Sample One - Excerpts from
Chapter 9: Family History, Cultural Heritage, Names and Family Relationships

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Family history and cultural heritage
Unless we have a long-term relationship with a patient, we usually meet them at a time of crisis. We see a snapshot, a stressful moment in an often long and complex life. Learning something about a patient’s family history and cultural heritage can help us understand them better and offer more appropriate support and care.

This is especially important with people whose life experience and culture are very different from our own. Rather than simply assuming that they will be comfortable with our systems and routines, we can help them maintain their customary ways of doing things as far as possible. We may also come to understand and sympathise with behaviour that we might otherwise ignore, or dismiss as irrational or downright difficult.

Families, relationships and roles
Although the idea and the underlying principles of the family are universal, what is meant by the family varies enormously from culture to culture and within cultures. The late 20th century saw tremendous changes in the English family and there are now great variations. The roles of men and women in the UK are generally less differentiated. Many women are more autonomous and independent. Long-term unemployment has removed the traditional role of breadwinner from many men. Most adult women now work outside the home. In some families women are the main earners and are less able to care for ill or frail family members. The number of single-parent families is increasing. As more people re-marry or form second long-term relationships, more complex families are forming (see Chapter 2 Not cultural facts but cultural possibilities).

‘When I came here from Ireland I found the strangest thing was all the divorce. My husband’s parents had split up and both re-married and had more children of their own. And they were all part of his family and they all seemed to get on quite well. I was astonished!’

Despite these changes, many people in the UK still view the nuclear family - a married couple with children - as the norm against which they judge other families. Many English people have little contact with any relatives outside their nuclear family. Most feel that a married couple should be financially and emotionally independent of their parents and other relatives. Marriage does not usually create an alliance between two families; the husband’s and wife’s parents may never really get to know each other. Older people often expect and are expected to be independent for as long as possible.

In order to make an appropriate assessment of each patient’s needs and to plan and provide care, it is necessary to understand their family situation, including the responsibilities and expectations of different members.

Take a moment to reflect on your own views about families:

	•	How important is your family to you? Every day? When major life events occur?
	•	What do you think of as a family? How many people? How many generations?
	•	Which do you think is the most important relationship in the family?
	•	In your family do men and women have different roles and responsibilities?
	•	Who do you feel has the right to give advice to whom in a family?
	•	Who would you turn to if you were seriously ill? How would you expect them to respond?
	•	Do you feel closer to your family or to some of your friends?
	•	At what age or stage in their lives do you feel that people should stand on their own feet and be independent of their families?
	•	Whom should a person involve in decisions about their marriage or relationship?
	•	Who has ultimate authority over you?
	•	Does your reputation affect your family? Does this influence your behaviour?
	•	When you are old do you expect to live with your children?

Different families
Ideas about how families should function, and how they should support and care for sick or frail members vary from culture to culture. For example:

Family involvement In many communities the normal family is extended rather than nuclear. A large number of relatives may be concerned about the patient and actively involved in their care. Parents, for example, may be very closely involved with their adult children all their lives, in a way that many Westerners find strange. This has implications for confidentiality and patient autonomy (see Chapters 15 Maintaining patient confidentiality and 17 Working together).

In many cultures people always turn to family members for practical help, support and advice. Some may feel they would lose face or be considered strange or disloyal if they asked for outside help, even from health professionals. Some see health professionals as having responsibility for practical and physical things, but not as people with whom to discuss feelings.

Sometimes the people closest to the patient are not members of their legal family. They need the same sensitive care and recognition as blood relations. (In this book we use the words family and relatives to mean all those people who are close to the patient.)

Decision making In some cultures each person is seen as an autonomous individual who makes their own decisions; in others, each individual is part of a family group. It is expected that decisions will be made by the whole family, taking their joint perspectives into account.

Authority In many cultures there is a hierarchy of authority within the family. Older people, and especially older men, may have great authority within the family and may make all major decisions. Again this may have implications for decision making, consent and confidentiality.

In such families the person who makes many of the decisions may not be the person who carries them out. A daughter-in-law married to younger son may be the primary ‘hands on’ care giver for ageing parents, but decisions about their care may be taken by the oldest son even if he has little first-hand knowledge of the situation (Van Steenberg, Ansak and Chin‑Hansen 1993). Health professionals may need to work sensitively with both.

