Famil

C A S E B O O K
y
B O O K
CONTENTS

List of family’s recent and continuing illness events page 4

Cultural and social environment of the family page 5

Inter-relationships with disease page 6

Family Genogram page 8

Sources of Social Support page 9

Definition of illness page10

Dealing with illness in the family and occupancy of sick role

page11
Medical and social resources available in the community page 12

Extent to which household health care needs have been met page 13

Why needs remain unmet page 14

How community efforts to prevent disease and promote health page 15

Impinge on the family

Demography, Epidemiology and Psychosocial factors page 16

Of illness and disease

Impact of the student’s presence on the family page 20

Difficulties and satisfactions encountered page 21

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 THE PACE FAMILY
Ms. Cettina Pace, a 59 year old female from Cospicua was chosen to be
the index case for the purpose of the family casebook. Ms. Pace nee
Vassallo is married to Mr. Charles Pace and together with their daughter
reside in a ground floor government housing apartment. The casebook
interview was conducted at their apartment on the 24th February 2009 and
took the format of a discussion.

At the start of my interview, I asked the household what they understand

by family and who is a member of their family. This question was posed as
the elder offspring of Mr. & Mrs. Pace does not reside in the same
household. Although the family were disappointed that Roberto (son) had
chosen to stop residing in their household, they still considered him an
important part of their family. Hence this family, consisting of both parents
and their children, is an example of a nuclear family. They explained their
desire to be an extended family, by having Cettina’s mother, Lisa reside
with them, however due to their small accommodation Lisa had to be
institutionalized after the death of her husband George. For
completeness’s sake, the third type of family model is the single parent
type, where an unmarried, separated or divorced parent lives with his or
her children.
FAMILY STORY OF RECENT AND
CONTINUING ILLNESSES
Cettina has a past medical history of hypercholesterolemia, hypertension,
hypothyroidism, depression, sciatica and a past surgical history of hysterectomy,
pilonidal sinus removal and hernia repair. Cettina’s daughter, Tiziana complains that
although her mother’s flexibility has increased since she started exercising, her
mother still finds difficulty in proximal gross movements, like brushing her hair. Her
recent sciatica pain has limited her even more.

Apart from Cettina, the case index, Charles 58, also suffers from hypertension.

Tiziana, 26 suffers from irritable bowel syndrome and Roberto 29 has had no serious
illness or disease.

In this family, Charles and Roberto are smokers. They have both started smoking at a
young age, and Roberto followed his father’s bad habits. The family was not happy
Roberto started smoking, especially Cettina; however Charles himself could not stop
Roberto from being a smoker when he too was a smoker. Charles is disappointed at
the financial burden his habit had on the family. Health wise he believes that it does
not affect the family, since he does not smoke indoors.

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CULTURAL AND SOCIAL
ENVIRONMENT OF THE FAMILY
The family seem to be a very closely knit unit who enjoy each other’s company and
the fact that Roberto has left his parents residence without marriage has hurt the
family as it is something not usually done in the culture they have been brought up
in.

It is very evident that the Pace family has close connections with their extended
family, especially on Cettina’s side of the family, where a Pace family member visits
her mother Lisa at least once a day. This family is also in close contact with her sister
Josephine and they frequently visit Freddie, Cettina’s disabled brother, who lives at
Dar tal- Providenza. On Charlie’s side, contact between brothers and sisters was
greatly reduced when their mother passed away.

Apart from the extended family, Cettina trusts “blindly” in her GP, however the rest
of her family seem a bit skeptical to this devout trust of Cettina to the GP.

Regarding gender-roles within the family, there seems to be division of labor with the
house chores shared by both parents and Tiziana too. However, Cettina states that
only she is allowed in the kitchen and also claimed to be the main rearer of her
children, for who she had quit her job. She is now back on the work bench occupying
the role of an executive officer within the public sector. She considers her job to be
very common. Charles is a senior auditor who considers himself to have a prestigious
job but one that does not give him the authority he would like. Both parents had 11
years of schooling to reach A level standard of education. Their children, both
obtained degrees from University with Roberto obtaining a Masters in European
Studies. Education gives one acquisition of knowledge and skills that promote health
and improved “health literacy”.

This family’s educational attainments, occupational status and a parental gross

income of approximately €37000, which is shared among the whole family show that
this family have a high socio-economic status. This is good news for the family, as an
association between socio-economic status and health has been recognized for
centuries (Antonovsky, 1967).

