Culture-Sensitive Health Care: Hispanic

The term "Hispanic" was created by the U.S. Census Bureau in 1970 as an ethnic category for persons who identify themselves as being of Spanish origin. Unlike other Census Bureau designations, "Hispanic" denotes neither race nor color, and a Hispanic may be White, Black, or American Indian. Although the term is widely used by non-Hispanics and Hispanics in Florida, many members of the Hispanic population prefer the term "Latino."

The classification "Hispanic" includes people of many different origins and cultures. Because the pattern of interactions among Spanish settlers, indigenous Indian populations, and imported African slaves differed across the many Latin American countries, the resulting diversity in these countries is considerable. Therefore, although there is a unifying thread of language and some cultural similarities inherited from the Spanish settlers, there is also tremendous variety within the Hispanic community. In this section, the commonalities are emphasized to guide health practitioners in providing appropriate care.

1. Show respeto. People from many Hispanic cultures offer (and expect to receive) deference on the basis of age, sex, and status. Patients will naturally offer respeto to the health provider, an authority figure with high social, educational, and economic status. In return, patients rightfully expect to be treated with respect.

The health provider shows respeto by:

• addressing adults by title and family name (Mr./Señor X, Mrs./Señora Y, or Madam/Doña).
• shaking hands at the beginning of each meeting.
• using usted rather than the informal tu for "you," when speaking Spanish.
• making eye contact, without necessarily expecting reciprocation, since some (especially rural) patients may consider it disrespectful to look the health provider, an authority figure, in the eye.
• speaking directly to the patient, even when speaking through an interpreter.
2. Show personalismo. Patients from many Hispanic cultures expect to establish a personal, one-on-one relationship—not to be confused with an informal relationship—with the health provider. Although establishing a relationship based on personalismo may seem time-consuming, it can actually save time and prevent negative outcomes that can result from misunderstanding of treatment or noncompliance with care.

The health provider shows personalismo by:

• treating patients in a warm and friendly—but not unduly informal—manner.
• showing genuine interest in and concern for patients by asking them about themselves and their family.
• sitting close, leaning forward, and using gestures when speaking with the patient.
3. Involve the family in decision making and care. Families are a source of emotional and physical support and are expected to participate in important medical decisions.
• The definition of la familia is much broader in most Hispanic cultures than in Anglo cultures and may include not only parents and siblings, but also grandparents, cousins, aunts and uncles, and even close family friends.
• La familia may show loyalty and support by gathering at the hospital. Health providers should understand that any noise and confusion (by U.S. standards) that result from "the gathering of the clan" contribute a great deal to both the patient's and the family's sense of well-being.
4. Accept a different sense of time. Many people from Hispanic cultures have what might be called a "global" or "indefinite" sense of time—rather than an exact sense of day and hour—in making and keeping appointments. Similarly, in presenting a complaint, they may not be able to attach a specific calendar date to the onset or conclusion of a medical complaint or an event such as menses or conception. They may instead be able to link the event to a season, a phase of the moon, or a particular occurrence, such as a holiday or celebration.
5. Take pains to establish understanding and agreement. Many patients' sense of respect for authority may cause them to avoid conflict or confrontation with the health provider by saying too readily that they understand how to take a medication or will follow a treatment plan. The health provider must ensure that understanding is achieved and must try to gain real acceptance of the treatment plan and a commitment to follow it.
6. Respect the spiritual side of physical complaints. Many Hispanic patients complain that health practitioners, by discounting supernatural and psychological causes of complaints, offer only a fragmentary approach to care. To these patients, this amounts to treating the symptoms, not the disease itself. Practitioners are advised to ask their patients what they believe to be the cause of a complaint and to refrain from ridiculing or discounting the patient's belief in supernatural or psychological causes.

Potential Culture-Related Health Concerns among Hispanic Populations

Persons from some Hispanic cultures may have a tendency toward certain health concerns because of cultural factors. Many items on the following list are derived from a 1985 report by the Task Force on Black and Minority Health, U.S. Department of Health and Human Services.

