with the early Spaniards or the early
members of the Church of Latter Day Saints (Mormons), most
of them own their land and their homes. Whether they uti
lize them properly is the question. Training in disease
prevention through the use of a good water system, sewage
systems, window and door screens, insect and pest control,
paints, poisons, and other chemicals is a vital need. They,
being the owners, cannot depend on or turn to a landlord.
Through federal grants in the last few years, all
communities have developed community water systems. Unfor
tunately, only three towns in the three counties have a
community sewage system, which adds to the problem of sew
age disposal. Many people use a hole in the ground for a
septic tank and others use old open wells. ' A brochure and
classes could be developed to teach these people how to
build low-cost and functional septic tanks and cesspools.
58
Those who do not live near communities are not able
to use the community water systems. Since the water table
in the San Luis Valley is high, these people use open wells
to get their drinking water. They should be educated in
keeping the wells covered and screened. The proximity of
their septic tanks and cesspools to the drinking-water wells
could make a difference between remaining healthy and be
coming ill to these people.
The state universities and the health departments of
both Colorado and New Mexico will test drinking water free
of charge. Unfortunately, many of the inhabitants are not
aware of such service. As a public service, the local news
media could be utilized to make people aware of the service
and the need to test their drinking water. A monthly re
minder (more frequently during the summer months) would cer
tainly help.
Since a great number of the residents speak only
Spanish at home, or feel more at ease in using Spanish
rather than English, all brochures, newsletters, public
notices, and so on should be printed in both languages.
This would not only bring a better understanding to the
Spanish-speaking people, especially the older generation,
but would help restore and maintain their culture.
59
Although traveling 20 or 30 miles in a suburban
area for medical care is not unusual or difficult, in an
isolated rural area like the Valley, transportation is a
major problem. Many residents do not seek medical or dental
care until they are forced to do so, because of the diffi
culty in reaching such care. In some areas of the Valley,
many of the roads are gravel or dirt, which means they may
be impassable during the winter months or on a rainy day.
Prevention is the key word here. Very little can be done tq
improve road conditions or decrease the distance. The only
alternative would be to teach these consumers that when
they do go to to town, they should take advantage of the
opportunity to schedule regular medical and dental checkups.
Regular reminders such as posters in post offices and other
public places, the news media, and other sources should be
used to stress the importance of regular checkups. The
people should be aware that if they wait to see the doctor
until they are in a serious condition, roads might not be
passable and unnecessary suffering or death might occur.
Distance and road conditions could be used by the health
educators as tools to stimulate the consumer to have regu
lar medical and dental checkups. Since only one-third of
the residents now have regular medical checkups, a greater
60
effort should be made to get the other two-thirds to do
the same.
Since 48 percent of the residents now have regular
dental checkups (which is still a low percentage), this
indicates that the dental profession has done a better job
in educating their patients than has the medical profession.
Credit should also be given to television advertisements of
toothpastes, in which the audience is reminded to have regu
lar dental checkups. Nothing of that sort has been done on
television in connection with medical care. When a drug is
being advertised, e.g., Bayer aspirin, Alka Seltzer,
Rolaids, and other such products, no reminder is given that
regular medical checkups are necessary.
It is very unfortunate that a high percentage of
the residents of the Valley do not use their local physi
cians and dentists as their family health providers. This
may be because the physicians and dentists practicing within,
the three counties practice in federally funded clinics and
generally do not remain for more than two years. It was
found that most of the physicians and dentists listed in the
questionnaires as being family providers are practicing in
one of the two large towns near the subject area— Alamosa,
Colorado, or Taos, New Mexico.
61
It seems that it would be the responsibility of the
federally funded clinics to sell their services through a
well-planned health education program. Although the great
est drawback is that the providers do not remain for a long
period of time, the specialists to whom they make referrals
do remain. It should be emphasized that medical records do
not leave with the provider, but remain in the clinic for
continuity. The clinics should stress that all health ser
vices are offered under one roof--medical, dental, home
health care, transportation, nutrition, social services—
and that it would be to the consumers' advantage to use
such services. It should also be mentioned that fees are
based on a sliding scale according to the family's income
and size. These clinics could develop pamphlets that ex
plain the services that are available, how fees are deter
mined, and how to use such services. Thus there would be
no reason for almost one-third of the residents being un
aware of the services available in their own community.
Since manipulation therapy or massage has been used
by the Spanish-speaking people for centuries, an attempt
was made to determine how many residents go to a licensed
practitioner who practices manipulation therapy— the chiro
practor. It was found that a small percentage of the popu-
62
lation does see chiropractors, mainly because there are very
few available in the area; therefore, the use of massage for
healing purposes is still widely used. A pamphlet could be
developed to show the proper methods of rubbing and knead
ing the muscles and joints to make them work better and in
crease the circulation of blood.
As a result of special requests from the public, an
attempt was made to include chiropractic services as part
of the services financed through federally funded clinics.
The request was denied, and funds could be used only if a
licensed physician practicing within the clinic would refer
the patient to a chiropractor.
Because approximately 3 5 percent of the people in
the Valley do not recognize the medical and dental special
ties through their titles, this information is included in
the proposed "Self-Training Handbook" in Appendix D of this
study. The handbook contains other pertinent information
that could be useful and may be duplicated and made avail
able to anyone who requests it.
Recommendations
The following are recommendations for a program to
benefit the Spanish-speaking people in the San Luis Valley.
Participating physicians, nurses, and other professional
63
health providers in the Valley should strive for better
knowledge of the value systems and cultural orientations of
the people with whom they are working, along with becoming
aware of their own values and goals insofar as these are
culturally derived. In many communities, it would be desir
able for them to know Spanish so that they might communi
cate more readily with patients or family members who either
do not know English well or are not at ease in its use.
A fee-for-service principle of payment would prob
ably be preferable to a prepayment plan, at least in the
early years of a program, since it more closely conforms
with the existing and traditional patterns of Spanish
speaking people in paying for medical services.
Required participation of Spanish-speaking laymen
in the administrative or organizational aspects of the pro
gram should probably be held to a minimum. Attending meet
ings, voting, electing officers, formulating policy, par
ticipating in making administrative decisions, and similar
activities not immediately and directly relevant to the
giving or receiving of medical care should not become
requisites to obtaining such care. These activities could
undoubtedly have an educational function, which in the long
run might permit a given program to approach the expected
64
ideal. To require these activities as a condition of get
ting medical care is to add greatly to the difficulties of
acceptance by Spanish-speaking people.
This is not to suggest that Spanish-speaking per
sons be excluded from such activities. On the contrary,
the more they can be drawn in, the better for the success of
the program. They should certainly be encouraged to par
ticipate. However, no one should be excluded from partici
pation in the program because of lack of interest in orga
nizational activities.
Relations between those giving medical care and
those receiving it should be as direct, personal, and con
venient as possible. The physician or nurse should be
easily accessible, and there should be a minimum of waiting
by patients and a minimum of preliminary contacts with
clerical personnel. If it is necessary for a clerk to
obtain information from a patient or family member, this is
perhaps better done after than before the doctor or nurse
is seen. Relationships and procedures should be made as
informal as possible, and there may be times when efficienc;y
needs to be sacrificed for informality.
The personalities of the physican and nurse are
important factors and, wherever possible, should be taken
65
into consideration along with more technical qualifications
when health personnel are being recruited. If a choice must
be made, it may be better— at least in the early stages of
any such program— to give greater weight to personality
factors than to professional qualificaitons. Personality
should also be considered in selecting nonmedical personnel,
