Faith-based organizations and the Affordable Care Act: Reducing Latino mental health care disparities.

The Patient Protection and Affordable Care Act (ACA; 2010) is expected to increase access to mental health care through provisions aimed at increasing health coverage among the nation's uninsured, including 10.2 million eligible Latino adults. The ACA will increase health coverage by expanding Medicaid eligibility to individuals living below 138% of the federal poverty level, subsidizing the purchase of private insurance among individuals not eligible for Medicaid, and requiring employers with 50 or more employees to offer health insurance. An anticipated result of this landmark legislation is improvement in the screening, diagnosis, and treatment of mental disorders in racial/ethnic minorities, particularly for Latinos, who traditionally have had less access to these services. However, these efforts alone may not sufficiently ameliorate mental health care disparities for Latinos. Faith-based organizations (FBOs) could play an integral role in the mental health care of Latinos by increasing help seeking, providing religion-based mental health services, and delivering supportive services that address common access barriers among Latinos. Thus, in determining ways to eliminate Latino mental health care disparities under the ACA, examining pathways into care through the faith-based sector offers unique opportunities to address some of the cultural barriers confronted by this population. We examine how partnerships between FBOs and primary care patient-centered health homes may help reduce the gap of unmet mental health needs among Latinos in this era of health reform. We also describe the challenges FBOs and primary care providers need to overcome to be partners in integrated care efforts.

Effects of language concordance and interpreter use on therapeutic alliance in Spanish-speaking integrated behavioral health care patients.

The discrepancy between the growing number of Spanish speakers in the U.S. and the availability of bilingual providers creates a barrier to accessing quality mental health care. Use of interpreters provides one strategy for overcoming this linguistic barrier; however, concerns about whether sessions with interpreters, versus bilingual providers, impede therapeutic alliance remain. The current study explored associations between the use of interpreters and therapeutic alliance in a sample of 458 Spanish-speaking patients seen for integrated behavioral health visits at primary care clinics. Patients completed a brief (4 item) therapeutic alliance scale at their behavioral health appointment. In addition, to supplement the quantitative study data, a pilot study of 30 qualitative interviews was conducted with a new sample of 10 Spanish-speaking patients, 10 behavioral health consultants (BHCs), and 10 trained interpreters. Quantitative results showed that interpreter use did not relate to therapeutic alliance, even when controlling for relevant demographic variables. However, qualitative interviews suggested major themes regarding the relative benefits and challenges of using interpreters for patients, interpreters, and BHCs. In interviews, patients expressed a strong preference for bilingual providers. Benefits included greater privacy, sense of trust, and accuracy of communication. However, in their absence, interpreters were seen as increasing access to services and facilitating communication with providers, thereby addressing the behavioral health needs of patients with limited English proficiency. BHCs and interpreters emphasized the importance of interpreter training and a good collaborative relationship with interpreters to minimize negative effects on the quality of care.

Vitamin D Status and Rates of Cognitive Decline in a Multiethnic Cohort of Older Adults.

