Health disparities are believed to be the
result of the complex interaction among genetic variations, environmental
factors, and specific health behaviors. (U.S. DHHS, 2000).
Hispanics/Latinos generally have lower mortality rates but higher
morbidity rates compared with the overall U.S. population. As a result,
morbidity and chronic disease management are areas of great concern for
providers working with the Hispanic/Latino population. (Kaiser Permanente,
2001).
Terminology
The term Hispanic did not gain wide use until the 1970s
and 1980s. In earlier decades, Hispanics tended to organize around
their own national or regional identities as Mexicans, Mexican
Americans, Puerto Ricans, Cuban Americans, Central Americans, and
South Americans. By the early 1970s, new organizations formed that
coalesced the numerous Hispanic subgroups into a more unified voice
around a variety of social, civil, and political causes. Today, the
term Hispanic has become a cloak that covers all
Spanish-speaking ethnic subgroups. Hispanics in the U.S. can be of
any racial background—white, black, Asian, or American Indian, for
example. (National Alliance for Hispanic Health, 2000).
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Hispanics/Latinos living in the U.S. are almost twice as
likely to die from diabetes as are non-Hispanic whites. Hispanics account
for a disproportionate percentage of new cases of tuberculosis. They also
have higher rates of high blood pressure and obesity than do non-Hispanic
whites. There are differences among Hispanic populations as well. For
example, whereas the rate of low-birth-weight infants is lower for the
total Hispanic/ Latino population than for whites,
the rate for Puerto Ricans is 50% higher than the rate for whites. (U.S.
DHHS, 2000).
This chapter provides information on traditional health practices and
beliefs as well as the health status of different Hispanic/Latino
subgroups: Mexican Americans, Puerto Ricans, Central and South Americans,
and Cuban Americans.
• Demographics
• Health Status
• Traditional Health Beliefs and Practices
• Risk Factors and Challenges
• Strengths and Protective Factors
• Diet
• Adherence Factors
• Complementary and Alternative Medicine
• References and Resources
v Demographics
Size and Origin of Population
• In 2002, there were 37.4 million Latinos in the U.S.,
representing 13.3% of the
total U.S. population. This means that more than
one in eight people in the U.S.
are of Hispanic origin. (Ramirez and de la
Cruz, 2003).
• The Hispanic/Latino population in the U.S. is very diverse in terms
of national
origin, immigration and migration patterns, historical
backgrounds, languages and
dialects,and cultural values and beliefs.
(National Minority AIDS Council, 1999).
Among the Hispanic population,
66.9% are of Mexican origin, 14.3% are Central and
South American, 8.6%
are Puerto Rican, and 3.7% are Cuban. (Ramirez and de la
Cruz, 2003).
• In 1992, 40.2% of the Hispanic population in the U.S. (or 15
million people) was
foreign born. (Ramirez and de la Cruz, 2003).
• In the year 2050, the U.S. Census Bureau estimates that the
Hispanic/Latino
population will number more than 98 million people, or
24.3% of the total
population. It is also projected that 80% of the
Hispanic/Latino population will be
U.S. born and 20% will be foreign born.
(U.S. Census Bureau, 2000).
Location
• Within the U.S., Hispanics residing in the West and South are
mainly of Mexican
origin; those in the Southeast are mainly Cuban; and
those in the Northeast are
mainly Puerto Rican. (American Cancer Society,
2003).
• The Northeast has a larger proportion of residents of Hispanic
origin than the
Midwest does. The West has a disproportionately high
concentration of persons of
Hispanic origin. (Eberhardt et al., 2001).
• Persons of Hispanic origin constituted only 8% of central county
residents in the
Midwest in 1998 but 18% to 29% in other regions. In the
West, 11% of the most
rural population was of Hispanic origin, compared
with less than 6% for American
Indians/Alaska Natives and Hispanics
combined in all other regions. (Eberhardt et
al., 2001).
• 84% of Hispanics/Latinos reside in nine states: Arizona,
California, Colorado,
Florida, Illinois, New Jersey, New Mexico, New York,
and Texas. (CDC, 1998).