especially those who are likely to have direct contact with
patients and their families.
A system of precisely timed appointments should
probably not be used, and, if possible, all matters per
taining to a given illness should be taken care of during a
single visit. In instances where this cannot be done, every
effort should be made to see that the patient or a near
relative has a clear understanding of the illness and the
probable course of diagnostic or treatment procedures.
Enough should be known about the individual patient and his
environment to ensure that the medical orders given are
realistic for his situation. This may be particularly im
portant for orders that concern foods.
Physicians and others in professional roles will
probably have to accept a somewhat more personal relation
ship than would be necessary with an urban Anglo clientele.
Once a good relationship has been established, they can
66
expect to be consulted about many nonmedical matters.
More initiative may also be required, particularly
in the case of those services concerned with preventing
rather than remedying illness. A prospective mother left
to her own devices might never seek prenatal examination
and advice. The same woman might readily accompany a vis
iting nurse or someone else who explains the desirability
of such a procedure and offers to go with her the first
time. Similarly, a person with a nondisabling chronic
disease might benefit from services that he would never
seek on his own initiative but would accept if someone put
him in touch with them. Illnesses involving considerable
pain or discomfort probably supply their own motivations,
but those with ailments to which one can adjust with reason
able comfort or that require immediate action to achieve or
prevent some future condition are likely to require assis
tance from another person. With a rural Spanish-speaking
group, it is not enough to announce that medical services
of various kinds are available and that anyone needing them
should present himself and be treated. For many, particu
larly when an initial contact with any part of the medical
program is involved, additional and frequent personal stim
ulation is needed; in some instances even to the extent of
67
bringing the service to the person or the person to the
service. Treatment of the sick in their homes and by their
families, which until recently was the rule rather than the
exception in the Anglo culture, again is being endorsed in
certain types of illness, notably tuberculosis, and is still
a strong tradition among Spanish-speaking people. Any pro
gram that seeks to bring about changes in this area too
rapidly is likely to encounter considerable resistance.
Hospitalization of the patient and the use of specialized
nursing and auxiliary personnel probably result in better
care from a technical point of view, more physical comfort
and greater safety for the patient, convenience for the
physician, and the opportunity to use a wider range of
specialized devices, services, and procedures than would
otherwise be possible. These values are very well known to
Anglo medical people and to many Anglo laymen. They are
perhaps less well appreciated by Spanish-speaking laymen,
many of whom would, in certain situations, tend to regard
them as more harmful than helpful and their use as an inde
fensible abrogation of the family's responsibility for the
sick member.
Certainly it would be unwise, in attempting to
institute a medical program for Spanish-speaking people, to
68
fail to consider curanderos (healers) or parteras (mid-?
wives), for in the absence of acceptable medical facilities
and personnel, they are the ultimate medical resource of the
people who use their services, and it is not likely that
their influence will cease abruptly when scientific medical
care is introduced. They should be drawn into any new pro
gram, if for no other reason than that their good will or
ill will may be a powerful influence in determining the
degree of acceptance or rejection of the undertaking. But
their usefulness need not stop at lending passive support.
They could give some types of treatment and perform some
nursing functions. They could supervise the carrying out of
doctors' or nurses' orders by the patient. They could pro
vide an easier and more certain accessibility to patients
than the physician or nurse might be able to achieve working
alone. In many cases of language difficulty, they could
interpret the physician's instructions. To suggest that
they be drawn into a program is not to imply that all of
their present folk medical knowledge needs to be recognized
as sound, nor that all of their present practices are
approved. However, if that part of their knowledge which
is sound could be retained and broadened, and the part that
may be potentially harmful could be reduced or eliminated,
69
not by forbidding or ridiculing or ignoring it, but through
friendly, relaxed, informal teaching, lay practitioners
could become valuable allies in the development of adequate
medical programs for Spanish-speaking people.
The foregoing recommendations indicate that health
programs need to be flexible enough to permit modification
to fit varying situations. However, flexibility is not
easily attained— there is bound to be some rigidity owing
to the fact that any program requires an organizational
framework. Formal organizations are necessarily somewhat
inflexible, and the larger they get, the less adaptable they
are likely to become. Organization requires that relation
ships be structured, which is to say that the privileges and
responsibilities of each position be specified and delim
ited; that time and energy be devoted to activities and ends
not directly related to the purpose for which the organiza
tion was formed; and, not infrequently, that its major goal
be subordinated to other considerations. Organizations also
are modeled after preexisting patterns and this, too, in
troduces a degree of rigidity.
Not only is the organization itself likely to be
somewhat inflexible, but it operates in an environment that
imposes limits oh its activity range. Some of these
70
restrictions are formal, such as the laws that specify what
various types of organizations can and cannot do. Others
are informal, but no less restrictive. For example, the
kinds of controls a state or county medical society can
exercise over the operations of a health program must be
considered.
There is likely to be inflexibility also on the
part of the persons who operate the program. Health per
sonnel, as those in other areas of professional activity,
come to have what is virtually a trained incapacity for
practicing their professions under any but a rather narrowly
limited range of circumstances. Their deep immersion in
scientific medicine, their reliance on the urban hospital
(in which most of them were trained), their shared concep
tion of their own professional roles and functions, their
somewhat specialized value judgments with respect to health
and disease, all make difficult for many the concessions
necessary if their professional skills are to be acceptable
to rural laymen such as those living in the San Luis Valley.
In the treatment of disease there can be no compromise with
the highest professional standards; in the treatment of
people there may have to be some compromise if the treatment,
relationship is to be accepted. Modification in the
71
approach to and handling of a person need not be accompanied
by a change in the treatment of his disease. But because it
is so difficult- on the practical level to separate medical
procedure from the accompanying circumstances in which it is
used, any suggestion for change in the circumstances is
easily interpreted as requiring change in these procedures.
Although medical programs designed for Spanish-speaking
people are usually less flexible than they might ideally be
because of the tendency of Anglo professional persons to
resist experimentation in social arrangements for giving
care, in the belief that they are protecting the quality of
that care, it is recommended that some flexibility be exer
cised in establishing any health program in the San Luis
Valley.
For some time to come, the greater part of the
impetus required for improving medical care for Spanish
speaking people will probably have to be supplied by Anglos
and those in the Spanish-speaking population who are the
most Anglicized. Increasing numbers of Spanish-speaking
men and women are receiving training that will fit them for
professional careers in medicine and related fields. Many
of these, because of their bicultural conditioning, will be
able to gain acceptance of their professional services more
72
easily than anyone else. Physicians are learning that they
can earn a living and make satisfactory use of their pro
fessional skills in rural communities that are largely or
wholly Spanish speaking. Organizations such as the New
Mexico Health Foundation have provided stimulation and some
financial help in the building and staffing of small rural
clinics, the first one located at Moriarty. Public health
services are slowly being extended into new geographic
areas and the range and scope of the services are being
expanded. The type of federal aid provided under the Hill-
Burton Bill has stimulated interest in rural hospitals and
made possible some that otherwise might not have been built
One good example is the Conejos County Hospital at La Jara.
International organizations such as the World Health Orga
nization are exploring new arrangements for improving rural
health services among people of diverse cultures, and some
of their findings may well be applicable in the San Luis
Valley. The developing concept of the medical team is
improving communication and understanding between various
levels of health personnel and between them and laymen,
widening the area of possible cooperative action. Medical,
nursing, and social work educators are becoming increasingly
concerned with the need to introduce their students to some
of the concepts and methods of the social sciences, par