IMPORTANCE: Vitamin D (VitD) deficiency is associated with brain structural abnormalities, cognitive decline, and incident dementia. OBJECTIVE: To assess associations between VitD status and trajectories of change in subdomains of cognitive function in a cohort of ethnically diverse older adults. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal multiethnic cohort study of 382 participants in an outpatient clinic enrolled between February 2002 and August 2010 with baseline assessment and yearly follow-up visits. Serum 25-hydroxyvitamin D (25-OHD) was measured, with VitD status defined as the following: deficient, less than 12 ng/mL (to convert to nanomoles per liter, multiply by 2.496); insufficient, 12 to less than 20 ng/mL; adequate, 20 to less than 50 ng/mL; or high, 50 ng/mL or higher. Subdomains of cognitive function were assessed using the Spanish and English Neuropsychological Assessment Scales. Associations were evaluated between 25-OHD levels (as continuous and categorical [deficient, insufficient, or adequate]) and trajectories of cognitive decline. MAIN OUTCOMES AND MEASURES: Serum 25-OHD levels, cognitive function, and associations between 25-OHD levels and trajectories of cognitive decline. RESULTS: Participants (N = 382 at baseline) had a mean (SD) age of 75.5 (7.0) years; 61.8% were women; and 41.4% were white, 29.6% African American, 25.1% Hispanic, and 3.9% other race/ethnicity. Diagnosis at enrollment included 17.5% with dementia, 32.7% with mild cognitive impairment, and 49.5% cognitively normal. The mean (SD) 25-OHD level was 19.2 (11.7) ng/mL, with 26.2% of participants being VitD deficient and 35.1% insufficient. The mean (SD) 25-OHD levels were significantly lower for African American and Hispanic participants compared with white participants (17.9 [15.8] and 17.2 [8.4] vs 21.7 [10.0] ng/mL, respectively; P < .001 for both). The mean (SD) 25-OHD levels were similarly lower in the dementia group compared with the mild cognitive impairment and cognitively normal groups (16.2 [9.4] vs 20.0 [10.3] and 19.7 [13.1] ng/mL, respectively; P = .006). The mean (SD) follow-up was 4.8 (2.5) years. Rates of decline in episodic memory and executive function among VitD-deficient (episodic memory: ß = -0.04 [SE = 0.02], P = .049; executive function: ß = -0.05 [SE = 0.02], P = .01) and VitD-insufficient (episodic memory: ß = -0.06 [SE = 0.02], P < .001; executive function: ß = -0.04 [SE = 0.02], P = .008) participants were greater than those with adequate status after controlling for age, sex, education, ethnicity, body mass index, season of blood draw, vascular risk, and apolipoprotein E4 genotype. Vitamin D status was not significantly associated with decline in semantic memory or visuospatial ability. Exclusion of participants with dementia did not substantially affect the associations between VitD status and rates of cognitive decline. CONCLUSIONS AND RELEVANCE: Low VitD status was associated with accelerated decline in cognitive function domains in ethnically diverse older adults, including African American and Hispanic individuals who exhibited a high prevalence of VitD insufficiency or deficiency. It remains to be determined whether VitD supplementation slows cognitive decline.

Depression Treatment Uptake in Integrated Primary Care: How a "Warm Handoff" and Other Factors Affect Decision Making by Latinos.

OBJECTIVE: Integrated behavioral health care has the potential to reduce barriers to mental health treatment among low-income and minority populations. This study aimed to identify predictors of Latino patients' decision to follow through with referrals to depression treatment in an integrated primary care setting, including type of referral (a "warm handoff" from a primary care provider [PCP] to a behavioral health care provider or a prescribed referral). METHODS: The authors conducted a sequential medical record review of 431 patients referred for depression treatment in integrated behavioral health services followed by qualitative semistructured interviews with a subsample of 16 patients. RESULTS: English-speaking Latinos were four times less likely to attend an initial visit within two months of a referral if they received a warm handoff rather than a prescribed referral. The strength of the patient-provider relationship and the quality of the referral experience, including whether the PCP addressed patients' health literacy and expectations for depression care, affected patients' decision to engage in depression treatment. CONCLUSIONS: Engaging Latinos in needed mental health treatment is a challenge, even when treatment is provided in primary care settings. Warm handoffs are considered effective components of engagement, but this study suggests that the effectiveness of warm handoffs may vary depending on the patient's primary language. The following factors seem important to engaging Latinos into care: patient-provider relationship, quality of the referral process, addressing expectations about depression care, and reducing communication barriers, including health literacy and linguistic barriers. Future studies of engagement strategies should explore these factors.

Fortification of corn masa flour with folic acid in the United States: an overview of the evidence.

Corn masa flour, used to make products such as corn tortillas, is a staple food for Hispanic populations residing in the United States, particularly among Mexican Americans and Central Americans. Research has indicated that Hispanic women in the United States continue to be at a higher risk of having a neural tube defect-affected pregnancy than women of other races/ethnicities, even after the introduction of folic acid fortification of cereal grain products labeled as "enriched." Corn masa flour has, therefore, been suggested as a potential food vehicle for folic acid in the United States. This paper explores the potential impact that folic acid fortification of corn masa flour could have on the Hispanic population in the United States.

A review of barriers to effective asthma management in Puerto Ricans: cultural, healthcare system and pharmacogenomic issues.