In families where the oldest man is head and has always made all the decisions, particular problems may arise if he becomes ill or incapacitated. Family members may be unsure how to react and what steps to take if he is confused or demented and behaves strangely or irrationally (Patel, Mirza et al. 1998).

Men and women In some communities men and women have clearly differentiated roles and may lead largely segregated lives. Some may be unused to dealing with strangers of the opposite sex or receiving intimate care or treatment from them (see also Chapter 12 Modesty).

Women in conservative families who rarely leave their homes may find being in or visiting hospital or other residential care particularly difficult. If their husband dies, they may have great difficulty in dealing alone with certifying the death, making funeral arrangements, and financial and other practical matters. If there are no male relatives who can help, special help and support may be needed.

In the West, monogamy is generally regarded as the only acceptable form of marriage. Polygamy is often seen as degrading to women. Under Islamic law, men can take up to four wives under certain conditions (see Chapter 45 Polygamy). In certain areas of Africa polygamy is common among people of all religions. In cultures where polygamy is accepted, there are often recognised advantages for women. Wives usually support each other especially at times of illness and difficulty. The first wife is regarded as senior; existing wives must normally agree before their husband can marry again.

Reputation In some cultures the behaviour of any one member affects the reputation and prospects of the whole extended family. Codes of correct behaviour may be strictly enforced for the sake of all the family members. Discreet behaviour and modesty may be particularly expected of women (see also Chapter 12 Modesty).

Families’ public behaviour varies between and within cultures. In some cultures it is traditional for men to do all the talking outside the home. In some cultures it is considered that all private matters should be kept within the family. Some families are very formal in public and can appear silent and unsupportive to outsiders. In some cultures it is customary for everyone to be physically affectionate in public, in others public affection is only shown by family members of the same sex, in others not at all.

Care for older people and people who are ill In many communities older people are traditionally looked after entirely within their family. Everyone is expected to show them respect and to defer to them even when they become ill and frail. Families in Britain may feel an obligation to provide all the support for dependent older members even where this is not possible. Some may feel extremely anxious about the care of their relative away from home. Some older people may feel ashamed and publicly humiliated because they are not being cared for by their own family (see also Chapters 4 The needs and perspectives of older people and 16 Care at home).

Acceptable behaviour when people are ill and the amount of sympathy and support they receive also varies between cultures and between families.

Family conflict Every family system has its strengths and tensions. Family difficulties, unhappiness and conflict occur in all cultures, though how they are expressed and dealt with may differ. Differences in values and religious beliefs often cause distress and strife within families, especially when a member is seriously ill or dying. Friction may be more likely when some family members hold more traditional views than others, or when family members are of different cultures and religions.

Health professionals often see people in crisis; it can be difficult to sort out how different a person’s current behaviour is from that which is accepted within their community, what their strengths are, and what support is available to them. When working across cultures, there is also a danger that negative stereotypical images about people’s family organisation and behaviour, derived from moments of stress and difficulty, will become the basis for everyday ‘knowledge’ about their community (Arnold 1992).

Recognising clinical signs in skin

‘You only see what you have been taught to see.’ (Zatouroff 1996)

Textbook descriptions of the clinical signs of systemic illness that may be observed in the patient’s skin (for example, cyanosis, pallor, inflammation and jaundice) are, in the vast majority of publications, based on the assumption that skin is white. This is a graphic demonstration of how ‘cultural lenses’ operate (see Chapter 1) and results in unintentional discriminatory practice. Not only are descriptions of signs in different colour skins missing, many health professionals seem not to have noticed.

European television engineers installing broadcasting equipment in East Africa were amazed to find that the local people were far more discerning and critical about the different tones of black skin reproduced on the screen than they were. They had to spend a lot of time adjusting the equipment to get the tones just right, though they themselves could not really see the difference.

Both within and between different ethnic groups there is a wide variety of skin tones and colours affecting the way skin looks during illness (Baxter 1993). Failure to observe clinical signs accurately can delay diagnosis and treatment and may sometimes be life threatening.

Health professionals who are familiar with black skin can usually recognise changes fairly readily.

However, they may have difficulty in convincing their white colleagues.