73
ticularly in reference to cultural differences and the ways
in which attitudes may be understood and modified and behav
ior patterns changed.
It is recommended that emphasis continue to be
placed on preventive medicine and health promotion. There
is a growing awareness of the gains to be made by adjusting
health activities and programs to the levels of acceptance
and understanding of the populations to be served, and from
these and other trends, rural Spanish-speaking people are
certain to benefit.
Appendix C of this study includes further recom
mendations made by the author concerning the problems most
commonly mentioned by Valley residents of Spanish descent.
The opinions and recommendations expressed are based on
the Spanish-descent author's experience and family back
ground , mot as a specialist or an authority in the field.
It is hoped that the material in this appendix will be of
use to health providers in the San Luis Valley (or else
where) in improving their understanding of their Spanish
speaking patients.
74
APPENDIXES
APPENDIX A
QUESTIONNAIRE
76
APPENDIX A
QUESTIONNAIRE
General Information
Instructions :
Please answer as many questions as possible. I f you feel that
a certain question does not f i t your situation or you desire not to
answer, please leave blank.
1. Number of persons in your household. ______
2. Annual income of your family. _ _ _ _ _ _ _
3. Education level of head of the household.
4. You own _ _ _ _ _ or you rent your house.
5. Number of rooms in the house.
6. Number of bedrooms in the house.
7. House has hot and cold running water. _____ Cold only.
8. Number of bathrooms in the house. ______
9. Ethnic background of family. Anglo , Spanish descent
Black , Oriental , Indian ;____, Other_____ .
10. Language most often spoken at home. ________________________
11. Number of miles to nearest physician ________ , dentist______
hospital _________.
12. Do you or your family members go to your doctor for regular
medical checkups? _____ or do you wait until you are sick?
13. Do you or your family members go to your dentist for regular
dental checkups? or do you wait until you have cavities or
a toothache? _____
77
14. Name of doctor you consider as your family doctor.
15. Name of dentist you consider as your family dentist.
16. Are you aware of all the medical and dental services that are
available in your area? ______
17. Do you know what services are available in the c lin ic you most
often go to? ______
18. Do you ever go to chiropractors for services? ______
19. Do you go out of the San Luis Valley for health services?
20. Please check the specialist you are fam iliar with and know what
services they provide.
General surgeon -
Psychiatrist________________ ______
Internist___________________________
Obstetrician/Gynocologist ______
Optometrist_________________ ______ ;
Pediatrician________________ ______
Neurologist ______
OpthalmologiSt ______
Orthodontist ______
Cardiologist ______
Orthopedist ______
78
Medical Health Setting
Instructions :
Following are some statements about the medical health setting in your
area. Please indicate the extent to which each statement characterizes
the medical services you most frequently use by circling the appropriate
response at the right.
N = Never, R = Rarely, S = Sometimes, 0 = Often, A = Always
.1. The physician is friendly. N R S 0 A
2. The mannerisms of the physician are annoying. N R S 0 A
3. The physician spends time explaining your
problem with you or members of your family. N R S 0 A
4. The physician uses terms you understand. N R S 0 A
5. The physician understands your culture. N R S 0 A
6. The physician speaks your native language. N R S 0 A
7. The physician pressures you for payment.
N R S 0 A
8. The physician discusses your progress with you.
N R S 0 A
9.
The physician discusses your family and their
medical problems with you.
N R S 0 A
10. The physician
asks you to return for followup.
N R S 0 A
11 . The physician dresses to your conformity.
N R S 0 A
12. The physician refers patients to other
medical specialists when needed.
N R S 0 A
13. The physician
follows his appointment system.
N R S 0 A
14. The physician s office is well staffed.
N R S 0 A
15. You
recommend your physician to your friends.
N R S 0 A
79
Dental Health Setting
Instructions :
Following are some statements about the dental health setting in your
area. Please indicate the extent to which each statement characterizes
the dental services you most frequently use by circling the appropriate
response at the right of each statement.
N = Never, R = Rarely, S = Sometimes, 0 = Often, A = Always
1. The dentist is friendly. N R S 0 A
2. The mannerisms of the dentist are annoying. N R S 0 A
3. The dentist spends time explaining your problem
with you or members of your family. N R S 0 A
4. The denti st uses terms you understand. N R S 0 A
5. The dentist understands your culture. N R S 0 A
6. The dentist speaks your native language. N R S 0 A
7. The denti st pressures you for payment. N R S 0 A
8. The denti st discusses your progress with you. N R S 0 A
9. The dentist discusses your family and their
dental problems with you.
N R S 0 A
10. The denti st asks you to return for followup. N R S 0 A
11. The denti sts dresses to your conformity.
N R S 0 A
12. The dentist refers patients to other dental
specialists when needed.
N R S 0 A
13. The denti st follows his appointment system.
N R S 0 A
14. The denti st s office is well staffed.
N R S 0 A
15. You recommend your dentist to your friends.
N R S 0 A
80
APPENDIX B
CONSUMER INTERVIEW
81
APPENDIX B
CONSUMER INTERVIEW
Name of consumer:
Address:
Name of head of household i f d iffe r
Number of persons in household:
Location of interview:
ent from above :
QUESTION ANSW ER
1. In the past 12 months, has
any member of your family
had any sudden illness or
injury? What was the prob-
1 em?
2. How many hours of of 24
would a car and driver be
immediately available i f
you had to go for health
care?
3. From whom do you get advice
f ir s t when you or someone
in your immediate family
is sick?
4. As a man/woman, would you
go to a doctor of the
opposite sex? I f no, why
not?
5. Do you prefer to be treated
at a hospital or at home?
Why?
82
6. What f ir s t aid or medical
supplies do you have
available in your home?
7. What herbs or other home
remedies do you have
available in your home?
8. Have your or any member of
your family ever received
prescriptions or medical
advice from a doctor that
you couldn't understand?
9. Have you.or any member of
your household ever become
i l l due to evil eye, frig h t,
fallen fontanelle, empacho?
10. Which ethnic or racial
group does your family
identify with?
11. In the past, what has your
physician (dentist) said
that you f e lt you did not
understand?
12. In the past, what have you
wanted to te ll the physi
cian (dentist) but did
not know how?
83
APPENDIX C
PROBLEM-SOLVING RECOMMENDATIONS
84
APPENDIX C
PROBLEM-SOLVING RECOMMENDATIONS
The author's personal recommendations for helping
solve the problems listed in Chapter IV are offered here.
They have not been statistically measured and are included
here as an invitation for other researchers to solve. It is
hoped that the information and ideas given will help provide
better health services to the Spanish-speaking people in the
San Luis Valley.
Recommendations on Economic Problems
1. It is not a simple matter to convince Spanish-i
speaking people that there are advantages in prepayment
health plans, but there may be some way for public health
personnel to encourage more extensive use of hospitalization
plans or health insurance.
2. Since part-pay clinics are available in the area,
it is recommended that they be supported and, if possible,
their services extended.
3. The problem of transportation to hospitals and
85
clinics is being improved through the establishment of '
transportation services financed through an HEW grant. An i
additional possibility might be considered— the extension of
medical care to local people through branch clinics in scat-'
tered areas.
4. Mothers with small children complain of the dif
ficulties they have in keeping medical appointments. Neigh
borhood cooperative nurseries could perhaps help solve the
problem of child care; local services groups might be en
couraged to support such projects.
Recommendations on Communication Problems
1. Health workers should approach Spanish-speaking
people cautiously and try to determine which language they
prefer to speak. Some may be offended at the suggestion
that they do not understand English. If possible, Spanish
should be used with patients who obviously prefer that
language. Using interpreters is less satisfactory than
direct conversation between patient and health worker. Any
plan is worthy of consideration that would encourage more
public health personnel in Spanish-speaking areas to learn
some Spanish.
2. It is recommended that administrators in areas
with significant numbers of Spanish-speaking people either
86
consider hiring receptionists who can receive calls from
Spanish-speaking people or make arrangements for relaying
such calls to another staff member who can receive messages
and supply information in Spanish. These bilingual employe
ees could be called upon when necessary to act as
interpreters.
3. It is easy for health workers to overestimate
the vocabularies and scientific knowledge of their clients.
Explanations, whether in English or in Spanish, should be
simple and free from technical terminology.
4. Reading comprehension in the three counties is
considerably below the level of that of the general public.
Health literature aimed at an audience of children or young
adults should be in English (preferably not over fifth-grade
reading level). Older adults are more likely to read mate
rials in simple Spanish. Materials designed for people of
all ages had best be printed in both languages. Common lan
guage, however, does not necessarily constitute good commu
nication. Although written materials should always be writ
ten in terms that the people can understand, they sometimes