BACKGROUND: Among the Hispanic community, Puerto Ricans have the highest prevalence of asthma and manifest the worst outcomes. The expected growth of the Hispanic population in the USA in the next several decades make elimination of disparate care in Puerto Rican asthmatics a matter of national importance. The purpose of this review of the literature (ROL) is to examine a variety of health system, genetic and cultural barriers in the Puerto Rican community which have created disparities in asthma care and outcomes among adult and pediatric Hispanic populations. In addition, this ROL describes several culturally sensitive, community-based educational interventions which can be used as a framework for future projects to improved asthma outcomes. METHODS: Databases searched included Medline, PubMED, EBSCOhost, PsycINFO, CINAHL, Google Scholar and ERIC. Papers published in English from January 1990 to January 2012 were reviewed. RESULTS: Health system policies, insurer compensation patterns, clinician attitudes and cultural values/folk remedies in the Puerto Rican community represent barriers to effective asthma management, the use of controller medication and the implementation of educational interventions. In addition, genetic factors involving the beta-2 adrenergic receptor gene, which impair the response to albuterol, appear to contribute to poorer outcomes in Puerto Rican asthmatics. In contrast, several comprehensive, community-based, culturally sensitive educational interventions such as Controlling Asthma in American Cities Project (CAACP), the Racial and Ethnic Approach to Community Health in the US Program and Healthy Hoops programs (REACH) have been described. CONCLUSIONS: We believe that culturally sensitive community-based asthma education programs can serve as models for programs targeted toward Puerto Ricans to help decrease asthma morbidity. Moreover, greater sensitivity to Puerto Rican mores and folk remedies on the part of healthcare providers may improve the patient-clinician rapport and, hence, asthma outcomes. Finally, given ethnically based differences in pharmacogenomics, clinical trials targeting the Puerto Rican population may help to better define optimal asthma medication regimens in this ethnic group.

Family caregivers' narratives of mental health treatment usage processes by their Latino adult relatives with serious and persistent mental illness.

Family caregivers' views and experiences related to treatment usage processes by their adult relatives with serious and persistent mental illness (SPMI) were empirically examined in a sample of Latino caregivers (n = 17) who were users of services at the National Alliance on Mental Illness (NAMI) in a predominantly Latino- (80%) and Mexican-descent large city in the Southwest United States. We conducted a stability check of qualitative findings with a second sample of Latino caregivers with no exposure to NAMI (n = 15). Overall, the combined sample (N = 32) compared similarly with larger samples of Latino adults and caregivers in quantitative measures of acculturation, familism, caregiver stigma, and depression symptoms. Together, caregivers' stigma and cultural beliefs, such as vergüenza (shame), use of folk healers, and lack of insurance, were major reported barriers to service usage. Family support (and lack of) for treatment also weighed heavily as a facilitator (and a barrier) of service usage, thus highlighting the complexity of family relationship contexts. Substantial portions of caregivers reported that treatment initiation was prompted by psychiatric hospitalization (50%), and that positive experiences with service providers were influential in treatment retention (72%). Given the high levels of family involvement reported among Latino caregivers, the findings underscore the potential role of family caregivers in treatment engagement and retention. Future research is needed that examines family caregivers' role in treatment with models that consider the interplay between cultural background, family level relationships, and service system contexts.

Vitamin D status in cord blood and newborns: ethnic differences.

BACKGROUND: A deficiency in vitamin D (25OHD) is common throughout the world in both adults and children, being related to skin pigmentation, sun exposure, dietary intake and obesity. Limited data are available for the neonatal age. The aim of the study is to understand the differences in 25OHD levels with respect to skin colour and ethnicity in newborns. METHODS: We randomly enrolled 62 neonates, born at term and appropriate for gestational age. Thirty two were born from Italian mothers with fair skin (FS) and 30 from non-Caucasian mothers (North African, African, Asian and Latin American): 10 with light olive/light brown (LOB) and 20 with medium brown/black skin (MBB). Vitamin D was measured in the cord blood at birth and in neonatal serum during metabolic screening. RESULTS: 25OHD levels were (mean ± SD) 21.4 ± 11 ng/ml in cord blood and 14.9 ± 7 ng/ml in serum after birth. 25OHD values were higher in cord blood (p < 0.01) and neonatal serum (p < 0.001) in subjects supplemented with Vitamin D. Newborn FS showed higher vitamin D levels in cord blood when compared to LOB and MBB (p < 0.01), and higher levels in neonatal serum when compared to LOB (p < 0.01). In cord blood, 25OHD levels were higher in Italian newborns than in North African (p < 0.004) and African (p < 0.01). In neonatal serum, 25OHD levels were higher in Italian infants only when compared with North African infants (p < 0.03). CONCLUSIONS: The present study shows a high prevalence of vitamin D insufficiency and deficiency in newborns with significant differences observed to be due to ethnicity, skin colour and maternal supplementation during the pregnancy.

