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OBJECTIVES

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  • Describe the challenges of providing care to underserved populations in the context of family.

  • Define alternative family structures.

  • Define a model of care centered on the family.

  • Outline key domains of family functioning.

  • Describe the process and content of family assessment.

  • Illustrate family-focused interventions.

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INTRODUCTION

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Mrs. Escalante, a 40-year-old single parent with uncontrolled hypertension, lives with her son, Jimmy, who is 14 and has diabetes. Doctors rely on Jimmy to interpret for his mother. Medicaid covers his care, and although his mother works, she is undocumented, uninsured, and ineligible for Medicaid.

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Families play an extraordinary role in the ways people experience the world and are the principal channel for the transmission of culture. Negotiating society’s demands and experiencing illness, health, and caretaking are all learned within the context of families. Hence, patient-centered care must also be crafted using the family as a framework.

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Health care in the United States and other systems with a narrow biomedical perspective, however, focus on the individual patient and not the family. Increasing evidence suggests that by broadening the focus to involve a patient’s family, providers may be better able to understand the onset and development of disease and improve treatment outcomes.1,2,3,4,5,6 This chapter addresses how considering the family as the context of care can improve the overall health of families in underserved populations.

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DEFINING THE FAMILY

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During the last century, the nuclear family—consisting of two heterosexual, legally married adults living with their biological children—was promoted as the ideal family structure. This exclusionary definition has been challenged: it sanctions only heterosexual unions and legally married partnerships, and it diminishes blended families, families with adoptive children, extended families, and kin relationships.

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In fact, the traditional nuclear family has never accurately represented the “typical” family structure in the United States. Only 20% of respondents to the 2010 census might be considered part of traditional families—­consisting of a married couple with children. Single-parent households comprise 9% of the total households in the United States and 24% of children live only with their mothers, and 4% live only with their fathers.7 Lesbian and gay Americans living in committed relationships in the same residence are estimated to total 3.1 million. Sixteen percent of same-sex households include a biological, step, or adopted child.8

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Families internationally are in flux, though two-parent families in some parts of the world are more common than they are in the United States. In the Middle East and in Asia, a majority of children live with two parents. In Europe, North America, Oceania, South America, sub-Saharan Africa, about 20% of children live either with someone other than their biologic parent or in a single-parent household. Many European countries estimate that the number of children living with one parent will increase ...

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