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INTER-RELATIONSHIPS WITH
HEALTH AND DISEASE

Social Class
Group I is made up of professionals, Group II of intermediates, Group IIIN of skilled-
non manual workers, Group IIIM- skilled manual workers, Group IV semi-skilled
manual workers and Group V unskilled manual workers. The Pace family falls in group
II, since the parents who were the providers of the family fell into this category. Their
children are both professionals, and do not depend on their parents any longer,
especially Roberto who has moved out of his parents house. During my discussion
with the family, they do not seem to agree that their particular social class had any
effects on their health. They argued that it depends on who your peers are, and bad
habits such as smoking and illicit drug use are common practices within all social
groups.

Occupation
Regarding their occupations, all the family members argued that their work does not
affect health. They argued that there was no exposure to toxic fumes or dust in their
occupations. However, when I dug deeper into the matter they did realize that their
work could be related to ill health. For example the index case, has suffered
tenosynovitis due to keyboard operation. When asked about stress all the family
related that their jobs were stressful, and that this stress has caused them an
ailment. Cettina for example, at times feels mentally drained and starts to panic,
which she describes a trigger to her depression. Recently she had a prospect of
promotion in her career, however this extra responsibility and her need to learn new
procedures, stressed her so much, that her family gave her advice not to except the
post as it was not doing her right health wise. Charles explains how this stress affect
the family as a whole, especially since they reside in a small apartment. They are
however happy that their jobs are effort- rewarding jobs rather than a demanding
control type and they agree that the reward they get is in proportion to their hard-
work. This motivates them to work hard.

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Environment
They spoke to me about Malta and its polluted, noisy environment as a factor
contributing to ill health. It causes them frustration and this frustration together with
a day’s stressors results in anger many times within the family, the place they feel
most comftable bursting out. Roberto has also suffered from asthma and Tiziana hay
fever, which they attribute to the pollution especially in their area, very close to
Fgura and Marsa, areas known for pollution.

Accommodation
Their small accommodation seems to be their greatest stressor and affects their
health the most. They feel they are crowded, and there is lack of privacy. The single
desk in the children’s bedroom was not enough for both Roberto and Tiziana to study
on and an additional desk was put in the parents’ bedroom for Tiziana to study. They
explained how when she was studying, they could not switch on television, and that
they had to sleep with lights on and their sleep disturbed by shuffling of papers,
drawing of chairs, etc. Roberto states, that the only reason he left home was because
he needed his own space. He said that he feels much better now in his rented
apartment in St. Julian’s, even though certain luxuries such as having your plate
ready and clothes done are now absent.

Neighborhood
In addition to the small apartment itself, its neighborhood was no better. They
complained about noise, vandalism and theft, which continued to add to their stress
and possibly an attribute to Cettina’s depression. However, they are also thankful to
some friendly neighbors who helped the family through cooking and cleaning when
Cettina fell ill.

Leisure
Cettina describes how she recently joined a yoga class and how this has improved
her health and quality of life. She described how this active leisure pursuit has
enhanced her fitness, and reduced her cholesterol level. Also the family describes
that they take daily walks and this not only promotes health but also helps to
strengthen their family ties.

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FAMILY GENOGRAM

SOURCES OF SOCIAL SUPPORT

page 8
Social support is not important only for assurance of food, warmth and other material
resources, but also equally important to provide love, security and other non-material
resources that are necessary for normal human development (Berkman & Glass,
2000). Social support is made up of instrumental, emotional and informational
support. The Pace family unit in the past used to offer instrumental support to all its
members in the form of cash. Since both the children started working, the parents no
longer offer instrumental support to their children, who self-support themselves
financially. However they still support their children with emotional support and so do
the children support their parents emotionally especially Cettina who needs constant
moral support. The family seems quite reluctant to gain emotional support from
outsiders. Cettina and Tiziana’s informational support come from their sport
instructor; however Charles seems to dismiss this information, causing confusion
mostly in Cettina who is easily influenced. The family GP is also a source of
informational support, especially for Cettina who confides in him and is very
dependant and strictly obedient to his orders.

The people who provide this social support are the family’s social network. I have
realized that this family has a poor social network since they prefer to self support
themselves. Cettina is the one who would like the most to expand her social structure
but feels constrained by her family who do not approve of this. This poor social
network may be a reason for her depression, because a wealth of information
indicate that good social support buffers the effects of stressful life events and helps
prevent psychiatric disorders (Kawachi and Berckmann, 2001).

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THE DEFINITION OF ILLNESS
For the professional, illness is a mechanical process that went bad, one he has to try
and fix. However, for the patient, an illness is a life-changing event, not only for
himself, but also for his family. The patient may have to change his life-style, give up
things he likes, his body image might change. Hence a normal day of a professional
may be the life-changing day of the patient and his family. It is easy for a doctor to
become immune to the sadness surrounding his job, but he must be careful because
he is dealing with a family’s harsh reality and he must not be inhuman.