are not.
5. Since language has strong emotional value, it is
not advisable to attack language use directly. For example,
87
if hospital patients want to speak Spanish among themselves,
they should be allowed to do so. They will feel more at
ease and less isolated from their own community. It might
be advantageous, in fact, to use bilingual patients for
explaining treatment procedures to other hospital patients
who understand only Spanish.
6. If health programs use mass media, the program
planners should consider using not only English channels but
also Spanish ones. Radio programs in Spanish are particu
larly effective in reaching a large audience. Both KGIW in
Alamosa, Colorado, and KKIT in Taos, New Mexico, broadcast
Spanish at certain hours.
7. If health programs disseminate information
through local organizations, some preliminary effort should
be made to determine which groups in the community are most
influential. These vary from one area to another in the
Valley.
8. School children are sometimes used as couriers
to carry information back to the parents. Although this
procedure is satisfactory for factual reports, it is not
very effective for the introduction of new ideas designed
to change attitudes or behavior patterns because the young
have relatively low status in Spanish-speaking families. It
88
is recommended that adults be contacted directly whenever
possible.
Recommendations on Conflict with
Folk Beliefs
1. It is recommended that medical workers try to
learn something about local medical beliefs and practices in
order to gain stature, to avoid appearing ignorant, and to
be enabled to work toward dispelling those folk customs that
are detrimental. The use of ridicule should be avoided in
all situations. With those who are convinced of the valid
ity of their beliefs, it might be possible to work within
the context of folk medicine. For example, if a mother sug
gests that her child is suffering from "fallen fontanelle,"
a doctor or nurse might point out that Anglos call this dis
order by another name— dehydration. Differences in ideas of
etiology might simply be ignored. Conflict might also be
avoided by saying, "Yes, 1 know about that disease, but it
I
seems to me that his is something else."
2. Since there is strong faith in the healing qual
ities of herbal remedies, it might be advisable, in encour
aging the use of prescribed medication, to explain that
drugs are often made from herbs: "Doctors have found that
such and such an herb is an excellent remedy for this
89
condition; the medicine I am giving you is made from that
herb, but it is much purer than the crude plant." The sug
gestion has been made that if a child is to be given large
quantities of boiled water in the treatment of diarrhea, it
is advisable to prescribe instead large quantities of herbal
teas. Mothers may not see the value in forcing plain water
on the infant, but they have confidence in the value of
herbal teas and will be much more likely to follow the
instructions.
3. Medical workers should recognize the strength of
religious convictions among many of their Spanish-speaking
patients, particularly those who rely on faith healing.
There seems to be no need for health workers to secularize
everything. Sneering at faith healing can drive away de
voutly religious patients who might gladly come to be cured
if the physician were willing to let them regard him as an
instrument of God.
4. Health workers dealing with problems of nutri
tional deficiency should not try to encourage sudden and
marked changes in diet. Better results can be obtained by
recommending the use of different proportions of foods
already in the local diet.
5. It is recommended that simple Mexican foods be
90
served more frequently to Spanish-speaking patients in hos
pitals— for example, Spanish rice, pinto beans, tortillas,
and hot chili sauce. If chili sauce could be provided to
Spanish-speaking patients regularly as a condiment (as cat
sup is served to Anglos), many foods otherwise thought
tasteless could be enjoyed.
Recommendations Related to
Definition of Disease
1. The preclinical stage of illness should be care
fully explained. A good approach might be to inform asymp
tomatic patients that of course they feel well now but that
they have been exposed to a dangerous illness that is
attacking their bodies and that unless they receive prompt
treatment they will become very sick indeed.
2. From the patient's point of view, reassurance
that his symptoms are not pathological may be as important
as the diagnosis and treatment of "real" disease.
(
Recommendations Related to
Problems of Modesty
1. Health workers should try to avoid embarrassing
patients; for example, more bodily exposure than absolutely
necessary should be avoided; beds in hospitals should be
screened during any period of body exposure; sexual topics
91
should not be discussed in mixed groups; and in venereal- |
disease control, private conferences are advisable.
I
2. Because Spanish-speaking women and girls are !
extremely modest, it is advisable to consult with fathers
rather than mothers concerning genital-urinary problems of
male children.
Recommendations on Problems Related to
Medical Roles
1. It is not advisable to expect a patient to make
a medical decision until he has had a chance to consult with
family members. Medical workers should avoid approaches
that fix individual responsibility; group responsibility
should be recognized. It is desirable for public health
workers to make an effort to consult with those of the
patient's family who have real authority in the group. For
example, if possible, a child's health problems should be
discussed with both parents. The mother alone may not have
authority to act on the child's behalf. If a patient is
accompanied to a clinic or a doctor's office by other family
members, it is well to inquire about their relationship to
the patient and to consult with them about the patient's
welfare. County nurses would be wise to determine some of
of the compadrazgo relationships of their clients ; if there
92
is difficulty in getting cooperation from the patient or
his immediate family, compadres (godparents) may be willing
to use their influence in getting the patient to take medi
cal action. It is advisable to try to include an older per
son in a family discussion. A grandmother, for example, can
be a powerful influence in medical decisions.
It may be best to encourage whole families or groups
of families to adopt a new health program, rather than put
ting pressure on a single individual, who may be more afraid
of what people will say than of what the doctor may think.
In most public health services there are time, space, and
personnel limitations that make it difficult for doctors or
nurses to work with whole groups of people at one time.
Public health projects, however, can be much more effective
if an approach is used that includes whole family groups.
2. It is advisable to remember that people have
problems other than medical ones, and that their responsi
bilities to family or other social groups may supersede
medical demands. Sometimes the effort of a public health
worker to help a client get a boy out of juvenile hall or
locate a job, for example, may clear the way for tackling
medical problems.
3. A cold and impersonal approach to Spanish-
93
speaking clients should by all means be avoided. A patient
will not trust medical workers who are unfriendly, but will
have confidence in those who seem sincerely interested in
him, in his family, and in his feelings. If patients seem
ill at ease or disturbed, it might be advisable to ask
frankly, "Are you afraid of something? What can I do to
help you feel better about this?"
4. A patient or his family should not be scolded or
blamed for an illness. If it is thought that the disorder
is due to real negligence, it is advisable to wait until the
illness is under control, then say, "We have learned that
there is a way to prevent this happening again. Would you
like be to tell you about it so that you can protect your
family?" It is advisable to stress the positive advantages
to be gained from following a proposed course of action
rather than antagonizing the patient by pointing to his
failures or omissions.
Recommendations for Solving Problems
of Social Distance
1. Any approach which conspicuously indicates that
Spanish-speaking people are basically different in some way
from other people will offend group loyalties, and should
be avoided. Such approaches may be interpreted as
94
discriminatory. Spatial segregation in hospitals and
clinics should be discouraged, for example. As indicated
previously, it is often necessary to cater to special prob
lems of Spanish-speaking patients; however, workers should
do this inconspicuously so that it will not occur to the
patient that he is receiving unusual treatment but merely
that he is dealing with friendly, helpful people.
2. Program planners will find it advantageous to
discover the persons of prestige or power in the local com
munity and enlist their support in public health programs.
It should be remembered that those whom Anglos regard as
"Mexican leaders" may be thought of as "big shots" or "out
siders" by members of the target group. Such people may not
be well accepted among their own people. A health program
can prove ineffective simply because Spanish-speaking people
resent having their affairs turned over to outsiders. Those
who are effective leaders in their own neighborhoods may be
harder to find and more difficult for Anglos to work with;
efforts to gain their cooperation and support, however, are
rarely wasted.
3. Medical personnel can often minimize their
social distance from patients by avoiding patronizing atti
tudes or authoritarian approaches. Health workers need not
95
hesitate to make friends with patients and to take a personal,
interest in their affairs. A little extra time taken for
social amenities is well spent. Health workers, for exam
ple, should accept food or drink if it is offered. They
should not enter a home, however, until they are specifically