• In 2000, the four cities with the largest concentrations of
Hispanics/Latinos were
New York City, Los Angeles, Chicago, and San
Antonio. (Kaiser Permanente, 2001).
• Hispanics are more likely than non-Hispanic whites to live in
central cities within
metropolitan areas. Nearly half of all Hispanics
lived in central cities, compared
with slightly more than one-fifth
(21.1%) of non-Hispanic whites. Among Latino
groups, Puerto Ricans were
more likely than other groups to live in a central city
(57.4%). (Ramirez
and de la Cruz, 2003).
• Between 2000 and 2025, the Hispanic/Latino population in some
southern states is
projected to double or almost double—in Alabama,
from 37,000 to 63,000; in
Florida, from 40,000 to 80,000; in Georgia,
from 189,000 to 346,000; in South
Carolina, from 42,000 to 81,000; in
Tennessee, from 57,000 to 104,000; and in
Virginia, from 269,000 to
538,000. (U.S. Census Bureau, 1996).
Age
• In 2002, 34.4% of Hispanics were younger than 18 years, compared
with 22.8% of
non-Hispanic whites. Among Latinos, the Mexican-origin
population had the highest
proportion of individuals under 18 (37.1%),
and the Cuban-origin population had the
lowest (19.6%). The proportion
aged 65 and older ranged from 4% for Mexicans to
22.6% for Cubans.
(Ramirez and de la Cruz, 2003).
Family Size
• In 2002, more than one-quarter (26.5%) of Hispanic family
households consisted of
five or more people. In contrast, only 10.8% of
non-Hispanic white family
households were this large. Among Hispanic households, Mexican households,
particularly those in rural areas or
small towns, were most likely to have five or
more people (30.8%). (Ramirez and de la Cruz, 2003).
Underlying Causes of Health Disparities: Income and Education
Inequalities in income and education underlie many health
disparities in the U.S. Income and education are intrinsically
related and often serve as proxy measures for each other. In
general, population groups that suffer the worst health status are
also those that have the highest poverty rates and the least
education. Disparities in income and education levels are
associated with differences in the occurrence of death and
illness, including heart disease, diabetes, obesity, elevated
blood lead level, and low-birth weight. Higher incomes permit
increased access to medical care, enable people to afford better
housing and live in safer neighborhoods, and increase the
opportunity to engage in health-promoting behaviors. (U.S. DHHS,
2000).
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Education
• More than two in five Hispanics aged 25 or older have not
graduated from high
school. In addition, more than one-quarter of
Hispanics (27%) have less than a
ninth-grade education. (Ramirez and de
la Cruz, 2003).
• Among Latinos aged 25 years and older, Puerto Ricans, Cubans, and
Central and
South Americans were more likely to have graduated from high
school (70.8%,
66.8%, and 64.7%, respectively) than were Mexicans
(50.6%). (Ramirez and de la
Cruz, 2003).
• In 2000, 11% of Hispanics/Latinos had bachelor’s degrees. Among
Hispanic groups,
23% of Cuban Americans and 7% of Mexican Americans had
bachelor’s degrees.
(U.S. DHHS, 2003b).
Socioeconomic Status and Health Status
Socioeconomic status (SES) is a reliable predictor
of health status throughout the world. Generally, high SES is
associated with better health status, and low SES is associated with
poorer health status. In the U.S., people of lower SES have fewer
opportunities to adopt healthy eating and exercise patterns, and
they have less access to adequate, regular health care. People of
lower SES are more likely than their wealthier counterparts to
concentrate on day-to-day survival and experience feelings of
hopelessness, powerlessness, and social isolation. These disparities
in economic resources may negatively influence health beliefs and
behaviors. Even when SES changes for a person of color, the effects
may not lessen. (U.S. DHHS, 2003b).
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Income and Economic Status
• Hispanic workers earn less than non-Hispanic white
workers do. Among full-time,
year-round workers, 26.3% of Hispanics and
53.8% of non-Hispanic whites earned
$35,000 or more in 2002. The
proportion of workers making $50,000 or more was
12.4% for Hispanics and
31.8% for non-Hispanic whites. (Ramirez and de la Cruz,
2003).