Weight-loss interventions for Hispanic populations: the role of culture.

In the United States, ethnic minorities are overrepresented among the overweight and obese population, with Hispanic individuals being among the groups most at risk for obesity and obesity-related disease and disability. Most weight-loss interventions designed for the general population have been less successful with individuals from ethnic minorities and there is a pressing need to develop more effective interventions for these groups. This paper examines the importance of culture in the development of "culturally competent" weight-loss interventions for ethnic minority populations, and discusses specific culturally mediated factors that should be considered in the design and implementation of treatment interventions. While specifically focusing on Hispanic populations, we also address issues of relevance to other multiethnic societies.

Proportion of neural tube defects attributable to known risk factors.

BACKGROUND: Recognized risk factors for neural tube defects (NTDs) poorly predict population-level NTD risk. However, the proportion of NTDs that can be attributed to these risk factors is uncertain. METHODS: To determine the proportion of NTD cases that is attributable to known or suspected risk factors (i.e., female infant sex, family history of NTDs, and maternal Hispanic ethnicity, obesity, pregestational diabetes, gestational diabetes, low dietary folate intake, lack of folic acid supplementation, anticonvulsant use, and hot tub or sauna use), we estimated the adjusted population attributable fraction (aAF) for each factor, using the method of Eide and Geffler and data from the National Birth Defects Prevention Study. RESULTS: Our analyses of these data indicate that the proportion of cases of spina bifida and anencephaly that can be attributed to known risk factors is 28% and 44%, respectively. For spina bifida, the factor with the greatest attributable fraction was maternal obesity (aAF, 10%), whereas for anencephaly it was Hispanic ethnicity (aAF, 15%). CONCLUSION: Our analyses indicate that known risk factors account for <50% of NTD cases. Hence, the majority of NTD cases are attributable to, as yet, unidentified factors. These findings highlight the need for continued research to identify genetic and additional nongenetic risk factors for NTDs. Further, these findings suggest that strategies that aim to reduce the risk of NTDs associated with maternal Hispanic ethnicity and obesity may have the greatest impact on the population prevalence of these conditions.

The role of spirituality healing with perceptions of the medical encounter among Latinos.

BACKGROUND: Little is known about the relationship between spirituality healing and perceptions about the medical encounter among Latinos. OBJECTIVES: To examine the association between spirituality healing and attitudes of self-reported perceptions about the medical encounter. DESIGN: A cross-sectional telephone survey. PARTICIPANTS: 3,728 Latinos aged >or=18 years residing in the United States from Wave 1 of the Pew Hispanic Center/Robert Wood Johnson Foundation Latino Health Survey. MEASUREMENTS: Dependent variables were ever prayed for healing (yes/no), ever asked others to pray for healing (yes/no), considered important spiritual healing (very vs. somewhat or not important), and ever consulted a 'curandero' (folk healer in Latin America) (yes/no). The primary independent variables were feelings about the last time seeing a Doctor (confused by information given, or frustrated by lack of information) and perception of quality of medical care (excellent, good, fair or poor) within the past 12 months. RESULTS: Six percent of individuals reported that they had ever consulted a curandero, 60% prayed for healing, 49% asked others to pray for healing, and 69% considered spiritual healing as very important. In multivariable analyses, feeling confused was associated with increased odds of consulting a curandero (OR = 1.58; 95% CI, 1.02-2.45), praying for healing (OR = 1.30; 95% CI, 1.03-1.64), asking others to pray for healing (OR = 1.29; 95% CI, 1.03-1.62), and considering spiritual healing as very important (OR = 1.30; 95% CI, 1.01-1.66). Feeling frustrated by a lack of information was associated with asking others to pray for healing (OR = 1.29; 95% CI, 1.04-1.60). A better perception of quality of medical care was associated with lower odds of consulting a curandero (OR = 0.83; 95% CI, 0.70-0.98). CONCLUSION: Feelings about the medical encounter were associated with spirituality healing, praying for healing, and asking others to pray for healing. Feeling confused and perception of poor quality of medical care were associated with consulting a curandero.