invited. This time investment in the initial stages of a
medical relationship may actually save time later. A public
health worker who shows courtesy and graciousness will be
accepted as a warm and congenial person who can be trusted
and whose suggestions must be considered. County nurses
might consider the possibility of attending local gatherings
occasionally to show their sincere interest in the community
and its people. Even clinic physicians and nurses may be
able to establish friendly relations by taking a little time
at the beginning of an interview to socialize with patients.
Recommendations for Solving Problems
Related to Hospitalization
1. Until some of these problems are resolved, it is
advisable to allow Spanish-speaking patients to be cared for
at home whenever possible.
2. If hospital admission cannot be avoided because
of the severity or infectious nature of the illness, patients
should be allowed to have relatives with them as often as
96
possible and should be placed where they may converse with
other Spanish-speaking patients. Complete segregation,
however, should be discouraged for the reasons discussed
above.
97
APPENDIX D
A SELF-TRAINING HANDBOOK
98
APPENDIX D
A SELF-TRAINING HANDBOOK
Most young adults have not had to contend with the
often perplexing problems of securing medical services in a
strange community. A frequent dilemma that young married
people may have to face is the rapidly rising fever of a
child not a year old, its anguished cries, and its inability
to communicate to the parents what is wrong. If the young
parents were living in the community in which they grew to
adulthood, there probably would not be any problem. A hur
ried call to the family physician would lead to prompt care
for the child and assurance for the parents. But populatiôn-
mobility statistics indicate that a large number of young
adults will move to new communities to continue their edu
cation or to start new jobs. It is never too early to spend
a few moments looking at some aspects of the health picture
that might have to be faced in the very near future.
Some sort of medical services are available to
\
almost all communities in the Valley and are usually a part
of a team effort to provide for the citizens the most
99
comprehensive health care possible. A wide variety of
services are available; this handbook is an attempt to ex
plain the necessary training and qualifications of the médi
cal professionals and the way in which the professionals can
.best be used to benefit the individual.
The Medical Doctor
Man has always been plagued by disease and by the
question of what causes it. Theories of disease causation
have led to a wide variety of practices to prevent and cure
it. The history of man is alive with examples of witch doc
tors or medicine men casting their spells, of the bleeding
-of patients to create the best balance of body humors, and
of locking windows at dusk to keep out the bad night air.
Fear and superstition became a general part of the preven
tion and cure of disease because sick people often got well
regardless of the treatment. The homeostatic balance of the
body was unknown.
The road to becoming a physician today is long and
difficult. Much has been added to the curriculum as medical
science has advanced, but very little has been dropped. At
the turn of the century, it was possible to become a doctor
by serving an apprenticeship with a doctor and sometimes
taking additional courses in anatomy or physiology. Today
100
all 50 states and the District of Columbia have stringent
regulations for licensing.
Qualifications for physicians educated in the United
States and Canada who are granted licenses include graduation
from an accredited medical school that is approved in all
states and a one-year internship. The latter qualification
applies in 3 2 states and the District of Columbia. In ten
states, four years of preprofessional education are required
for entry into medical school; in two states, three years;
and in the remaining 3 9 states, two years.^
American medical schools are presently being asked
to evaluate the length and spacing of their professional
preparation programs in order to increase the number of
graduates to meet the critical shortage of physicians. New
medical schools are starting, but it will be some time be
fore they will be able to provide a steady stream of gradu
ates into the profession to help meet the need. One sugges
tion that has been presented calls for the individualization
of medical education to fit differing rates of achievement
and educational background. It might then be possible to
graduate qualified physicians in certain fields after three
National Center for Health Statistics, State
Licensing of Health Occupations (Washington, D.C.: U.S.
Public Health Service, 1957), p. 110.
101
years of medical school without lowering the quality of the
profession.
The health program of any community centers around
the family doctor. There are a number of paramedical pro
fessions that hold valuable adjunct positions on the medical
team, but the family doctor has the responsibility of coor
dinating the individual health care of his patients. The
role of the family doctor has formerly been filled by a
general practitioner (GP). An individual who has completed
his preprofessional preparation, four years of medical
school, and his internship is qualified to practice general
medicine. General practice is presently a rapidly diminish
ing sector of the medical profession. Some twenty years ago,
general practitioners outnumbered specialists three to one.
Today fewer than half of the licensed physicians are in
general practice.^
The young medical-school graduate is facing quite a
dilemma today. The knowledge explosion in the field of
medicine is forcing individuals into specialty education.
To concentrate on a specific specialty area limits the
physician's knowledge of the whole person and makes him less
2
Kenneth L. Jones, Louis W. Shainberg, and Curtis O.
Byer, Health Science (New York: Harper & Row, 1968),
p. 320.
102
proficient at general practice. But the research advances
made by specialists who know one area in depth have enabled
medicine to make great strides in such areas as cancer re
search, surgery, and psychiatry.
A young doctor who elects to specialize usually
faces an additional two to five years of graduate study and
residency under specialists in the field of his choice. The
fields of medicine approved by the American Medical Associa
tion for specialized preparation are:
Aerospace Medicine : Evaluation of flight personnel
and the study of the physiological response to conditions
encountered in flight, both in air and space.
Anesthesiology: Administration of anesthetics and
other drugs that produce loss of sensation or consciousness,
operation of heart/lung machines, and monitoring of the
patient's reactions.
Child Psychiatry: Diagnosis and management of the
emotional problems of children and their relationship with
their parents, including guidance for normal mental and
emotional development.
Colon and Rectal Surgery: Operative correction of
conditions and diseases of the colon and rectum.
103
Dermatology : Treatment of diseases of the skin and
scalp.
General Practice: Treatment of the whole body,
largely through nonsurgical means.
Internal Medicine; Treatment of nonsurgical dis
eases and illnesses. Among subspecialties are gastro
enterology, allergies, cardiovascular disease, and pulmonary
disease.
Neurological Surgery: Operative treatment of condi
tions of the brain, spinal cord, and peripheral nerves out
side the brain and spinal cord.
Neurology : Diagnosis and therapeutic management of
diseases of the nervous system.
Obstetrics and Gynecology; Management of pregnancy
and childbirth and the treatment of women's diseases, espe
cially of the reproductive organs.
Occupational Medicine: Protection of employed per
sons through preventive medicine practices, reduction of
exposure to hazardous substances, and immediate care of
injuries and sudden illness.
Opthalmology; Surgical and medical treatment of
diseases of the eye; refractions.
104
Orthopedic Surgery: Operative correction of deformi
ties, fractures, and other disorders and diseases of the
skeletal system and related structures.
Otolaryngology ; Operative and therapeutic treatment'
of disorders of the ear, nose, and throat.
Pathology ; The identification of disease through
the analysis of body tissues, fluids, and other body
specimens.
Pediatrics : Management and treatment of children
from birth to teens. Subspecialties include pediatric
allergy and pediatric cardiology.
Pediatric Allergy: Diagnosis and management of
children and adolescents with allergic diseases.
Pediatric Cardiology: Management of children with
heart disease, congenital or acquired.
Physical Medicine and Rehabilitation: Treatment and
restoration of the convalescent and physically handicapped
patient.
Public Health: The aspects of preventive medicine
often administered by government, usually in a department
of public health.
105
Plastic Surgery: Reparative operations on the
scalp, face, eye sockets, nose, mouth, neck, trunk, and
extremities.
Preventive Medicine: Study, prevention, and control
of epidemic, environmental, and occupational diseases and
hazards. Special affiliated fields include aviation medi
cine , general preventive medicine, occupational medicine,
and public health.
Psychiatry : Interpretation and treatment of mental
and personality disorders. A subspecialty is child
psychiatry.
Radiology : Diagnosis and treatment of illness by '
the use of radiant energy; for example, x-ray and radio
active isotopes.
Thoracic Surgery : Operative treatment of diseases
of the lungs, esophagus, and related organs.
Urology : Diagnosis, therapy, and operative treat
ment of diseases of the urinary tract, including the repro-
3
ductive organs in the male.
3
W. W. Bauer, ed., Today's Health Guide (Chicago;
American Medical Association, 1968), pp. 312-314.
106
Dentistry '
Dentistry today is becoming increasingly allied with
i