• Hispanics are more likely than non-Hispanic whites to live in
poverty. In 2002,
21.4% of Hispanics were living in poverty, compared
with 7.8% of whites. Hispanic
children represented 17.7% of all children
in the U.S. but constituted 30.4% of all
children living in poverty.
(Ramirez and de la Cruz, 2003). Lower-income
Hispanics/Latinos are also
more likely than whites to be exposed to urban violence.
(Kaiser
Permanente, 2001).
• There is social and economic variability within populations of
color, as there is in all
popu-lations. Although some of these
socioeconomic and environmental factors
may have less impact in a
privately insured population than in the general
population, the effects
of childhood poverty may have an impact on the health
status of upwardly mobile persons of color. (Tucker and Tervalon, 2003).
Employment
• Hispanics and non-Hispanic whites have different occupational
distributions. In
2002, Hispanics were more likely than non-Hispanic
whites to work in service
occupations (22.1% versus 11.6%). Among Latino
groups, Central and South
Americans were more likely than other groups to work in service occupations
(27.3%). Mexicans were less likely than
other groups to work in managerial
occupations (11.9%). (Ramirez and de
la Cruz, 2003).
• Hispanics are much more likely than non-Hispanic whites to be
unemployed. In
March 2002, 8.1% of Hispanics in the civilian labor force
aged 16 and older were
unemployed, compared with only 5.1% of
non-Hispanic whites. Among Latino
groups, 8.4% of Mexicans, 9.4% of
Puerto Ricans, 6.8% of Central and South
Americans, and 6.1% of Cubans
were unemployed. (Ramirez and de la Cruz, 2003).
• A study that assessed the potential discriminatory treatment of
job applicants
found that opportunity denial (defined as the denial of
opportunity to obtain an
application, obtain an interview, or receive an
offer of employment) occurred 20%
of the time in black–white audits
and 31% of the time in Hispanic–Anglo audits
across all study sites. (Smedley
et al., 2003).
v Health Status
Leading Causes of Mortality
• Cardiovascular disease is the leading cause of death among people
of Hispanic
origin in the U.S., and cancer is the second leading cause
of death in this group.
(National Alliance for Hispanic Health, 2000).
• Mortality rates for coronary heart disease are 94 per 100,000 for
Puerto Ricans, 92
per 100,000 for Cuban Americans, and 88 per 100,000
for Mexican Americans. In
contrast, the rates are 121 per 100,000 for
non-Latino whites and 188 per 100,000
for African Americans. (Kaiser Permanente, 2001).
Specific Health Concerns
• Asthma is the leading chronic disease among Latino children.
According to a 1999
meta-analysis, Puerto Rican children are most
affected (11.2%), followed by
non-Latino African- American (5.9%),
Cuban-American (5.2%), non-Latino white
(3.3%), and Mexican- American
(2.7%) children. Studies have shown that Puerto
Rican children may be at
higher risk for asthma due to a smaller airway size, more
severe
inflammatory reactions, and lower birth weight. (Kaiser Permanente,
2001).
Recommendation
Educate Latino parents on the importance of
reducing potential asthma triggers in the home. Provide referrals to
organizations that can assist them in controlling household and
other environmental triggers. (Kaiser Permanente, 2001).
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Traditional Health Beliefs and Practices
• Involvement of la familia (family) is often
critical in the health care of a patient.
Traditionally, Hispanics include
many people in their extended families—not only
parents and siblings but also grandparents, aunts, uncles, cousins, compadres,
close friends, and
godparents (padrinos) of the family’s children. (Management
Sciences for Health, 2003).
• Respeto (respect) implies a mutual and
reciprocal deference. Respeto dictates
appropriate deferential
behavior toward others based on age, sex, social position,
economic
status, and authority. Older adults expect respect from those who are
younger, men from women, adults from children, teachers from students,
employers
from employees, and so on. (Management Sciences for Health,
2003).
• Personalismo—Hispanics tend to stress the importance of
personal relationships,
which is why many rely on community-based
organizations and clinics for their
primary care. Hispanics expect health care providers to be warm and friendly and to
take an active
interest in their patients’ lives. (Management Sciences for Health,
2003).