Self-reported pain and utilization of pain treatment between minorities and nonminorities in the United States.

OBJECTIVES: To investigate differences in reported pain and pain treatment utilization (use of over-the-counter and prescription pain medications, seeing a pain specialist, and use of complementary and alternative medicine) among minorities and nonminorities in the general population. DESIGN: Secondary analysis of a national probability survey conducted by the CBS News/New York Times in January 2003. SAMPLE: Adult population in the United States, 18 years or older, having a telephone line at home. MEASUREMENTS: The survey asked respondents a series of questions about demographics, pain characteristics, and utilization of pain treatment; logistic regression was used to identify variables predicting reported utilization of pain treatment. RESULTS: Of the 902 respondents completing the survey, 676 (75%) reported experiencing "any type of pain." Of these, 17% reported being diagnosed with chronic pain. Minorities reported a higher average daily pain than Whites (4.75 vs. 3.72; p<.001). However, race/ethnicity did not explain utilization of pain treatment; income, education, age, gender, and pain levels explained more variability in different pain treatment utilization variables than race/ethnicity. CONCLUSIONS: Although minorities report higher pain levels than Whites, race/ethnicity does not explain utilization of treatment for pain. Future studies should consider more nuanced examination of interactions among race/ethnicity, pain, and socioeconomic variables.

Addressing cultural heterogeneity among Hispanic subgroups by using Campinha-Bacote's model of cultural competency.

Campinha-Bacote's model "The Process of Cultural Competence in Delivery of Health Care Services" is used to describe Hispanic cultural heterogeneity and to guide nurses in providing culturally competent and sensitive holistic care to individuals from different Hispanic subgroups. But for nurses to do so, healthcare organizations also must make the appropriate resources and structural supports available to them.

Reflections on a conversation with a curandera.

A curandera is recognized as a "culture or folk practitioner" in Latino cultures. Is the role of a curandera relevant to teaching transcultural nursing care in today's health care environment? Preconceived ideas of both Latino and non-Latino people have influenced how nurses and physicians view the role of the curandera. This article describes the lessons learned by the author and serves as encouragement for other nurses to be willing to incorporate the cultural practices of the curandera into modern health care.

Exploring older women's approaches to cervical cancer screening.

The purpose of this qualitative study (N = 98, 11 focus groups) is to investigate how low-income, African American and Hispanic older women make decisions about cervical cancer screening. Using the health belief model to guide content analysis of transcripts, we found that primary barriers to screening were; embarrassment with, fear of, and pain from the test, difficulty in accessing screening, stigma associated with Medicaid coverage, and prior negative experiences with cancer detection. Women experienced cues to screening from their own bodies, in symptoms, and relied on spiritual beliefs to support them in coping with their health problems. Enhanced understanding of these factors could increase uptake of cervical cancer screening among the unscreened and underscreened.

Hispanic adults' beliefs about type 2 diabetes: clinical implications.

PURPOSE: This integrative literature review focused on Hispanic adults' beliefs about type 2 diabetes. Type 2 diabetes is a progressive, chronic illness with the potential for debilitating complications that disproportionately affect Hispanic adults. By understanding Hispanic adults' beliefs about type 2 diabetes, health professionals will be able to offer more culturally competent health care. DATA SOURCES: Published research reports on Hispanic adults' beliefs about type 2 diabetes were obtained using multiple computerized databases and by searching reference lists of published reports. A total of 15 research reports comprised this review. CONCLUSION: While there was some variance among Hispanic subgroups, in general, Hispanic adults' understanding of the etiology of diabetes was an integration of biomedical causes such as heredity and traditional or folk beliefs such as susto, which is the concept of strong emotions. Hispanic adults believed that diabetes is a serious illness and that they could identify many of the symptoms of diabetes. They identified both biomedical and herbal treatments for diabetes. Negative attitudes toward insulin were common. Religious beliefs also factored into Hispanic adult's explanatory models of type 2 diabetes. IMPLICATIONS FOR PRACTICE: Hispanic adults have a fairly cohesive explanatory model of diabetes. Healthcare professionals can use this information as a starting point to discuss each individual patient's explanatory model of illness, clarify misconceptions, and develop an individualized plan of care.