the field of medicine. Preprofessional training parallels
that of the medical student, with major emphasis being
placed on the basic sciences.
Dentists are licensed in all states and the District
of Columbia. A minimum of six years of education beyond
high school is required for a licence in all states but
Washington. In Washington, only one year of college is re
quired, but at least two years of college is a requirement
for admission to the four-year program leading to the Doctor
of Dental Surgery or Doctor of Dental Medicine degrees. At
the present time, only one state, Delaware, requires a one-
year residency before licensing as a general dental prac-
. 4
titioner.
Dentistry is defined as the branch of the healing
arts that is concerned with the teeth, oral cavity, and
associated parts, including the diagnosis and treatment of
their diseases and the restoration of defective and missing
tissue.^ Professional programs in dentistry are providing
4
National Center for Health Statistics, State
Licensing, p. 45.
5
Dorland's Illustrated Medical Dictionary, 24th ed.
(Philadelphia: W. B. Saunders Co., 1965), p. 398.
107
more specialized preparation as dentists are becoming key
figures in the detection of oral cancer and in the treatment
of dental problems associated with such diseases as aller
gies , diabetes, and hemophilia. A dentist is also licensed
to prescribe medication.
Specialty education is also available for any den
tists who wish to specialize. The dental specialties usu
ally require two or three years of additional professional
preparation. The American Dental Association lists the fol
lowing dental specialities:
Dental Public Health: The aspect of public health
that deals with dentists and dental health.
Endodontics: The treatment of diseases of the dental
pulp or lesions caused by such disease.
Oral Surgery: Surgical treatment and repair of
teeth involving cutting into the jawbone.
Orthodontics : The straightening of irregularities
of the teeth and corrections of malocclusions of the jaw.
Pedodontics: Treatment of the dental ills of
children.
Periodontics : The treatment of diseases of tissues
around the teeth.
108
Prosthodontics: The construction of special appli
ances to compensate mechanically for such deficiencies as a
cleft palate.
Oral Pathology: Treatment of the essential nature
of dental disease through the study of structural and func
tional changes in tissue and organs of the oral cavity.^
Choosing a Medical Adviser
A complaint frequently heard in many communities is
"You can never get a doctor when you need one!" This could
be a statement made by anyone who follows the practice of
waiting for an emergency before he attempts to contact a
physician. In seeking medical care, one must decide what
his needs are. The most frequently recommended plan is for
a family to select a general practitioner to deal with the
family's medical problems and to rely on his program and
referral to qualified specialists when their services are
required.
It is becoming increasingly difficult to find a
general practitioner today. In light of the increasing num
ber of young doctors electing to specialize, a young family
^American Dental Association, 1968 American Dental
Directory (Chicago: American Dental Association, 196 8),
p. R63.
109
may be forced to turn to specialists to provide their gen
eral medical care. It may be desirable to select several
specialists— for example, a pediatrician for the children
and an internal medicine specialist for the adults.
In choosing a physician, the following procedures
are recommended ;
1. If moving to a new locality, ask your present
physician at home for recommendations of physicians in your
new residence area. It is possible that he may know someone
personally in the area who could help you secure medical
care.
2. Contact the San Luis Valley Medical Society.
The society will furnish names of members who will be able
to take additional clients.
3. Use your telephone directory. From the list
provided by the Valley Medical Society, select names of
family physicians or specialists of your choice who are
close enough to make care easily accessible.
4. Use your library. If you wish to check the
credentials of recommended physicians, you can find meaning
ful information listed in the American Medical Association
Directory at your local library. The directory will tell
you whether a physician is a member of the local medical
110
1
society or the AMA and will also list specialty training, '
as well as fellowship in the American College of Surgeons or
the American College of Physicians.
5. Contact your local hospitals. Find out whether
hospitals functioning in your area are accredited by the
Joint Committee on Accreditation of Hospitals (JCAH). After
establishing the accreditation status of the hospitals, de
termine which physicians on your list are staff members of
or are entitled to practice in the hospital. If you must go
to a hospital, your physician's services will be permitted
only if he is allowed to practice there.
6. Visit the physician of your choice. After you
have narrowed your choice to one or two possible individuals,
arrange to meet with the physician. A visit to his office
will answer many questions about the physical environment,
such as neatness, cleanliness, and efficient functioning.
You should feel free to ask the physician questions: What
are your needs and your family's needs? Is he available for
emergencies and, if not, does another physician cover for
him? Who is this other physician? What fees does the phy
sician charge? Following the visit, you should decide if
the physician is the sort of individual you want as your
health adviser.
Ill
The general procedures listed above can also serve
as a guide in locating a dentist. There is also a San Luis
Valley Dental Society. Most dentists feel that the last
step in the recommended procedure for choosing a physician
is also the most important item when looking for dental
services. You should be satisfied with the environment in
which the dentist functions and the relationship that devel
ops between you and the dentist.
Use of Medical Advisers
Once the choice of a medical adviser has been made,
the individual can do much to ensure better medical care at
a lower cost. The key to the best use of your physician's
or dentist's services is to have regular checkups. This
will allow for compilation of an accurate, up-to-date medi
cal history. If you have moved from a previous location,
tell your new physician and dentist the names and addresses
of the previous ones so that they can request your previous
medical history. Many people feel that medical and dental
examinations are costly and inconclusive. It is true that
periodic examinations can be the most costly procedure pres
ently in use; but when regular checkups lead to the compila
tion of a complete history, they may result eventually in
considerable savings. Any change in one's normal pattern
112
will be noted quickly and can lead to prompt early diagnosis^
which may prevent a catastrophic siege at some later date.
Equally as important as annual checkups are truthful
discussions with your physician and dentist about all of
your health problems. The physicians and dentists have been
educated over a long period of time, but they need the pa
tient's help in order to function with maximum skill. It is
surprising, but many patients really try an adviser's skill
by withholding vital information from him. One should not
withhold any symptoms that might be plaguing him because he
is afraid that by exposing them he would be subject to some
unpleasant news. The only person he is fooling is himself.
Another dilemma is produced when you (or your child)
does not feel up to par. Should you go to work (or send the
child to school), call the doctor, or just stay in bed?
While it is difficult to formulate any surefire rules to
follow, experience of physicians can be related to help the
layman reach a decision concerning the right course of ac
tion to follow. The rules listed below are based on the
opinions of Drs. Maynard, Minturn, and Edgerton, who have
7
had years of experience.
7
Interviews with Tyrus Maynard, M.D., Obie Minturn,
M.D., and Phil Edgerton, D.D.S., of the Sangre de Cristo
Comprehensive Health System, Inc., San Luis, Colorado,
1 July 1974 to 30 June 1975.
113
Fever : An adult should stay home when his tempera
ture is above his normal range, usually between 9 6 and 99
degrees.
Cold : When you have just a runny nose and there is
.no fever, you may be a little uncomfortable, but you'll
survive, and may as well go ahead and face the day. Good
personal hygiene— having plenty of tissues and avoiding
close contact with others— will reduce contagion. If it's
a heavy cold, you belong in bed. There, rest will speed
your recovery, and isolation will prevent your wheezing and
sneezing from annoying and showering germs upon others. If
your cold has not improved in three days, there may be some
other factor involved and you should have your case evalu
ated by a doctor.
Rash : If it's localized and there's no temperature
elevation or other symptoms, there's probably no cause for
concern. An allergic reaction is a good possibility. If
there is itching, you'll have to judge whether you can bear
it in public until it goes away or can be relieved by medi
cation. A generalized rash, particularly with fever, prob
ably indicates the presence of one of the many viral or bac
terial illnesses and you'd best find out what it is before
mingling with other people. Among the better-known possi-
114
billties are measles, chicken pox, and scarlet fever (and,
in adults, syphilis).
Headache ; By itself, except in extreme cases, a
headach is not sufficient reason for staying home. We know
aspirin works, but if the headache is "splitting" enough to
hamper your functioning, or is accompanied by fever (pos
sible virus attack), it is better to stay home.
Pain : If the pain is in the limbs, possibly after a
fall or hard bump, there are two approved tests of whether
it is anything serious, like a fracture or torn ligament or