Specific concerns include:

1. a high incidence of teenage pregnancy among Mexican and Puerto Rican populations, due to a large percentage of women of childbearing age.
2. a low incidence of breast-feeding, especially in the Puerto Rican population.
3. where breast-feeding is practiced, a tendency to do so for a short period and to introduce solid foods earlier than recommended in current pediatric guidelines.
4. a very low intake of vitamin A.
5. alcohol abuse, especially by young Mexican males (abetted by cultural taboos against female disclosure of alcohol use).
6. drug use at levels higher than among non-Hispanic Whites.
7. a high prevalence of undetected non-insulin-dependent diabetes (especially among Mexicans with Pima Indian blood).
8. a high incidence of tuberculosis (the National Coalition of Hispanic Health and Human Service Organizations [COSSMOS] recommends aggressive screening with Mantough tuberculin skin test and, if the test if positive, use of the NIH's preventive therapy, because of the high use of BCG in Latin America.
9. high risk for mental health problems such as depression, anxiety, and substance abuse.
10. dietary concerns due to:
• a high consumption of fats (often lard, especially for low-income people) and fried food
• a traditional diet high in carbohydrates from beans and rice (Puerto Rico, Cuba, and the Caribbean islands) or corn tortilla (Mexico)
• low intake of green or leafy vegetables and/or milk and eggs, especially in conjunction with increased consumption of meat and fast foods as acculturation occurs.
11. lack of sunshine (primarily for immigrants to northern cities).
12. little tradition for "recreational" physical exercise outside the context of field or other physical labor.
13. excessive reliance on Azarcon (also called "Greta" or "Alarcon"), which is about 90 percent lead, as a home remedy for gastrointestinal/intestinal complaints.
14. sharing, with family and friends, of hypodermic needles and syringes, which in Mexico are often used to administer vitamins, medications, and contraceptives.

1. Good health is a matter of luck that can easily change. Sick persons may be the innocent victims of "fate," with little responsibility for taking action to regain health.
2. Illness may be the result of negative forces in the environment or a punishment for transgressions.
3. Balance and harmony are important to health and well-being. Illness may be the result of an imbalance.
4. The natural and supernatural worlds are not clearly distinguishable, and body and soul are inseparable. Telling a patient that an illness is all in the mind is meaningless because there is little or no distinction between somatic and psychosomatic illness.
5. Cure requires family participation and support. The family's role is to indulge the patient, provide unconditional love and support, and participate in health care decision making.
6. While education and training may be somewhat important, what truly matters is the caregiver's "gift" or "calling" for curing illness.
7. Moaning, far from being a sign of low tolerance to pain, is a way to reduce pain and to share it with interested others.
8. Diseases may be divided into Anglo and traditional diseases, and traditional diseases may be either natural or unnatural. Many people mix and match "modern" medicine and traditional care, consulting modern health providers for Anglo and natural diseases, and folk healers for traditional and unnatural diseases.

Major Folk Illnesses among Hispanic Populations

Ataque. A culturally condoned emotional response to a great shock or bad news, characterized by hyperventilation, bizarre behavior, violence, and/or mutism.

Bilis. An illness believed to be caused by strong emotions that result in an imbalance of bile, which "boils over" into the bloodstream. Symptoms include vomiting, diarrhea, headaches, dizziness, and/or migraine headaches.

Diseases of hot/cold imbalance. The hot/cold theory of disease traces its roots to the Aristotelian system of humors, which were either hot or cold, wet or dry. The hot/cold portion of the theory survives in many Hispanics of Mexican and Puerto Rican origin. Body organs, diseases, foods, and liquids may be "hot" or "cold," and good health depends on maintaining a balance of hot and cold. A "hot" ailment calls for "cold" herbs and foods to restore the balance, and vice versa.

Note that temperature is not the key factor in the classification scheme; ice is "hot" because it can burn, and Linden tea, though served hot, is "cold" and is often used by Mexicans to treat "hot" ailments. Penicillin, neutral in temperature, is considered "hot" because it may cause hot symptoms, such as diarrhea or rash.

Acceptance of the hot/cold system can affect compliance with treatment. For instance, a patient suffering from a high fever may resist cold compresses, reacting against the treatment of a "hot" ailment (fever) with a "hot" treatment (ice).

Indirect questions can help a provider determine whether a patient subscribes to the hot/cold belief system. If the patient does, the provider should try to work within the hot/cold framework to increase patient trust and maximize compliance.

Mollera cerrado or cerrado de mollera (fallen fontanel). Said to exist when an infant's anterior fontanel is either visibly depressed or believed to have been depressed as the result of trauma. Symptoms are excessive crying, lack of desire or ability to feed, diarrhea, vomiting, restlessness, and irritability. Whether real or imagined, this problem warrants attention because the family may believe it to be fatal if not treated.

Embrujado (bewitchment). A socially accepted psychological disease (in contrast to being considered "mad"), embrujado may be manifested through physical or psychological illness, depending on the intent of the bewitcher (who is always female). Some researchers have suggested that embrujado may be a culturally accepted behavior for males who cannot cope with the Anglo world.

Mal de ojo (evil eye). A spell usually cast on a child when a person with the evil eye admires the child without touching it. Children may be protected by special earrings, necklaces, amulets, or other jewelry, which should not be removed from the child's person during examinations. The most common treatment is prayer while sweeping the child's body with a mixture of eggs, lemons, and bay leaves—a treatment called limpia in Mexico and barrida in Puerto Rico. This process is also used to diagnose mal de ojo.

Susto (soul loss). A disease that can attack anyone, regardless of gender, age, racial group, or economic status, believed to result from a series of overwhelming events that causes the soul to become dislodged and escape from the body. It is manifested by a number of clinically diagnosed diseases, including cancer, kidney failure, diabetes, and high blood pressure. The variety of symptoms and pathologies through which susto is manifested absolves patients and relatives of any "guilt" for failing to take timely precautions or seek treatment for the disease. A long time is usually said to elapse between the event or events and the physical manifestations of susto. Many Hispanics of both rural and urban backgrounds accept this theory, regardless of their culture of origin.

Curanderismo. A system of care derived from a mixture of Aztec, Spanish, spiritualistic, homeopathic, and modern medicine, curanderismo is used to treat physical, psychological, and social illnesses. Used throughout Latin America, it is more widely practiced by Mexican immigrants than by Puerto Rican, Cuban, and Caribbean immigrant groups. There is also considerable diversity in curanderismo according to regional culture.

Curanderismo shares many scientific concepts and procedures with modern scientific medicine, and health practitioners should beware of dismissing it as "quackery." In fact, because of the major role curanderismo plays in Hispanic health beliefs and practices, hospitals and clinics in metropolitan areas with large Hispanic populations are beginning to cooperate with curanderos—sometimes even placing them on hospital staff.

A practitioner is either a curandero (male) or a curandera (female), and may be a member of the patient's nuclear or extended family. Sometimes the curandera is a señora or older woman who has developed a reputation for success in treating friends and family. Sometimes the curandero is a sovodor, a male who heals through massage (although this is less frequent in the United States than in Mexico). A partera or midwife is often used in Mexico (and less often by Mexican immigrants in the United States) because a woman is believed to have a better understanding of the female reproductive system than any man, including a "scientific" physician.

Santero or brujería. A structured system of healing magic that originated in what is now Nigeria. When brought to Puerto Rico, Cuba, and Brazil by African slaves, who were later converted to Catholicism, santero became fused with the Catholic system of saints and imagery.

The santero, a religious healer or "spiritualist," performs religious or magical ceremonies, administers potions, and prepares amulets. In Spanish Harlem in New York, parts of Florida, and others areas heavily populated by Puerto Ricans, Cubans, or people from the Caribbean, santeros often practice espiritismo in storefronts, basements, homes, and similar locations. People can also purchase herbs, potions, and charms at a botanica without consulting a healer.

Estimates vary as to the extent to which folk healers and cures are used in the United States, ranging from a low estimate of 4 percent of Hispanics nationwide to a high of 73 percent in a survey of mental health patients at a Los Angeles clinic. As a general rule, providers may assume that Hispanic patients who come to them after having delayed seeking health care for an inordinate length of time may have unsuccessfully tried a folk healing system first. On the other hand, patients who disappear after receiving a negative prognosis or failing to experience an immediate cure may have left the health care system for some form of folk healing. Often, however, they return so late that successful treatment is no longer possible.

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