Recommendation
Sit closer to your Hispanic patients than you
might with patients from other cultures. Lean forward when speaking
or listening to the patient, and give a comforting pat on the
shoulder or other gesture that indicates interest. (National
Alliance for Hispanic Health, 2001).
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• Over time, by respecting the patient’s culture and
showing personal interest, a
healthcare provider can expect to win a
patient’s confianza (trust). When there is
confianza,
Hispanics value the time they spend talking with their health care
providers and are more likely to believe what they say. Confianza means
that the
provider has their best interests at heart. (Management Sciences for Health,
2003).
Recommendation
Be particularly sensitive about the nonverbal
messages you may be sending to your Hispanic patients. For example,
when a non-Hispanic provider sits the customary two feet away from a
Hispanic patient, he or she may be perceived as not only physically
distant but also (wrongly) uninterested and detached. Overall,
Hispanics tend to be highly attuned to others’ nonverbal messages.
(National Alliance for Hispanic Health, 2001).
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• Hispanic culture tends to view health from a
more synergistic point of view,
expressed as the continuum of body, mind,
and espiritu (spirit). (Management
Sciences for Health, 2003).
Recommendation
Understand and accept that many Hispanics have a
broad definition of health that combines a respect for the benefits
of mainstream medicine, tradition, and traditional healing, along
with a strong religious component in daily life. (National Alliance
for Hispanic Health, 2001).
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Traditional Illnesses
Some Hispanic/Latino clients—particularly those who are older or are
recent arrivals in the U.S.—may have traditional syndromes, symptoms,
behaviors, or illnesses that are unfamiliar to U.S.-trained providers.
Depending on your client’s country of origin, he or she may have
different terms for such traditional illnesses or syndromes, which include
the following:
• Ataque—severe expression of shock, anxiety, or sadness. May
be expressed
through hyperventilation, bizarre behavior, or violence.
(Rhode Island Department
of Health, 2001).
• Bilis—vomiting, diarrhea, headache, dizziness, migraine,
nightmares, loss of
appetite, inability to urinate. Believed to stem
from bile pouring into the
bloodstream in response to strong emotion,
rage, or revenge fantasies. (Rhode
Island Department of Health, 2001).
• Embrujado—bewitchment manifested through physical or
psychological illness,
depending on the intent of the bewitcher (who is
always female). A socially
accepted psychological disease, in contrast
to being "mad," which is not socially
accepted. (Diversity
Resources, 2002).
• Empacho—lack of appetite, stomachache, diarrhea, vomiting.
Thought to be
caused by poorly digested or uncooked food. (Rhode Island
Department of Health,
2001). The symptoms of empacho overlap with
those of several biomedical
conditions, such as gastroenteritis, formula
sensitivity, milk allergy, obstruction,
pyloric stenosis, appendicitis, and intussusception. (Kaiser Permanente, 2001).
Treatment includes dietary
restrictions, herbal teas, or abdominal massage with
warm oil. Parents may take a child with empacho to a traditional healer before
seeking
medical care.
• Fatiga—the name used by some Puerto
Ricans for asthma. (Rhode Island
Department of Health, 2002).
• Mal de ojo (evil eye)—vomiting, fever, crying,
restlessness. Thought to be caused
by an admiring or covetous look from
a person with an evil eye. (Rhode Island
Department of Health, 2001). Mal
de ojo is believed to "heat up" a child’s blood,
resulting in fever, uncontrollable crying, and other symptoms. Treatment
consists
of visiting a folk healer for herbal remedies and ritual cures
or sweeping the child’s
body with an egg, lemon, chili pepper, or rue.
The symptoms of mal de ojo overlap
with conditions such as
bacteremia, sepsis, dehydration, and gastroenteritis.
(Kaiser Permanente, 2001).
• Mollera caida (fallen fontanel)—believed to occur when the
breast or bottle is
removed too rapidly or when the infant is bounced or
tossed around. As a result, it
is believed that the soft palate
collapses in the mouth. Symptoms include fever,
diarrhea, and fussiness.
Treatment is aimed at realigning the fontanel by pushing up
the soft
palate with the thumb, pulling the hair, sucking the fontanel, or
hanging
the infant over a basin of water and tapping the feet. The
symptoms of mollera
caida overlap with those of sepsis,
dehydration, meningitis, or dysentery. (Kaiser
Permanente, 2001).