I asked the family to recount an experience of illness that changed their life. They
told me about the time when Cettina had her hysterectomy done. They said that their
life was disturbed. There was nobody to cook, since this is Cettina’s role. The children
were too young to know how to cook and Charles was busy at work and hospital.
Cettina felt guilty that this was happening, she felt as if she had neglected her family.
She thanks her neighbors and sisters who used to help at times by cooking for the
family and see to her children. She found that spirituality also helped her pass
through this difficult time. At the same time, the children were worried and confused
about what was going on.

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DEALING WITH ILLNESS AND
THE OCUPANCY OF THE SICK
ROLE

The family undergo regular check-ups and encourage and support each other to keep
doctor appointments. Nobody goes alone to the doctor, the patient is always
supported.

The next step to deal with an illness is to accept this new state, and not only take the
medications required but also to change your lifestyle. This includes a change in diet,
where Cettina prepares low salt and cholesterol diets for her family and avoids
certain foods that upset Tiziana’s gut due to her irritable bowel syndrome. The whole
family goes for walks. Tiziana also likes to read on the internet about her family’s
illnesses and conditions to be more informed and this helps her to deal with her
family’s illnesses.

When Cettina said that she felt guilty that she is always sick, this caused a stir in the
rest of the family members. They told her that with the occupancy of the sick role
one is exempt from responsibility for the incapacity since it is beyond the sick
person’s control. This implies that she is exempt from her normal tasks and roles for
the duration of the illness and hence Cettina should never feel guilty when she
occupies the sick role. However they did add that as an occupant of the sick role,
Cettina is duty bound to recognize that being ill is inherently undesirable, and that
she has an obligation to try and get well. Another duty of the sick person, according
to this family is to seek competent help and to cooperate in the process of getting
well.

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LIST THE MEDICAL AND SOCIAL
RESOURCES AVAILABLE IN THE
COMMUNITY

• Health Centres or Private GPs

• Hospital: Outpatients Appointments for checkups regarding state of

chronic diseases such as hypertension, hypercholesterolemia,
hypothyroidism, colonoscopy screening and follow up with
consultation.

• Accident and emergency department: for acute conditions

• Hospital in-patient

• Pharmaceutical services and free medications (Schedule V and the

pink card)

• Community nursing and midwifery service

• Immunisation services

• Speech and Language Department

• Child Development and Assessment Unit

• Support Line 179

• Adolescent Outreach

• Programm Ulied Darna

• Social Housing Department

• Other Institutions e.g., Hospice, Caritas, Sedqa, Meals on Wheels,

Appogg, Richmond’s foundation.

• A number of support groups e.g. for diabetics, alcoholics, help to quit

smoking.

• A number of institutional homes, for the elderly and disabled.

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HAVE THE FAMILY HEALTH CARE
NEEDS BEEN MET BY THE
AVAILABLE RESOURCES?

Cettina, the case index has a very good relationship with her general practitioner,
and has been using the same GP as long as she can remember. Cettina states that
she will never change her GP as he knows not only her past medical, social and
family history, but he has also developed a good friendly relationship with her. She
cannot understand why her family keeps on insisting she needs second opinions on
certain issues when her GP surely knows it all the best way.

Cettina also gets support from her psychiatrist regarding her depression. She
explains how tough it is to open up to this new doctor, especially regarding these
problems which are a bit of a taboo. Her family however does not understand her
feelings, they argue that the doctor is not a friend; the doctor is a professional and
opening up to any doctor should be as easy.

They also make use of the outpatients department for check-up appointments
regarding their chronic conditions, however they complain about the bad service, and
prefer private clinics, as they trust them better.

The family is entitled to free medications for anti-hypertensive and cholesterol-

lowering drugs under the regulations of Schedule V, and they are very grateful as it is
very helpful financially.

The family also makes use of the community nurse. The nurse explains to the family,
how Charles should prepare himself for colonoscopy.

The family also made use of Hospice, when Cettina’s father was dying with prostate
cancer. The family also needed the resources of Caritas when their son was caught in
possession of illicit drugs.

They also needed to use the service of the Bormla home for the elderly for Cettina’s
mum, since they did not have space to keep her at their place and Dar tal-
Providenza, for Freddie, Cettina’s brother.

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Why needs remain unmet
Cettina clearly needs more help regarding her depression and her psychiatrist does
not seem to be helping her enough, partly due to her lack of trust in him and her
envisagement of her condition as a taboo. An association, for example the
Richmond’s foundation would be of great help to her. Her thyroid problem, however,
makes her lethargic and she finds it hard to cope with her life already, and she
argues that she cannot cope with another activity in her life.

Also, it would be very helpful for a directory of all the medical and social services
available in Malta to exist.

Charles suggested that it would be a very good idea if a child care centre existed for
the children of those who have a sick parent or a parent in hospital.