muscles, that should send a person to the doctor instead of
to work or school. Generally, if you can move the arm or
leg through its full range of motion, or put substantial
weight on it,: without experiencing acute pain, it is nothing
serious. If the pain is in the chest, have it checked out
by a doctar right away— it could be muscular, but it could
also be a lung problem or some irregularity in blood circu
lation to the heart. Pain in the back or ankle is usually
a sprain, which responds most favorably to rest.
Stomachache : The first rule is to stay home if the
pain is severe enough to limit activity. Stay indoors if
there is any vomiting or diarrhea (possible gastrointestinal
115
infection). It is advisable to see a physician if there has
been any known blow to the abdominal area. Parents should
remember that appendicitis can occur from about the age of
four, and it sometimes urgently needs medical attention on
the first day of pain.
Vomiting : When there has been just one episode and
a meal has been eaten and retained since, there probably is
no problem. In a high percentage of cases, the cause is
simply a reaction to something eaten, a mild gastrointestinal
attack, or mild emotional disturbance. If there is more
than one episode with no apparent explanation, it is better
to have an examination by a doctor.
Sore Throat : If it looks just a little red and
there are no other symptoms, it is probably all right to go
forth. A low-grade viral infection is most likely. If it
is going to develop into anything more troublesome, it will
■do so within 24 hours. However, if white spots are to be
seen, this may well be a strep infection. You should stay
home and check with your doctor; if he believes it is strep
throat, he is likely to prescribe an antibiotic.
Earache ; When it is associated with a cold, it is
usually safe to go ahead with normal activities. Clogged
116
passages are causing pressures similar to those felt in !
airplanes at higher altitudes. Nose drops should be helpful.
Sharp pain may indicate an infection, and any discharge of
fluid in the ear definitely does. See a doctor immediately,
because hearing loss can result from infection.
Cough; If you are hacking away pretty steadily,
stay put. Bed rest seems to be warranted, and it is the
best medicine for a cough. Coughing is a healthy sign that
your system is handling the situation. The cough reflex
gets rid of excessive mucous accumulations. Whooping cough
is now controlled quite effectively by inoculation, but the
characteristic "whoop" will tell you whether a case of it
has slipped through.
Fatigue ; If you feel completely exhausted, it is
considered better to take the day off than to drive your
self under such circumstances. You will probably make up
for the lost time with renewed vigor the next day. If you
still feel "dead tired" the second day, see your physician.
Toothache ; Go straight to a dentist. Most tooth
aches are caused by infections not likely to improve without
treatment. A person with a toothache is not able to func
tion normally until it has been relieved.
117
Once the decision to see a medical doctor has been
made, follow his instructions and do not interfere with his
efforts by attempting to tell him how to run his practice.
The Paramedical Professions
Whether we use the term "allied health professions"
or "paramedical professions," essentially we are talking
about the same group of people— people who assist the medi
cal profession in a variety of ways. If we attempted to
list all of the career possibilities under this grouping,
the list would be endless. Qualifications for such profes
sions range from a high school diploma with one or two addi
tional years of specialized preparation up to one or more
years of graduate education beyond the bachelor’s degree.
One of the sweeping changes in the paramedical field
within recent years has been the introduction of several new
specialized programs that will attempt to bridge the gaps
between the professional registered nurse, the medical tech
nologist, and the physician. Many medical centers now have
programs for the preparation of physician's assistants who
will be able to assist the physician in both clinical/
research endeavors and the undertaking of many procedures
traditionally performed by the physician. The physician's-
assistant program is generally a two-year program beyond the
118
high school diploma and is designed primarily to free phy
sicians from many routine tasks so that they can devote more
time to patient contact.
A number of other professionals are specially pre
pared to work with physicians or independently to assist
in adjunct areas, as follows.
Optometrist ; The optometrist is an individual who
has received special preparation to measure visual acuity
and to prescribe corrective lenses for visual defects. The
optometrist examines eyes without the use of drugs, and he
does not treat diseases of the eye. Most optometrists have
been prepared to recognize pathological conditions of the
eye and to refer these conditions to an opthalmologist.
Optometry is a well-recognized profession, and preparation
leads to a bachelor's degree or, for advanced, the degree
of Doctor of Optometry. "
Optician ; An optician is a skilled technician spe
cially trained to compound, fill, and adapt prescriptions
written by an opthalmologist or optometrist.
Nurses ; Nurses are prepared to staff a variety of
positions. The primary preparation leading to the R.N.
title (registered nurse) is instruction in caring for the
sick. Minimum preparation beyond high school is not
119
specified in a number of states, but individual curriculum
requirements dictate the length of the programs in these
states, with a two-year minimum required for licensing in
31 states.
There are three categories of professional prepara
tion presently recognized that lead to the title R.N. The
Baccalaureate Nurse has a bachelor's degree in nursing fol
lowing four years of preparation in a degree-granting insti
tution. The Diploma Nurse has received three years of
training, usually associated with an accredited hospital
school of nursing. The Associate Degree Nurse receives two
years of professional preparation beyond the high school
diploma. Graduates from each of these three categories must
take State Board examinations before receiving the R.N.
classification.
Hospital demands have necessitated creation of the
practical nurse. The licensed practical nurse (L.P.N.) must
meet certain requirements in 4 8 states and in the District
of Columbia. Texas and California license a vocational
nurse (L.V.N.) Usual preparation of the L.P.N. or L.V.N. is
one year of study beyond the high school diploma.
Medical Technologist; Medical technologists provide
services under the supervision of physicians. Laboratory
120
technologists are primarily prepared to work under the di- !
rection of a pathologist in making tests on blood, urine,
and tissues. The findings from these tests are used by the
physician in making a diagnosis. Because of the scientific
demands of their work, laboratory technologists must have at
least three years of college work in the basic sciences plus
a year of supervised laboratory experience.
Laboratory technicians are prepared to carry out
types of work similar to those undertaken by technologists,
but do not require as high a degree of specialized prepara
tion. X-ray technicians are prepared to operate X-ray ma
chines by taking pictures and developing the plates for
reading by a radiologist.
Therapist : Therapy specialists are prepared pri
marily to assist the patient in rehabilitation following an
accident, acute illness, or chronic disease. Therapy spe
cialists are college graduates who usually have some work
beyond the bachelor's degree.
Dental Hygienist: A dental hygienist is prepared to
assist the dentist and to undertake routine tasks under the
dentist's supervision. All states and the District of
Columbia require the licensing of dental hygienists. Two
years of professional preparation beyond high school are
121
usually required, but seven states specify only one year of '
preparation in dental hygiene.
Pharmacist : Pharmacists dispense prescriptions
ordered by medical personnel and sell general proprietary
drugs and medical supplies. To receive a license as a reg
istered pharmacist required, in all states and the District
of Columbia, a minimum of five years of professional educa
tion, of which the last three or four must be in an accred
ited college of pharmacy. A pharmacist is responsible for
all drugs dispensed but he is not qualified to prescribe
individually any type of medication.
Health Educators: The health education specialist
is a college graduate, often with an advanced degree. The
function of a health educator is to use functional tech
niques to translate scientific information about health to
the people and to motivate them to use all this information
to improve their own health, the health of their families,
and the health of the community.
Signs and Symptoms of Alcoholism
Alcoholism is the nation's No. 1 drug problem. Cer
tainly during the years that heroin, marijuana, and LSD were
grabbing headlines, the real problem-causing drug was
122
alcohol. Chances are that it always will be. Alcohol in
distilled beverages is used by at least one-third of the
world's population. In most countries, 7 0 to 90 percent of
jadults drink alcoholic beverages. A welcome friend to some,
!
for others it spells pain, degradation, and premature death.
■ Brain and heart damage threaten any heavy drinker;
■cirrhosis of the liver, a usually fatal disease, is the fate
I
.of most alcoholics who survive heart damage. Alcohol has a j
I
(devastating effect on the brain; it impairs the functioning j
Iof the central nervous system, weakens such mental functions
; as memory, concentration, learning new tasks, dnd logical
thinking. Alcohol interferes with essential molecular pro
cesses in the brain. Alcohol's effect on the heart height-
;ens the risk of coronary disease. It weakens the heart,
