You are on page 1of 24




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
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

page 2

THE PACE FAMILY Ms. This question was posed as the elder offspring of Mr. Pace nee Vassallo is married to Mr. Although the family were disappointed that Roberto (son) had chosen to stop residing in their household. where an unmarried. is an example of a nuclear family. the third type of family model is the single parent type. Ms. Lisa reside with them. Pace does not reside in the same household. by having Cettina’s mother. . consisting of both parents and their children. They explained their desire to be an extended family. however due to their small accommodation Lisa had to be institutionalized after the death of her husband George. For completeness’s sake. they still considered him an important part of their family. Charles Pace and together with their daughter reside in a ground floor government housing apartment. At the start of my interview. Cettina Pace. The casebook interview was conducted at their apartment on the 24th February 2009 and took the format of a discussion. Hence this family. I asked the household what they understand by family and who is a member of their family. & Mrs. a 59 year old female from Cospicua was chosen to be the index case for the purpose of the family casebook. separated or divorced parent lives with his or her children.

Charles and Roberto are smokers. Health wise he believes that it does not affect the family. Apart from Cettina. page 4 . pilonidal sinus removal and hernia repair. the case index. since he does not smoke indoors.FAMILY STORY OF RECENT AND CONTINUING ILLNESSES Cettina has a past medical history of hypercholesterolemia. Tiziana complains that although her mother’s flexibility has increased since she started exercising. sciatica and a past surgical history of hysterectomy. Charles 58. however Charles himself could not stop Roberto from being a smoker when he too was a smoker. hypothyroidism. Tiziana. also suffers from hypertension. Cettina’s daughter. like brushing her hair. especially Cettina. They have both started smoking at a young age. 26 suffers from irritable bowel syndrome and Roberto 29 has had no serious illness or disease. Her recent sciatica pain has limited her even more. Charles is disappointed at the financial burden his habit had on the family. hypertension. her mother still finds difficulty in proximal gross movements. The family was not happy Roberto started smoking. and Roberto followed his father’s bad habits. depression. In this family.

which is shared among the whole family show that this family have a high socio-economic status. occupational status and a parental gross income of approximately €37000. This family’s educational attainments. page 5 .Providenza. 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. Their children. Regarding gender-roles within the family. Education gives one acquisition of knowledge and skills that promote health and improved “health literacy”. 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. for who she had quit her job. however the rest of her family seem a bit skeptical to this devout trust of Cettina to the GP. both obtained degrees from University with Roberto obtaining a Masters in European Studies. Cettina trusts “blindly” in her GP. It is very evident that the Pace family has close connections with their extended family. as an association between socio-economic status and health has been recognized for centuries (Antonovsky. 1967). Apart from the extended family. Cettina’s disabled brother. who lives at Dar tal.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. This is good news for the family. She considers her job to be very common. there seems to be division of labor with the house chores shared by both parents and Tiziana too. Cettina states that only she is allowed in the kitchen and also claimed to be the main rearer of her children. However. On Charlie’s side. contact between brothers and sisters was greatly reduced when their mother passed away. Both parents had 11 years of schooling to reach A level standard of education. She is now back on the work bench occupying the role of an executive officer within the public sector. especially on Cettina’s side of the family.

During my discussion with the family. they do not seem to agree that their particular social class had any effects on their health. since the parents who were the providers of the family fell into this category. when I dug deeper into the matter they did realize that their work could be related to ill health. Group IV semi-skilled manual workers and Group V unskilled manual workers. which she describes a trigger to her depression. at times feels mentally drained and starts to panic.INTER-RELATIONSHIPS WITH HEALTH AND DISEASE Social Class Group I is made up of professionals. however this extra responsibility and her need to learn new procedures. They argued that there was no exposure to toxic fumes or dust in their occupations. Charles explains how this stress affect the family as a whole. and bad habits such as smoking and illicit drug use are common practices within all social groups. that her family gave her advice not to except the post as it was not doing her right health wise. has suffered tenosynovitis due to keyboard operation. stressed her so much. especially Roberto who has moved out of his parents house. Group IIIM. Group II of intermediates. and that this stress has caused them an ailment. all the family members argued that their work does not affect health. However. This motivates them to work hard. They are however happy that their jobs are effort. Cettina for example. and do not depend on their parents any longer. Their children are both professionals. especially since they reside in a small apartment.rewarding jobs rather than a demanding control type and they agree that the reward they get is in proportion to their hard- work.skilled manual workers. They argued that it depends on who your peers are. For example the index case. Recently she had a prospect of promotion in her career. Occupation Regarding their occupations. page 6 . The Pace family falls in group II. When asked about stress all the family related that their jobs were stressful. Group IIIN of skilled- non manual workers.