• Nervios—restlessness, insomnia, loss of appetite, headache,
nonspecific aches
and pains. It is often linked to chronic, negative
life circumstances, especially in
inter-personal relationships. (Kaiser
Permanente, 2001).
• Pasmo—tonic spasm of voluntary muscle, chronic cough or
stomach pain, arrested
growth and development. Thought to be brought on
by exposure to cold air when
the body is overheated. (Rhode Island
Department of Health, 2001).
• Susto—soul loss or fright characterized by anorexia,
insomnia, hallucinations,
weakness, painful sensations. Thought to be
caused by a traumatic experience.
(Rhode Island Department of Health,
2001).
v
Risk Factors and Challenges
Racism
• Vulnerable and marginalized groups in society experience an undue
proportion of
health problems. Many health disparities are rooted in
fundamental inequalities in
the social structure, which are inextricably
related to racism and other forms of
discrimi-nation in society. Research
has shown that inequalities in the health and
health care of ethnic and
racial groups are evident, and racism is the most
disturbing explanation for these inequalities. (World Health Organization, 2001).
• Studies in the U.S. report an association between perceived
racial discrimination
and high blood pressure, birth weight, and sick
days. In a recent study from the
United Kingdom, victims of
discrimination were more likely to have respiratory
illness, high blood
pressure, anxiety, depression, and psychosis. Stress responses
have been considered possible mechanisms for the effects of racism on health.
(McKenzie, 2003).
Environmental and Occupational Hazards
Urban Environment: Increased Risk and Alienation
Residents in urban settings have an increased risk
for exposure to hazards such as toxic waste; air pollution; crime
and violence; and older, poorly maintained buildings with inadequate
heating, lead paint, and cockroach allergens. Researchers believe
that exposure to violence may increase feelings of alienation,
powerlessness, and hopelessness. Individuals who live under these
conditions may see limited benefits in adopting health-promoting
behavioral changes. (U.S. DHHS, 2003b).
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• About 90% of Hispanics/Latinos live in urban
settings, compared with 70% of
whites. Thus, Hispanics/Latinos are more
likely to be exposed to the hazards of an
urban environment, including
toxic waste, air pollution, crime and violence, and
older, poorly maintained buildings. (Kaiser Permanente, 2001).
Recommendation
Infor m patients about preventive measures to
decrease exposure to lead paint toxins and household allergens.
Refer patients to local and federal agencies that may assist in
controlling hazardous materials in the workplace or home. (Kaiser
Permanente, 2001).
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• The Environmental Protection Agency indicates that Latinos are
the group most
likely to live in areas that fail to meet air quality
standards. Approximately 80% of
Latinos live in areas that fail to meet
at least one National Ambient Air Quality
Standard, compared with 65% of
African Americans and 57% of non-Latino whites.
More than 18% of Latinos
are exposed to the nation’s worst air pollution, compared
with 9.2% of
African Americans and 6% of non-Latino whites. In addition, more
than 8 million Latinos live in communities with uncontrolled toxic waste.
(Kaiser
Permanente, 2001).
• Hispanic/Latino men are more likely to hold jobs that expose them
to hazardous
materials and agents such as asbestos, textiles, silica and
coal dust, poisons,
radiation, and certain biological agents. (Kaiser
Permanente, 2001). For example, a
substantial number of
Hispanics/Latinos work in the semiconductor and agricultural
industries. Semi-conductor workers experience occupational illness at a rate three
times that of workers in other manufacturing industries. (Kaiser
Permanente, 2001).
Agricultural workers may be exposed to pesticides
that are associated with several
types of cancer, lung damage, chemical
burns, and adverse reproductive and
developmental effects. Hispanics
constitute 71% of all seasonal agricultural workers
and 95% of all migrant farmworkers. Exposure to agrochemicals has been
associated with
a variety of cancers. (National Alliance for Hispanic Health, 2001).
Recommendation
Providers who work with Hispanic patients in rural
areas should be familiar with the signs, symptoms, and long-term
impacts of various pesticide and other agrochemical exposures.