Examining or observing patients with dark skin, especially very dark or black, requires careful attention and practice. It is not always possible to rely on signs that are more obvious in white skin. However, careful observation may reveal subtle changes. When people are ill, the depth and richness of their normal skin tone may be lost, the skin may lose its sheen and become dull. Even so, unless you know the patient well and have paid attention to the normal colour, tone and quality of their skin, it is easy to miss early changes, even those that are acute and require urgent attention.

Sometimes it is easier to see the first signs of a problem in the patient’s general demeanour rather than in colour changes. Observe carefully people who become lethargic, anxious, restless, anorexic or nauseated or who complain of soreness, itching or dyspnoea. Patients or relatives who say that there is something wrong should always be taken seriously. If no problem can be identified after careful evaluation, make sure to keep checking, especially if the symptoms persist or worsen, and to encourage patients and relatives to keep reporting what they notice.

In patients with dark skins, pay extra attention to those parts of the body with less pigmentation. These vary from person to person; they may be the palms, the tongue, palate and oral mucosa, the conjunctivae, the sclerae and the fingernail beds.

Nail beds are often an important place for observing skin changes in people with dark skins. With some women this may be more difficult. Women of several communities, including Somali women, often use henna to stain their finger and toe nails. This takes time to fade. Since it is extremely important to be able to observe the nail beds for cyanosis, women with dark skins who use henna who are awaiting surgery should be asked to let the henna fade and the reasons explained. Women with dark skins who wear nail varnish can be asked to remove it or let it grow out. Note that asymptomatic pigmentation in the oral mucosa, and dark longitudinal stripes or bands in the nail beds which increase with age, are normal variants in people of African heritage.

Pallor may be due to pigmentation or vaso-constriction as well to a low haemoglobin. In people with dark skins, pallor is usually visible in the conjunctivae, which become pale, and in the oral mucosa which become pale or greyish-white. The skin may look ashen or have a greyish tinge. Depending on the degree of pigmentation, the lips and nail-beds may also be ashen. If a patient is in shock, the skin becomes cool and moist.

Cyanosis Depending on the depth of pigmentation, there may be a blue-grey tinge to the skin. Peripheral cyanosis is usually visible in the palms and in the fingernail beds. In some people the nail beds take on a dark, maroon tinge. However these changes may not be at all obvious in people with very dark skins or pigmented nail-beds. Central cyanosis can be detected in the tongue, gums and palate which become greyish-white. Depending on the degree of pigmentation, the lips may also become greyish-white or take on a purple tinge.

Jaundice Patients of Far-Eastern heritage, for example China and Vietnam, who become jaundiced tend to look sun-tanned and or have a slight orangey tinge to their skin. In dark-skinned patients the skin may take on a greenish rather than a yellow tinge. The most sensitive indicator are the sclerae. Observation should be made in good light, preferably daylight, removing any yellow clothing or bed linen first. In the absence of observable skin changes, the first indications of obstructive jaundice can include itching, especially at night causing insomnia; changes in the colour of the urine and stools; and changes in the distal third of the finger nails which may become shiny. The sweat of patients with severe obstructive jaundice may leave yellowish stains on bed linen.

Rashes In people with very dark skin, raised rashes (such as pustules and vesicles) are more obvious than flat rashes (such as petechiae and macules). However, careful observation may reveal differences between areas with and without the rash. Examine the whole of the patient’s skin in a good light, preferably daylight, and listen carefully to what the patient has observed.

Inflammation In acute inflammation, swelling may be visible or palpable. The skin may become shiny and smooth looking and hot to the touch. The patient is likely to complain of loss of function and of tenderness. In chronic inflammation, the main symptom is loss of mobility in the affected part; swelling, tenderness and heat may no longer be noticeable. Patients with dark skins who complain of soreness, for example on pressure areas or around wounds or stoma sites, should be taken seriously even when there are no obvious signs of inflammation (see also Chapter 12 Skin care).

Bruising The discolouration that is obvious in white skin may not be easily observed in very dark skin. When bruised, the skin may appear darker or more purple when compared with surrounding skin. It may be necessary in some cases to rely on palpable changes such as hardness, lumpiness and on the patient’s own description of tenderness and pain.

(The above is based on descriptions given by health professionals of different ethnicities and on Zatouroff 1996, Archer and Robertson 1995, Werner, Thuman and Maxwell 1993, Baxter 1993 and Schull 1987.)

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