that the only reason he left home was because he needed his own space. vandalism and theft. and there is lack of privacy. However. which continued to add to their stress and possibly an attribute to Cettina’s depression. drawing of chairs. 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. page 7 . its neighborhood was no better. Leisure Cettina describes how she recently joined a yoga class and how this has improved her health and quality of life. the place they feel most comftable bursting out. noisy environment as a factor contributing to ill health. and reduced her cholesterol level. and that they had to sleep with lights on and their sleep disturbed by shuffling of papers. Accommodation Their small accommodation seems to be their greatest stressor and affects their health the most. It causes them frustration and this frustration together with a day’s stressors results in anger many times within the family. even though certain luxuries such as having your plate ready and clothes done are now absent. they are also thankful to some friendly neighbors who helped the family through cooking and cleaning when Cettina fell ill. etc. They complained about noise. Roberto states. She described how this active leisure pursuit has enhanced her fitness. He said that he feels much better now in his rented apartment in St. very close to Fgura and Marsa. Also the family describes that they take daily walks and this not only promotes health but also helps to strengthen their family ties. Julian’s. They explained how when she was studying. Roberto has also suffered from asthma and Tiziana hay fever.Environment They spoke to me about Malta and its polluted. they could not switch on television. which they attribute to the pollution especially in their area. areas known for pollution. They feel they are crowded. Neighborhood In addition to the small apartment itself.


page 9 . 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. the parents no longer offer instrumental support to their children. I have realized that this family has a poor social network since they prefer to self support themselves. Since both the children started working. The Pace family unit in the past used to offer instrumental support to all its members in the form of cash. Cettina and Tiziana’s informational support come from their sport instructor. who self-support themselves financially. The people who provide this social support are the family’s social network. The family seems quite reluctant to gain emotional support from outsiders. 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. however Charles seems to dismiss this information.Social support is not important only for assurance of food. The family GP is also a source of informational support. emotional and informational support. 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. causing confusion mostly in Cettina who is easily influenced. This poor social network may be a reason for her depression. especially for Cettina who confides in him and is very dependant and strictly obedient to his orders. 2000). Social support is made up of instrumental. security and other non-material resources that are necessary for normal human development (Berkman & Glass. warmth and other material resources. 2001). but also equally important to provide love.

I asked the family to recount an experience of illness that changed their life. since this is Cettina’s role. one he has to try and fix. They told me about the time when Cettina had her hysterectomy done. the children were worried and confused about what was going on. They said that their life was disturbed. illness is a mechanical process that went bad.THE DEFINITION OF ILLNESS For the professional. However. There was nobody to cook. 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. but also for his family. She thanks her neighbors and sisters who used to help at times by cooking for the family and see to her children. she felt as if she had neglected her family. not only for himself. Cettina felt guilty that this was happening. At the same time. an illness is a life-changing event. his body image might change. The patient may have to change his life-style. Hence a normal day of a professional may be the life-changing day of the patient and his family. page 10 . She found that spirituality also helped her pass through this difficult time. give up things he likes. The children were too young to know how to cook and Charles was busy at work and hospital. for the patient.

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. Cettina is duty bound to recognize that being ill is inherently undesirable. and not only take the medications required but also to change your lifestyle.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. This includes a change in diet. When Cettina said that she felt guilty that she is always sick. The next step to deal with an illness is to accept this new state. Another duty of the sick person. page 11 . 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. according to this family is to seek competent help and to cooperate in the process of getting well. the patient is always supported. this caused a stir in the rest of the family members. 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. However they did add that as an occupant of the sick role. 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. and that she has an obligation to try and get well.

g. hypercholesterolemia. Meals on Wheels.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. Caritas. Appogg. help to quit smoking. • 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. • A number of support groups e. hypothyroidism. Richmond’s foundation. for the elderly and disabled.. • A number of institutional homes.g. for diabetics. Hospice. page 12 . colonoscopy screening and follow up with consultation. alcoholics. Sedqa.

but he has also developed a good friendly relationship with her. Cettina’s brother. and they are very grateful as it is very helpful financially. Cettina states that she will never change her GP as he knows not only her past medical. and has been using the same GP as long as she can remember. since they did not have space to keep her at their place and Dar tal- Providenza.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. how Charles should prepare himself for colonoscopy. They also make use of the outpatients department for check-up appointments regarding their chronic conditions. Her family however does not understand her feelings. She explains how tough it is to open up to this new doctor. The family also makes use of the community nurse. for Freddie. Cettina also gets support from her psychiatrist regarding her depression. the doctor is a professional and opening up to any doctor should be as easy. social and family history. however they complain about the bad service. especially regarding these problems which are a bit of a taboo. The family is entitled to free medications for anti-hypertensive and cholesterol- lowering drugs under the regulations of Schedule V. and prefer private clinics. The family also made use of Hospice. they argue that the doctor is not a friend. The family also needed the resources of Caritas when their son was caught in possession of illicit drugs. 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. when Cettina’s father was dying with prostate cancer. page 13 . The nurse explains to the family. They also needed to use the service of the Bormla home for the elderly for Cettina’s mum. as they trust them better.