(National Alliance for Hispanic Health, 2001).
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Health Insurance Coverage and Access to Quality Care
• Of all major racial or ethnic groups, Latinos have the lowest
rate of health
insurance coverage. (Pew Hispanic Center, 2002).
• In 1999–2000, 32.9% of Hispanics were without health insurance
coverage. (U.S.
Census Bureau, 2002).
• The probability of Hispanics/Latinos under age 65 being uninsured
is 35%,
compared with 17.5% of the general population under age 65. This
disparity results
largely from the lack of job-based insurance provided
to Hispanics/Latinos,
who work disproportionately in blue-collar and
service-oriented jobs. (Smedley et
al., 2003).
• The vast majority of Hispanics are in working families, yet only
43% receive
health insurance through work. Cuban Americans have the
highest rate of job-
based or private health insurance coverage (65%) and
are less likely to be
uninsured (21%). Less than half of people of
Puerto Rican (45%), Central and
South American (46%), and Mexican (44%)
origin have job-based or other
private insurance. Over one-third of
Puerto Rican Americans (34%) are insured
by Medicaid or other publicly
funded programs. More than 40% of Americans of
Central and South
American heritage are uninsured, including 38% of Mexican
Americans. (Smedley
et al., 2003).
• Quality care comes from a doctor who knows you, but not everyone
has a regular
doctor. According to the Commonwealth 2001 Health Quality
Survey, 43% of
all Hispanics in this country do not have a regular
doctor. By contrast, only 20%
of white Americans do not have a regular
doctor. (National Cancer Institute, 2003).
Language and Communication
• More than 25% of Hispanic/Latino individuals in the U.S. live in
linguistically
isolated households. In addition, nearly 8 million
Hispanic/Latino Americans do not
speak English "very well."
Given recent population shifts, it is likely that these
figures grossly
underestimate the number of Hispanic/Latino Americans with limited
English proficiency. (Smedley et al., 2003).
• According to the Commonwealth 2001 Health Quality Survey, 33% of
all Hispanics
in the U.S. report having difficulty communicating with
their doctors. By contrast,
only 16% of white Americans report the same
difficulty. (National Cancer Institute,
2003).
• Among Hispanic/Latino elders, Cuban elders are the least likely
to be proficient in
English (54% are not proficient), making them the
most isolated linguistically.
Thirty-six percent of Puerto Rican elders
are not proficient in English, as are 28%
of Mexican- American elders. (Talamantes
et al., 2003).
Recommendation
To improve communication with your Hispanic/Latino patients:
• Utilize trained medical interpreters when communicating
with Hispanic/Latino patients who are not proficient in English.
• Avoid using friends, family, or children for medical
interpretation.
• When using a medical interpreter, arrange the seating so
that
you are facing the patient, and have the interpreter sit
alongside or slightly behind the patient.
• Use appropriate titles, such as Señor for Mr., Señora
for Mrs., and
Señorita for Miss, even if you don’t
speak Spanish. Using these
titles shows respect for your patients.
If you speak Spanish, show
respect by using the more formal usted rather than tu. (Kaiser
Permanente, 2001).
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• Out of a sense of respeto, many Hispanic patients tend to
avoid disagreeing with
or expressing doubts to their health care
providers about the treatment they are
receiving. They may even be
reluctant to ask questions or to admit that they are
confused about their medical instructions or treatment. Associated with this is a
cultural taboo against expressing negative feelings directly. This taboo may
manifest itself in a patient’s withholding information, not
following treatment orders,
or terminating medical care. (Management
Sciences for Health, 2003).
Obesity
• Data from the 1999–2000 National Health and Nutrition
Examination Survey show
that more adult women (33%) than men (28%) are
obese. Forty percent of
Mexican-American women are obese, compared with
30% of non-Hispanic white
women. (CDC, 2002).
• Mexican-American adolescents aged 12 to 19 were more likely to be
overweight
(24%) than were non-Hispanic white adolescents (13%). In
addition, Mexican -
American children aged 6 to 11 were more likely to be
overweight (24%) than were
non-Hispanic black children (20%) and non-Hispanic white children (12%).
(CDC,
2002).
