Case Study (Prepared by Willa Y Aaron and Julie Walsh Kroeker)

Miram is a 60-year-old grandmother who arrived in Honolulu from Majuro less than a month ago. She came to babysit her grandchildren so her daughter, Neimon, could find work. Neimon and her husband Thomas have three children under five years of age, and have lived in Honolulu for two years. They are also guardians for NeimonÕs older sisterÕs son, Jason, who is a high school student.

Case workers from Healthy Start visit the family once a month, since their youngest child, Joseph, is only 6 months old. The program is designed to help improve perinatal outcomes (reduced infant mortality, low-birth weights, and racial disparities) in at-risk populations. The families and children are visited for two years following the birth to track their health and well-being.

When the caseworkers arrive at the apartment at the scheduled time, they are greeted by Miram, who is confused about their presence and doesnÕt speak English. Miram calls for Jason to come interpret for her. Jason, who is usually in school during their visit, does not recognize the visitors but invites them inside when they mention NeimonÕs name and their appointment. Jason explains that Neimon is working now. HeÕs home for the summer and bubu (grandma) just arrived to help out.

The caseworkers play with the children, and begin their questions about the JosephÕs health. At their last visit, the baby had been ill with a fever and flu, but neither Jason nor Miram knew the answers to their questions about doctor visits or medication. Miram got up to prepare some food and drink to offer the visitors, leaving Jason to talk with them. When she came back with breadfruit slices and cold soda, the visitors refused the food and Jason told her, ŌThey have to go.Ķ The case workers left, noting the motherÕs absence in their records, and their remaining questions. Later in the week, one of the case workers called the family hoping to speak with Neimon, but the phone had been disconnected.

When they returned the following month for their regular visit, bubu answered the door, and speaking Marshallese, invited them in nervously. They noticed she was moving very slowly, and limping. Because no translator was available, they only stayed a few minutes to see the children, then they said goodbye and left.



Appropriate Care provider?


Lack of communication

Unable to help without enough info

Cultural protocol Đfood



Alternate case:

Bubu is sick, Jason takes her to doctor, Neimon stays home from work to babysit.

Miram and Jason were greeted by Dr. Lee at the door and were invited to sit down. Speaking directly to Jason because he is the translator, Dr. Lee asked Jason what was his grandmotherÕs chief complaint. Jason explained to the doctor that his grandmother has been having a lot of pain in her abdomen, is diabetic, and has hypertension. Dr. Lee glanced at Miram, who was sitting calmly and staring at the floor, before addressing the grandson again with several questions at once: Can she get up on the examining table so he can palpate her stomach? When was the last time she had her bowel movement, and is she experiencing any pain while urinating? What kinds of medications is she on?

Jason was silent for a moment, uncomfortable and uncertain as to how to ask his grandmother what the doctor wanted to know. After some careful consideration, Jason decided to tell his grandmother that Dr. Lee would like her to show the bottles of medications she is taking. After writing a new prescription for Miram, Dr. Lee noticed that MiramÕs left big toe has an ulcer and looks infected. He briefly explained to Jason the importance of taking the antibiotics he prescribed Miram until they are finished and of properly caring for her feet to prevent further infection and to promote healing.

Miram and Jason left with medications to help her feel better. When she did feel better, Miram stopped taking the antibiotics.

Weeks later, Miram was brought again to see Dr. Lee because her toe had worsened. She was informed that the doctor needed to amputate her foot right away to prevent spreading of the infection. However, because they had to have a relative fly over from the islands to baby-sit the grandchildren and help care for Miram and her daughterÕs family, Miram delayed having the surgery and the infection spread higher.