partly due to her lack of trust in him and her envisagement of her condition as a taboo. and she argues that she cannot cope with another activity in her life. page 14 . Her thyroid problem. for example the Richmond’s foundation would be of great help to her. Also. it would be very helpful for a directory of all the medical and social services available in Malta to exist.Why needs remain unmet Cettina clearly needs more help regarding her depression and her psychiatrist does not seem to be helping her enough. An association. makes her lethargic and she finds it hard to cope with her life already. however. 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.

The family appreciated the effort of the health promotion department and the variety of media it uses for promotion.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. but he himself has no will to change. Charles say that the promotional material do have potential to influence people. and no anti-smoking promotional material will make him quit smoking. page 15 . but they all agreed that a television advert is the most effective.


2005). Depression is one of the major symptoms associated with hypothyroidism.. It depicts a treatment paradigm that acknowledges the contribution of biological. If psychological and social factors are also dealt with. Haggerty JJ & Prange AJ. B. and may control the disease better than with merely the biomedical model of treatment (The biopsychosocial model and hypothyroidism. Roberts CGP & Ladeson PW). symptoms sometimes seem to recur even if she is well controlled.HYPOTHYROIDISM Hypothyroidism is more common in woman. page 15 . this chronic condition will be dealt with in a much better way. However. Hypothyroid has been successfully treated in many cases by the biomedical treatment such as drugs. 1st ed).T. Patients of Caucasian origin as my case study is are more affected than people of black descent. The hypercholesterolemia experienced by Cettina is most probably due to her ongoing hypothyroid disease. The biopsycosocial model represents a health concept. 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. For example. Cettina had no previous family history of the disease and no associated autoimmune disease. 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. This has been well documented in the literature (The diagnosis and management of hypothyroidism. psychological and social factors (The need for a new medical model: a challenge for biomedicine. Brown et al. Engel.2% of woman suffering from this diseases. with 1.5. Cettina’s hypothyroid is well controlled from her levels of TSH and T3 and T4. 1995). 1972).

HYPERTENSION Hypertension is also a disease that increases in its prevalence with age. his father Francis and brother Joe have also suffered from hypertension. Davidyan. Stress may activate the sympathetic nervous system. arterial pressure elevation. 1978). impaired endothelial faction and platelet activation (Effects on psychological and social factors on organic disease: a critical assessment of research on coronary heart disease. A). 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. 1987). leading to increased cardiac output. In the case of Charles. A few other personal characteristics influence hypertension. Haynes CG et al. are well documented in the etiology of hypertension (Circulation. The role of psychosocial factors such as: type A behavior. These include concurrent diagnosis of diabetes mellitus. vasoconstriction. Cettina’s mother also suffered from hypertension. Krantz DS. as seen in the genogram. Krantz DS et al. However there are some conflicting studies (The relationship of psychosocial factors to coronary artery disease in Framingham study I: methods and risk factors. the presence of obesity. depression and anxiety. page 16 . 2002). and this time the races of African descent have a higher prevalence f hypertension than the Caucasian race. Lisa. Biologically it is plausible that psychosocial factors may interact with hypertension. The genetic factors contributing to hypertension have not yet been found.

EVALUATION page 17 .

THE STUDENT’S INFLUENCE ON THE FAMILY Cettina Pace is my mum’s sister. hence during the interview we were discussing things as if we were talking normally. mental and social well being’. I believe I made them more aware that health is not just the absence of disease. As I have already said. During my interview. the Pace family especially Cettina are very close to their extended family. and they definitely did not feel like they were put in any uncomftable or unnatural situation. but as the World Health Organization describe it: ‘a state of complete physical. and hence I am part of their extended family. page 18 .

DIFFICULTIES AND SATISFACTIONS ENCOUNTERED I felt quite uncomftable asking Cettina about her mental health condition. and rarely mentioned even in the family. and they tried their very best to help me with all the information I needed. In order to treat the chronic conditions with this model. which for her is a taboo. and that the biopsychosocial factor was much more relevant. I realized. that there was much more to family medicine than just the biomedical model of curing a disease. . The satisfactions were plenty: I was well accepted in the family. During the preparation for the interview. the case index should be asked questions that point to his and his family’s biopsychosocial being.

page 20 .

page 21 .

page 22 .