• Mexican Americans of low socioeconomic status are often of Indian
rather than
European descent, in contrast to Mexican Americans of higher
socioeconomic
status. Indian heritage is associated with a higher
prevalence of obesity and
therefore a greater risk for diabetes.
(National Women’s Health Information Center,
2003).
• The prevalence of obesity in the Hispanic/Latino population aged
18 and over
increased from 11.6% in 1991 to 23.7% in 2001, according to
self-reported data
from the Behavioral Risk Factor Surveillance System.
(CDC, 2003).
Suggestion
Emphasize the strengths of the Hispanic/Latino diet and provide examples of low-fat alternatives by focusing on cultural values. For further information on healthy traditional foods and the patterns of a Latin American–style diet, see the Latin American diet pyramid at http://www.eguana. net/ organizations.php3?orgid=61&typeID=193&action=printContentItem&itemID=1535. (Oldways Preservation and Exchange Trust, 2003).
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Smoking
• Data from the 1997 National Health Interview
Survey show that overall,
smoking prevalence among Hispanic adults
was 20.4%, compared with
25.3% for whites. Among Hispanic men, 26.2%
smoked, compared with
27.4% of white men. For Hispanic women, the
smoking rate was 14.3%,
compared with 23.3% for white women. (CDC,
1998).
• The Centers for Disease Control and Prevention’s Youth Risk
Behavior Surveillance
System found that about one-third of Hispanic
students in grades 9 through 12
were current cigarette smokers. (CDC,
1998).
• Among Hispanic adults, 19% were current smokers, 16% were former
smokers, and
65% had never smoked. (Pleis and Coles, 2002).
• Rates of alcohol use vary significantly across Latino subgroups.
Heavy drinking
occurs in roughly 40% of Latino men aged 18 to 39.
Mexican Americans tend to
drink more heavily than either Puerto Ricans or Cuban Americans. The lifetime
prevalence rate of alcoholism among
Mexican-American men is 25%. (Kaiser
Permanente, 2001).
• Latinos typically delay getting treatment for alcoholism. In some
cases, by the time
they receive treatment for their disease, they have
suffered significant organ
damage. (Kaiser Permanente, 2001).
Recommendation
If you are a primary care provider, screen Hispanic/Latino patients
for alcohol problems and refer them for early treatment to reduce the
potential damage from untreated alcoholism. Emphasize the significant
positive impact this could have on the family and on loved ones’
physical and emotional health. (Kaiser Permanente, 2001).
• Latinos, like other Americans, begin drinking alcohol in early
adolescence. By age
18, nearly half of adolescents in all Latino groups
have used alcohol. Rates of
alcohol use among adolescent males and
females are almost the same. Cigarette
smoking and alcohol and drug use
among Latino women and girls are increasing,
reaching critical proportions. (Kaiser Permanente, 2001).
• Compared with Latino men, Latinas show high rates of abstaining
from alcohol and
relatively low rates of heavy drinking. In a recent
analysis of data from the 1993
National Household Survey of Drug Abuse,
close to half of the Cuban (46%),
Mexican-American (43%), and Puerto
Rican women (44%) reported abstaining from
alcohol. Frequent heavy
drinking was reported by 3% of Mexican-American women
and 1% or less of
Cuban and Puerto Rican women. (Collins and McNair, 2003).
• Mexican women who immigrate to the U.S. report higher levels of
abstention than
do women in the general U.S. population. However,
abstention rates tend to
decrease across generations. After three
generations, the drinking patterns of
Mexican-American women are similar
to those of the general population, including
higher rates of heavy drinking. (Collins and McNair, 2003).
Physical Activity
• Hispanics in general are more obese, less physically active, and
less likely to
participate in lifestyles that promote cardiovascular
health. As a consequence,
they are more likely to have diabetes than the
general U.S. population. (National
Women’s Health Information Center,
2003).
• According to the 1997 Behavioral Risk Factor Surveillance System
Report, 65% of
Hispanic adults in Texas do not participate in regular
physical activity. (Talamantes
et al., 2003).