diminishes the strength of contraction, and prevents the
correct flow of calcium, which is an element in the con
traction and relaxation of the normal movement of the heart
: muscle. Alcohol causes muscular atrophy and weakness.
These are the depressing aspects of alcohol. But
jthere is a cheerful note— heavy drinkers who quite can
I
,reverse some (but not all) of these devastations. The liver
j is noted for its recuperative powers and muscular weakness
I
I may be reversed.
I
i _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 2 ]
Frequently, methods designed to return an alcoholic
to controlled social drinking surface, attract attention,
perhaps some state or federal funding, then drop into richly
deserved oblivion. For the problem drinker of any age,
authorities on alcoholism point to lifetime sobriety as the
only answer. Once a person passes the invisible line between
!
•social and alcoholic drinking, he can never again safely
take even one drink.
I First, however, the problem drinker has to under-
jstand that he has a problem. For the teenager or a person
(in his early twenties, this may be difficult. The twenty
I
!test questions developed by Johns Hopkins University and
reproduced here provide guidelines for helping the drinker
Ipinpoint his problem. Once he comes to the realization
'that drinking is making his life unmanageable, help is as
close as the telephone.
; Are YOU an alcoholic?
! To answer this question, ask yourself the following
questions and answer them as honestly as you can.
Do you lose time from work due to drinking?
• Is drinking making your home life unhappy?
: Do you drink because you are shy with other people?
i
Is drinking affecting your reputation?
124
Have you ever felt remorse after drinking?
Have you gotten into financial difficulties as a
result of drinking?
Do you turn to lower companions and an inferior
environment when drinking?
Does your drinking make you careless of your fami
ly's welfare?
Has your ambition decreased since drinking?
Do you crave a drink at a definite time daily?
Do you want a drink the next morning?
Does drinking cause you to have difficulty in
sleeping?
Has your efficiency decreased since drinking?
Is drinking jeopardizing your job or business?
Do you drink to escape from worries or trouble?
Do you drink alone?
Have you ever had a complete loss of memory as a
result of drinking?
Has your physician ever treated you for drinking?
Do you drink to build up your self-confidence?
Have you ever been to a hospital or institution
on account of drinking?
If you have answered YES to any one of the ques
tions, there is a definite warning that you may be an
alcoholic i
If you have answered YES to any two, the chances
are that you are an alcoholic.
125
If you have answered YES to three or more, you
are definitely an a l c o h o l i c . 8
I Occurrence and Danger Signals of Cancer
j A woman's chances of developing cancer are 1 in 4 ;
■a man's, 1 in 5. A woman's chances of dying of cancer are
1 in 7 ; a man's, 1 in 8. Women are more likely to develop
icancer, but their chances of doing so decreases more with
Iage. Cancer is not considered a hereditary disease. It is
I
Ipossible, however, that some families have more of a ten-
I
jdency toward cancer than others. Cancer is chiefly a di-
isease of middle and old age. It strikes most often after
the age of 40, but it also occurs in infants, children, and
young adults. Cancer of the mouth, digestive system, and
I lungs is more common among men than among women. Breast
cancer is the most common among women; cancer of the uterus
is second. Cancer of the epithelial tissue, which is found
I
in the skin and forms the lining of most of the organs and
! the systems of the body, is called a carcinoma. Cancer of
!
nonepithelial tissues, such as connective tissue, is called
I a sarcoma.
Between physical examinations an individual can be
g
Paul Martin, "Teen-Age Alcoholism," Consumers
Digest 14 (July-August 1975): 22.
126
alert to signs that may warn of cancer, such as the fol
lowing .
1. A sore that does not heal.
2. A lump or thickening anywhere on the body.
3. Unusual bleeding or discharge from any natural
I body opening.
I 4. Any change in the appearance or size of a wart,
mole, or birthmark.
I 5. Indigestion or difficulty in swallowing that per-
i sists for more than two weeks.
I
' 6. Hoarseness or cough persisting for more than two
; weeks.
I
7. Change of bowel or bladder habits persisting for
i more than two weeks.
8. Any unexplained weight loss or apparent change in
body contour.^
These signs do not necessarily mean that cancer is
jpresent, but they do indicate that a visit to the doctor
Iwould be wise.
9
; American Educator Encyclopedia, 1970 ed., s.v
'"Cancer."
127
SOURCES CONSULTED
128
SOURCES CONSULTED
Alford, Robert R. Health Care Politics— Ideological and
Interest Group Barriers to Reform. Chicago: Uni-
veristy of Chicago Press, 1975.
American Dental Association. 196 8 American Dental Direc
tory. Chicago: American Dental Association, 1968
American Educator Encyclopedia, 1970 ed. S.v. "Cancer."
Anderson, Dewey. Health Services Is a Basic Right of All
the People. Washington, D.C.: Public Affairs
Institute, 1956.
Bauer, W. W., ed. Today's Health Guide. Chicago : American
Medical Association, 1968.
Clark, Margaret. Health in the Mexican-American Culture.
Los Angeles: University of California Press, 1970.
Colorado Department of Health, Records and Statistics Sec
tion. Colorado Counties and Planning Regions,
August 30, 1972, Planning Region No. 18. Denver:
Colorado Department of Health, 1972.
"Curriculum Change in Health Eduction." Bulletin of the
National Association of Secondary School Principals
52 (March 1968): whole issue.
Denver Department of Health and Hospitals. Smoking and
Health— An Instructional Guide for High School
Teachers. Denver : Department of Health and Hos
pitals, 1968.
Derryberry, Mayhew. "Health Education in Transition."
American Journal of Public Health and The Nation's
Dorland's Illustrated Medical Dictionary. 24th ed. Phila
delphia: W. B. Saunders Co., 1965.
Edgerton, Phil. Sangre de Cristo Comprehensive Health Sys
tem, San Luis, Colorado. Interviews, 1 July 1974
to 3 0 June 197 5.
.Fisher, John. A Foreign Language Guide to Health Care.
i Chicago : Blue Cross Association, 1975.
'Fodor, John T., and Dales, Gus T. Health Instruetion--
Theory and Application. Philadelphia: Lea &
Febiger, 1974.
Harrington, Michael. The Other America. New York: Mac
millan, 1962.
I
"Health Care in America--Why Does It Cost So Much To Be
I Sick?" Senior Scholastic 106 (March 1975) : 2-3.
jjaworski, Suzanne. Consumer Participation in Health--
I Curriculum. Washington, D.C.: Institute for the
I Study of Health and Society, 197 2.
•Jones, Kenneth L.; Shainberg, Louis W.; and Byer, Curtis O.
I Health Science. New York : Harper & Row, 1968.
(Katz, Alfred H., and Spencer, Felton J. Health and the
Community Reading in the Philosophy and Sciences of
Public Health. New York: Free Press, 1965.
iKime, Robert E. Health : A Consumer's Dilemma. Belmont,
I California : Wadsworth Publishing Co., 1970.
I
I
jMcEvoy, G. Edward, et al. The Team Description, Manpower
j Utilization, and Characteristics of Family Health
1 Workers. Final report for Department of Health,
I Education, and Welfare. Rockville, Maryland:
, Geomet, 1973.
I
^Marshall, Ann C. Marketing Family Health Center Services in’
! Southern Colorado. Saugache, Colorado : Saguache
' County Medical Clinic, 197 3.
, Martin, Paul. "Teen-Age Alcoholism." Consumers Digest 14
I (July-August 1975): 20-22.
130
[Maynard, Tyrus. Sangre de Cristo Comprehensive Health Sys-
I tern, San Luis, Colorado. Interviews, 1 July 1974 to
I 30 June 1975.
!
jMinturn, Obie. Sangre de Cristo Comprehensive Health Sys-
• tem, San Luis, Colorado. Interviews, 1 July 1974
; to 30 June 1975.
I
Mogulof, Melvin B. Citizen Participation; The Local Per
spective . New York: Urban Institute, 197 0.
, ________. Citizen Participation: A Review and Commentary
of Federal Policies and Practices. New York : Urban
Institute, 1969.
National Center for Health Statistics. State Licensing of
! Health Occupations. Washington, D.C.: Public
Health Service, 1967.
National Institute for New Careers. Comprehensive Health
Services Career Development--Technical Assistance
Bulletin. Washington, D.C.: University Research
Corporation, April 1970.
;New Mexico Department of Social Services. Division of Public
Welfare. Taos County Department Welfare Statistics,
i February 1971. Taos : New Mexico Department of j
I Social Services, 1971. 1
!Roger, Everet M., and Shoemaker, F. Floyd. Communication of
Innovations: A Crosscultural Approach. New York:
Free Press, 1971.
Saunders, Lyle. Cultural Differences and Medical Care— The
I Case of the Spanish-Speaking People of the South-
' west. New York : Russell Sage Foundation, 19 54.
I Smolensky, Jack, and Haar, Franklin B. Principles of Com-
I munity Health. Philadelphia: W. B. Saunders Co.,
I 1961.
"Survey Finds 15% of Americans Suffer Depression Symptoms."
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j u . S . Congress. Committee on Ways and Means. Basic Facts on
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l lhe World Almanac and Book of Facts— 1974. New York: News-
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132

Asset Metadata

Creator Lovato, Demetrio Richard (author)

Core Title A suggested program for consumer health education for the health services delivery centers in the San Luis Valley

Contributor Digitized by ProQuest (provenance)

School School of Public Administration

Degree Master of Public Administration

Degree Program Public Administration

Degree Conferral Date 1979-06

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag education,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c39-149053

Unique identifier UC11311653

Identifier EP64912.pdf (filename),usctheses-c39-149053 (legacy record id)

Legacy Identifier EP64912.pdf

Dmrecord 149053

Document Type Thesis

Format application/pdf (imt)

Rights Lovato, Demetrio Richard

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA