THE HEALTH CARE PRACTITIONER:

UNDERSTANDING THE

MEXICAN CULTURE

WITHIN AMERICAN SOCIETY

Presented byAnn Sparks, BSN, RN

December 4, 2009Illinois State University – Mennonite College of Nursing

Contents

INTRODUCTION 2

Dominant language 2

Cultural communication, etiquette and preferred name formats 2

Spirituality & Religion

Family roles and organization 2Familismo 2Men & Machismo 2-3Women & Pregnancy/child-bearing 3Elderly 3Children 3

Work force issues 3

High risk behaviors 3-4

Nutrition 4

Health careHealth seeking beliefs/behaviors: Health and Wellness 4Responsibility for health care 4Folk practices 4Barriers to health care 5Health care practitioners (views of them/status of them) 5

Appendix A 5

Appendix B 6

References

INTRODUCTION

Hispanics are the fastest growing minority in the United States, of which Mexicans are the largest sub-group. California, Texas and Illinois are listed as having the highest concentrations of Hispanic residents, with New Mexico and Arizona also having significant populations.

Understanding the history of Mexico helps to realize much of the cultural uniqueness of the people. Before Spanish colonization, Aztec and Mayan Native Indian people groups primarily inhabited the region. Over the past 400-500 years, Spanish immigrants populated the area and intermarried with the natives, bringing the Roman Catholic religion and the Spanish language. Therefore, the language, the religion and the rich cultural heritage of Mexico are a unique combination of Aztec, Mayan and Mediterranean Spanish.

First and often second generation Mexican-Americans carry much of their Mexican heritage with them to the United States. Those in the third generation and beyond continue to have significant influences from the Mexican heritage, but also can become “Americanized,” with many differences based on the area of residence in the United States, and their social and religious variations. To be noted is the Mexican culture is unusually tenacious through the generations, seemingly more so than other ethnicities.

Dominant language: Spanish (“Mexican Spanish”)The Aztec Nahuatl language was the primary native language in Mexico

prior to the Spanish influence, therefore the Mexican Spanish dialect is extremely sophisticated, unique, and sprinkled with numerous Nahuatl words.

Mexican Spanish has at least 11 different dialects and the Mexican government recognizes 63 indigenous Amerindian languages other than Spanish. The other languages affect about 6 million of Mexico’s residents. Therefore, even though Spanish is the primary language spoken, a Spanish-speaking interpreter may not be able to interpret subtleties accurately, nor would the interpreter be able to cover the other 63 Amerindian languages if the patient is from one of the other language speaking areas. Mexican Spanish is clearly different from Eastern (Castillian) Spanish

Most United States born Mexican-Americans speak quite effective English and various levels of Spanish, and often mix the languages into “Spanglish.” See Appendix A for common English-Spanish translation.

Cultural communication, etiquette and preferred name formats

Respect and honor are very important in the Latin culture. The way in which a health care provider greets and addresses the patient determines respect or disrespect. Always greet with Mr., Mrs. or Miss (Señor, Señora, or Señorita respectively), and the patient’s last name. To confirm the right patient, you may say “Señor Julio Perez,” rather than only Julio Perez. Also, it is important to continue to address the patient in a respectful manner throughout the encounter, for example, by addressing him as “Señor Perez.” Direct eye contact may be seen as aggressiveness or a challenging attitude.

Personal relationships are important and studies indicate that Hispanics expect a caregiver to show warmth to a patient and family members and should not be strictly business. Health care providers should be attentive, take their time, show respect, and if possible communicate in Spanish. Some simple phrases are listed in appendix A.

Privacy- Personal matters should be handled only within the family. Modesty is valued in Hispanic culture, and not just for women. For exams it is to be noted, the area between the waist and knees is considered particularly private.

Spirituality & ReligionReligious practice is primarily Roman Catholic Religion with traces of the

Aztec and Mayan religions blended in. The Roman Catholic influence is very strong as the Virgin of Guadalupe is considered their patron saint. Many homes have shrines with statues and pictures of saints. The patient will likely have a rosary, which has significant meaningfulness and should not be taken away.

With the Aztec influence, there is a strong belief in balance and supernatural powers (“hot” and “cold”), which can be seen today in some of the traditional medical beliefs. Witchcraft and superstition are often highly integrated. Shame and fear are often integrated into the belief system and “faith” may be limited. Give the patient and family privacy and time to practice their religious beliefs of prayer, penance, communion, confession and last rites. Prayers to specific saints for healing will likely take place.

Family roles and organization Familismo - In the Mexican culture, family is the center of existence. Mexican households often will have at least five people and three generations residing there. Men – The culture is predominantly paternal, indicating that the eldest man of the family makes the major decisions.

Machismo – defined as prominently excessive masculinity or toughness as a preferred characteristic of a man. As an attitude, machismo ranges from a personal sense of virility to a more extreme male chauvinism. Mexican-American men, as a group, are more likely to endorse traditional ‘macho man’ attitudes than European-American or black men. While many of the unique traits of Mexican-

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American men are admirable, special care may be called for in helping men cope with emotions.Women - The female’s role is equivalent in that she is the maternal powerhouse in her home. Women are sacred and revered, often protected, not because she can't handle herself or has no voice, but because the solidarity of the family unit depends on her well-being. Hispanic women tend to express immense love and concern through excessive care and attention to ill family members, sometimes to the point of interfering with rehabilitation.

Pregnancy & childbearing practices - Birth control other than the rhythm method is generally not allowed (Catholic origin) and large families and children are a blessing. In fact, the number of children she produces derives the woman’s status in large part. Thus, if feasible, she will avoid having a hysterectomy.

Many Mexican women view pregnancy as a normal condition, not necessarily requiring the assistance of a physician. Elder women provide support and information, and prenatal care is avoided.

A pregnant woman should avoid all contact with anything death-related. She is forbidden from attending funerals or burials and from visiting cemeteries. Pregnancy a “hot condition,” causing Hispanic women to avoid hot, protein-rich foods during pregnancy.

During pregnancy, a woman must avoid cold or hot baths, using warm water instead. Cold water is believed to affect bones and joints; the pelvis will be rigid and this could cause a longer and more difficult and painful labor. And varicose veins and other circulatory problems seem to appear as a consequence of hot baths. Many also believe that a pregnant woman should not expose herself to the sun’s heat or stand near a fire, since excess heat may burn the placenta or heat the baby and irritate it.

Mexican women often chant the phrase "aye yie yie" while in labor. What may appear to be an annoyance is actually a form of "folk Lamaze." Repeating the phrase in succession several times, necessitates taking long, slow, deep breaths. Thus, it is a cultural method for alleviating pain. If possible, a laboring Hispanic woman should be placed in the same room as a patient of the same or similar culture, so that their respective expressions of pain are not burdensome to the other patient.

During childbirth, it is thought that the woman’s womb loses heat and her ovaries and genitals soften, never returning to their original position. To prevent this, some traditional midwives place themselves between the woman’s legs at the moment she is giving birth, to help keep the heat in and curses out. Generally, Hispanic women prefer that their mothers attend to them during labor.

To attend a woman during delivery is a woman's job, ideally the job of her mother and midwife. Cultural tradition dictates that a husband not see his wife or

child until the delivery is over and both have been cleaned and dressed. A 40-day period of caring for the mother and child is considered essential

for the prevention of diseases and complications (called “lying-in”). During this period the woman’s body is thought to be extremely weak and vulnerable to external forces. The woman is not to bathe or exercise during this time.

Many Mexican women will not breast feed until they return home from the hospital. They believe that they have no milk until their breasts enlarge and they can actually see it. Some view colostrums as "bad milk" or "spoiled" and therefore not good for the baby. They do not realize that nursing stimulates milk production; others are too modest to expose their breasts. The mother should be informed of the importance of colostrums to the baby’s health and given privacy to feed.

Many Mexican mothers believe in the evil eye (mal de ojo), an evil that one casts on another causing them to become ill. In Mexican culture, babies are thought of as weak and very vulnerable to the power of an envious glance. A compliment without a touch can bring on the evil eye. Touching the person while complimenting neutralizes the power of the evil eye. Elderly – The elders within families are particularly revered for their knowledge and status. An individual who becomes sick will look particularly to the elderly for advice, comfort and support.Children – Offspring are not ever viewed as a burden.

Workforce issuesFew Mexican-Americans are highly educated. They emigrated here

hoping for a “better life.” Yet most often, they lack higher education being migrant farm workers, working in factories, and the hospitality/housekeeping industry. These positions are generally known as being low pay, high-risk jobs and exposure to hazards such as chemicals and job-related injury is high. If they are here illegally, or do not know English well, they are not able to insist on enforcement of labor laws. Often they will not seek assistance for fear of deportation.

High-risk behaviorso Sexuality/HIV/AIDS – Promiscuity, often starting at a young age.o Tuberculosis – Higher incidence in immigrants and larger family groups in

the same household.o Alcohol abuse and/or drug use – addictions more common in

Americanized residents than in first- and second-generation immigrants. Inner-city residents are at risk for gang-related activity as well.

o Dietary habits and body image concerns – culturally, thinness is viewed as unhealthy. Acculturation in the U.S. contributes to less healthy habits.

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o Contributes to high incidence of diabetes, heart disease/hypertension, and cancers.

o Machismo – The desire to “tough it out.”o Live for today – prevention is not important. Ex: no pre-natal care.o Sedentary lifestyle – Preventative exercise not seen as important.o Fatalistic beliefs – disease is seen as fate or consequences of bad

behavior. o Lack of education & Superstition:

o The lack of knowledge/trust in evidence-based practice. o The belief in supernatural powers that the patient/family may

actually have no control over health outcomes.o Traditional folk medicine and home herbal care will delay

treatment and possibly reduce positive outcomes.o Physical/emotional abuse is prevalent. The combination of paternalistic

Machismo, substance abuse, low economic resources, belief of “fate,” and lack of knowledge of resources contributes to dysfunctional families and abuse.

NutritionFoods that are primarily consumed in Mexico vary from region to region,

though beans (legumes), rice, wheat flour, corn meal, masa, fruits, and available meats prevail. Of significance are the high carbohydrate, and sometimes a high fat diet. Beans, tamales and tortillas are often cooked with lard, and deep fried foods such as Chicharrónes (deep fried pork rinds or chicken fat) are not uncommon.

Variations in dietary intake are common home remedy treatments, particularly with the use of “hot” and “cold” foods in the treatment of disease (see Appendix B). The acculturation process contributes to less healthy dietary habits, often higher in fat. Vitamin E, Calcium and Zinc often fall below the Recommended Daily Allowances.

Health care practicesHealth seeking beliefs/behaviors: Health and Wellness – Preventative care often is not considered by the Mexican-American Cultural as much of the thinking is based on “living for today,” and thoughts that much of health is based on fate. When illness strikes, cultural and socioeconomic influences dictate that home remedies be tried first, taking the advice of the elderly for herbal/natural healing methods. Then possibly a folk healer/curandero will be sought (see below). Modern western medicine is commonly the last resort for illness.

Emotions - Hispanics are far more emotionally expressive. They expect to be pampered when ill, as it is one way the family shows love and concern.

Time orientation - This is a present-oriented society, and as such they may neglect preventive health care, and may also show up late, or not at all, for appointments.

Body image/weight - Most Latin Americans see thinness as a problem and plumpness as the ideal. Advice to a patient to lose weight might not be followed because it would create a negative body image.

Mental Health - Typically, Hispanics look down on people who are mentally ill, believing that the illness is likely a result of Witchcraft or evil spirits. Patients with mental health concerns do not like to share this information with their relatives or friends and are shy of seeking professional help. Patients will need to be educated on psychiatric illness as often being caused by a simple chemical imbalance.Responsibility for health care - Although Mexican families tend to be Patriarchal, it is the mother who is in charge of health care. Home remedies are passed on from mother to daughter. When a family member is sick, it is a family crisis and often there will be many people to whom the practitioner will have to explain the disease process. Although the mother is the one in charge of health care, for more difficult and chronic treatments, it is often important to convince the father that this is necessary. Folk practices - Another large factor in health care is the use of the traditional or folk healer. One study has shown that 17% sought health care initially from a folk healer with 32% using health care professionals, and the rest (leaving over 50%) self-treating. It is important to realize that 72% of the people who receive care from a folk healer do not tell this information to their primary care provider. Recognition of use of folk medicine is essential because some remedies (greta and azarcon) contain lead and can be harmful. Mercury (Azogue) may also have been used.

Curanderismo is defined as a medical system. The historical roots combine Aztec, Spanish, spiritualistic, homeopathic, and scientific elements. The curandero is a holistic healer; the people who seek help from him do so for social, physical, and psychological purposes. Since the curandero has a religious orientation, much of the treatment includes artifacts: offerings of money, penance, confessions, and lighting of candles.

Barriers to health care Language Barrier – Many American providers to not know adequate Spanish.Machismo – “Tough it out” mentality; difficulty expressing emotional or vulnerability leads to addictive behaviors. Will not seek assistance for mental health concerns from even family because of shame/fear.Trust issues - It can be a challenge to earn the trust of the patient and family, as they do not necessarily recognize higher education as an adequate reason to

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assume increased trust. Strong relationships are important, therefore a rapport must be established Hispanics are much more likely to trust those of their own ethnicity.Lack of education/superstition - Traditional family or folk medicine often trumps Western Medicine, due to cultural and financial constraints. Even if modern medical care can be afforded, the traditions of the family are respected and often a combination of Western and traditional medicine is used. Also, customs include fatalism and submission to the will of God that the course of disease cannot be changed anyway.Financial constraints - Finances are often and issue with 38% being poor (as compared to 14% of non-Hispanic whites living below poverty level. It is also important to realize that 1/3 of the Hispanic population in the U.S. are children less than 15 years of age and should be covered by Medicaid.

Health care practitioners (views of them/status of them)Ethnic differences may prevent trust from being established. Strong

relational ties are required for trust to be built. Advanced education and evidence-based practice may mean little in the Mexican-American population. Also, suspicions of “Anglos/Gringos” often reduce health-seeking behaviors towards modern medicine. Those who do go to Anglo practitioners will most often combine folk practices in with their care.

Appendix A Common Mexican-Spanish terminology

English Spanish

Good morning Buenos días

Good afternoon Buenas tardes

Good bye Adiós

I am sorry, I do not speak Spanish Perdone, no hablo español.

We are waiting for an interpreter. Estamos esperando un intérprete

Mexican Spanish El español de México

Mr. Señor

Mrs. Señora

Miss Señorita

Shortness of breath Falta de aliento

Bath room Cuarto de bano

Water Agua

Hungry Hambriento

Tired/sleepy Cansado/sonoliento

(Chest) Pain Dolor (de pacho)

Appendix B Traditional Remedies - Healing Foods, Herbs & Spirituality

Food is often used to cure illness. Here we list some foods as they are categorized for healing, “Cold and Hot.”

Cold foodsBeanscorn productsdairy productscitrustropical fruitsinexpensive meats (goat, chicken, rabbit)

Hot foodsaromatic beverageschiliexpensive meats (beef, water fowl, fish, mutton)

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wheat products________________________________

Virgin (Lady) of Guadalupe and Jesus Christ (Crucifix)Common Catholic spiritual images

References

Cuevas De Caissie, Rebecca M. (2009). BellaOnline: The voice of women. Hispanic Culture Site. Retrieved November 17, 2009, from http://www.bellaonline.com/articles/art29820.asphttp://www.stemc.org/about_stemc/cultural_diversity/latinos.php?id=294

Mitchell, Braxton D. (2009). Faqs.org. Diet of Hispanics and Latinos. Retrieved November 17, 2009, from http://www.faqs.org/nutrition/Hea-Irr/Hispanics-and-Latinos-Diet-of.html

Smith, Andrea B. (2003). EthnoMed. Mexican Cultural Profile. Retrieved November 17, 2009, from http://ethnomed.org/culture/hispanic/mexican-cultural-profile

U.S. Department of Agriculture, Agricultural Research Service (1999). Data Tables: Food and Nutrient Intake by Hispanic Origins and Race, 1994-1996. Retrieved December 1, 2009, from http://www.barc.usda.gov/bhnrc

U.S. Department of Health and Human Services Centers for Disease Control and Prevention. (2008). Promoting cultural sensitivity: A practical guide for tuberculosis programs that provide services to persons from Mexico. Retrieved November 17, 2009, from http://www.cdc.gov/TB/publications/guidestoolkits/EthnographicGuides/Mexico/chapters/mexico.pdf

U.S. Department of Health and Human Services Health Resources and Services Administration. (2009). Quality health services for Hispanics: The cultural competency component. Retrieved November 23, 2009, from http://www.hrsa.gov/culturalcompetence/qualityhealthservices/aboutHispanics.htm#chapter6

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