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HOW THE EFFORTS OF THE
COMMUNITY TO PREVENT
DISEASE AND PROMOTE HEALTH
IMPINGE ON THE FAMILY

The health promotion department does a very good job according to this family.
Charles say that the promotional material do have potential to influence people, but
he himself has no will to change, and no anti-smoking promotional material will make
him quit smoking. The family appreciated the effort of the health promotion
department and the variety of media it uses for promotion, but they all agreed that a
television advert is the most effective.

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DEMOGRAPHY,
EPIDEMIOLOGY AND
PSYCHOSOCIAL
FACTORS OF ILLNESS
AND DISEASE
HYPOTHYROIDISM
Hypothyroidism is more common in woman, with 1.5- 2% of woman suffering
from this diseases. The incidence of hypothyroidism increases with age: among
persons older than 60 years of age 6% of women have laboratory evidence of
hypothyroidism where TSH levels are twice normal (Ferri: Ferri’s clinical advisor
2009, 1st ed). Patients of Caucasian origin as my case study is are more affected
than people of black descent. Cettina had no previous family history of the
disease and no associated autoimmune disease. The hypercholesterolemia
experienced by Cettina is most probably due to her ongoing hypothyroid disease.
Depression is one of the major symptoms associated with hypothyroidism.
Haggerty states that 100% of patients presenting with severe hypothyroidism are
found to have concurrent depression as was the case of the index patient
(Borderline Hypothyroidism and depression, Haggerty JJ & Prange AJ, 1995).

The biopsycosocial model represents a health concept. It depicts a treatment

paradigm that acknowledges the contribution of biological, psychological and
social factors (The need for a new medical model: a challenge for
biomedicine, Engel, 1972). Hypothyroid has been successfully treated in many
cases by the biomedical treatment such as drugs. For example, Cettina’s
hypothyroid is well controlled from her levels of TSH and T3 and T4. However,
symptoms sometimes seem to recur even if she is well controlled. This has been
well documented in the literature (The diagnosis and management of
hypothyroidism, Roberts CGP & Ladeson PW). If psychological and social factors
are also dealt with, this chronic condition will be dealt with in a much better way,
and may control the disease better than with merely the biomedical model of
treatment (The biopsychosocial model and hypothyroidism, B.T. Brown et
al., 2005).

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HYPERTENSION
Hypertension is also a disease that increases in its prevalence with age, and this
time the races of African descent have a higher prevalence f hypertension than
the Caucasian race. A few other personal characteristics influence hypertension.
These include concurrent diagnosis of diabetes mellitus, the presence of obesity,
lack of physical activity(present in this family before the diagnosis of
hypertension) and excessive use of sodium and alcohol (The prevalence and
demographics of hypertension, Davidyan, A). Lisa, Cettina’s mother also
suffered from hypertension, as seen in the genogram. In the case of Charles, his
father Francis and brother Joe have also suffered from hypertension. The genetic
factors contributing to hypertension have not yet been found.

The role of psychosocial factors such as: type A behavior, depression and anxiety,
are well documented in the etiology of hypertension (Circulation, Krantz DS et
al, 1987). However there are some conflicting studies (The relationship of
psychosocial factors to coronary artery disease in Framingham study I:
methods and risk factors, Haynes CG et al, 1978). Biologically it is plausible
that psychosocial factors may interact with hypertension. Stress may activate the
sympathetic nervous system, leading to increased cardiac output,
vasoconstriction, arterial pressure elevation, impaired endothelial faction and
platelet activation (Effects on psychological and social factors on organic
disease: a critical assessment of research on coronary heart disease,
Krantz DS, 2002).

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EVALUATION

page 17
THE STUDENT’S INFLUENCE ON
THE FAMILY

Cettina Pace is my mum’s sister, and hence I am part of their extended family. As I
have already said, the Pace family especially Cettina are very close to their extended
family, hence during the interview we were discussing things as if we were talking
normally, and they definitely did not feel like they were put in any uncomftable or
unnatural situation.

During my interview, I believe I made them more aware that health is not just the
absence of disease, but as the World Health Organization describe it: ‘a state of
complete physical, mental and social well being’.

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DIFFICULTIES AND
SATISFACTIONS ENCOUNTERED

I felt quite uncomftable asking Cettina about her mental health condition, which
for her is a taboo, and rarely mentioned even in the family.

The satisfactions were plenty: I was well accepted in the family, and they tried
their very best to help me with all the information I needed. During the
preparation for the interview, I realized, that there was much more to family
medicine than just the biomedical model of curing a disease, and that the
biopsychosocial factor was much more relevant. In order to treat the chronic
conditions with this model, the case index should be asked questions that point to
his and his family’s biopsychosocial being.
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