Coping with asthma in immigrant Hispanic families: a focus group study.

BACKGROUND: Little is known about how childhood asthma affects immigrant Hispanic families in the United States. Qualitative research is effective for understanding the social, cultural, functional, and structural aspects of asthma in the family context. Furthermore, such knowledge is necessary to develop culturally appropriate interventions for these families. OBJECTIVES: To describe participants' perceptions of their roles in caring for an asthmatic child, to compare family patterns of caring for an asthmatic child by parents' country of origin, to identify barriers to caring for an asthmatic child, and to evaluate specific coping needs of low-income immigrant Hispanic families caring for an asthmatic child. METHODS: Five focus groups were conducted with low-income, immigrant, Spanish-speaking Hispanic adults caring for an asthmatic child, including community health workers, mothers, fathers, and grandparents, along with women with asthma. Audiotaped focus groups were transcribed verbatim in Spanish, forward translated into English, and back translated into Spanish. Data analysis was performed using qualitative analytic methods. RESULTS: Forty-one participants represented a range of countries of origin. Different themes emerged for community health workers vs parents and grandparents and for women vs men caring for a child with asthma. All the participants reported strong beliefs in using folk medicines. Barriers identified included language, culture, poverty, lack of health insurance, and poor living conditions. CONCLUSIONS: Results highlight the lack of asthma self-management skills, diagnostic uncertainty, and the use of folk medicine as factors that should be taken into consideration when tailoring interventions to improve asthma outcomes in this vulnerable population.

Cardiovascular risk among older Hispanic women: a pilot study.

This study used a descriptive correlational design to describe the relationship between cardiovascular risk and anxiety, spirituality, acculturation, and the objective indices of cardiac risk among a sample of 21 adult Hispanic women. Objective indices of risk included weight, blood pressure, blood lipids, and glucose. Four survey instruments were used to assess anxiety, spirituality, acculturation, and perceived risk. Findings revealed that all study participants had 3 or more risk factors, placing them in the moderate risk category for developing heart disease or having a heart attack within 10 years. State and trait anxiety scores were lower than the normative samples for adult women. Spirituality scores were higher than average; individuals with higher anxiety scores had lower spirituality scores. More research is needed to determine the health needs of unskilled workers with limited education in employment settings.

Spirituality among Latinas/os: implications of culture in conceptualization and measurement.

Despite growing transnational migration between the United States and Latin American countries, culturally relevant conceptualizations of spirituality among Latinas/os remain lacking in healthcare research. Grounded in Latina feminist theology, this article elucidates cultural values that influence spirituality and describes findings from a study using a new questionnaire to explore spirituality among Latinas in Puerto Rico and the US mainland. Results support the saliency of cultural values such as personalismo and familismo as the context for spiritual perspectives, which may function independently of the Catholic Church structure.

Early infant feeding decisions in low-income Latinas.

Breastfeeding rates remain low, especially among low-income minority women. The objective of this qualitative study was to assess barriers to breastfeeding and reasons for combination feeding among low-income Latina women and their families. Meetings were held with key informants to inform the sampling plan and develop questions for focus groups. Data were collected from eight qualitative focus groups with primiparous mothers postpartum, mothers breastfeeding at 4 to 6 months, mothers formula feeding at 4 to 6 months, grandmothers and fathers, and 29 individual interviews with formula- and combination-feeding mothers. Transcripts of focus groups and interviews were content coded and analyzed for thematic domains and then compared for concurrence and differences. Four main domains with 15 categories were identified: (a) Best of both: Mothers desire to ensure their babies get both the healthy aspects of breast milk and "vitamins" in formula. (b) Breastfeeding can be a struggle: Breastfeeding is natural but can be painful, embarrassing, and associated with breast changes and diet restrictions. (c) Not in Mother's Control: Mothers want to breastfeed, but things happen that cause them to discontinue breastfeeding. (d) Family and cultural beliefs: Relatives give messages about supplementation for babies who are crying or not chubby. Negative emotions are to be avoided so as to not affect mother's milk. Those counseling Latina mothers about infant feeding should discourage and/or limit early supplementation with formula, discuss the myth of "best of both," understand the fatalism involved in problem-solving breastfeeding issues, and enlist the altruism embedded in the family unit for support of the mother-infant pair.