• Hispanics in general are more obese, less physically active, and
less likely to
participate in lifestyles that promote cardiovascular
health. As a consequence,
they are more likely to have diabetes than the
general U.S. population. (National
Women’s Health Information Center,
2003).
• According to the 1997 Behavioral Risk Factor Surveillance System
Report, 65% of
Hispanic adults in Texas do not participate in regular
physical activity. (Talamantes
et al., 2003).
Recommendation
Encourage your Latino patients and their families
to take up a physical activity that the whole family can enjoy:
dancing. Suggest that they move to the beat of salsa, meringue,
tejano, cumbia, and other Latin music, and that they dance to three
of their favorite songs every day. Other suggestions could include
going for a walk with a friend or family member, walking around
while talking on the phone, or taking the stairs instead of the
elevator. (American Diabetes Association, 2003).
|
Practical Tips For Treating Hispanic Patients
• Find out what, if any, care is under way.
Ask about treatments and if
any herbs, medicines, or foods are
being given as part of the treatment.
• Be aware of economic circumstances. Older
Hispanics or new immigrants
may have gotten inadequate health
care due to cost and accessibility.
• Be respectful. Build trust. Be open to the
family’s suggestions. Involve
both parents in decision making,
if possible.
• Use a normal tone of voice. Watch your
body language. Hispanics
present who don’t speak English
fluently will listen and learn from the
tone of voice used and
body language.
• Provide a Spanish interpreter. Language
problems can be a significant
barrier to getting health care.
Federal law requires the health care
provider to have an interpreter available. Don’t rely on a child to
interpret. The interpreter should have knowledge of health care terms
and
procedures. Bilingual Hispanics may prefer to use Spanish for
emphasis or to express pain. Ask for feedback so parents fully
understand what is being stated. Literature written in Spanish
may
help reinforce instructions about medicines and procedures.
• Match gender. Self-disclosure to the same
gender is preferred in
general.
• Allow amulets. Allow Hispanics to wear
ornaments that have spiritual
significance, if possible.
• Watch for non-compliance in taking
medicines. Patients may say yes,
then not take the medicines.
• Watch for presence of parasites in recent
immigrants. Parasites are
commonplace in their country of
origin.
Source: Children’s Hospitals and Clinics Minneapolis/St.
Paul, Minnesota.
|
Strengths and Protective Factors
• La familia (family). Traditionally,
Hispanics include in their extended families not
only parents and siblings but also grandparents, aunts, uncles, cousins, compadres,
close friends, and godparents (padrinos) of the family’s children.
When they are ill
or injured, Hispanics frequently consult with other
family members and may ask
them to come along on medical visits.
Hispanic extended families play an important
support role for patients.
(Management Sciences for Health, 2003).
• Personalismo. Hispanics tend to stress the importance of
personal relationships.
They expect health care providers to be warm and
friendly and to take an active
interest in their patients’ lives. Personalismo
conveys to the patient that the
provider is interested in him or her
as a person and helps put the patient at ease
before an exam or medical procedure. (Management Sciences for Health, 2003).
• Community. A network of hundreds of local organizations has
emerged in almost
every Hispanic community in America. For the past 30
years, these organizations
have acted as frontline advocates for and
providers of Hispanic health care and
social services. Community-based
organizations within Hispanic neighborhoods,
barrios, colonias,
and other ethnic enclaves provide a significant point of entry and
an opportunity to expand outreach efforts. Hispanics/Latinos continue to
rely on
community-based organizations and clinics for their primary
care. (Management
Sciences for Health, 2003).
Diet
• In general, the Hispanic/Latino diet is similar to that of the
majority population.
Underlying differences are associated with region
or country of origin. The major
differences may be in cooking style or
use of condiments rather than in basic
ingredients.
• A Latin American diet may include the following types of food:
•
Meat, Sweets, Eggs: beef, la4mb, pork,
eggs, puddings, cookies, creams.
•
Plant Oils, Milk Products: soy, corn, or olive
oil; milk; cheese.
•
Fish, Shellfish: shrimp, salmon, snapper,
mussels.
•
Poultry: fowl, turkey, chicken.
•
Beans, Grains, Tubers, Nuts: maize,
potato, rice, bread, taro, tortilla, arepas,
beans, seeds, quinoa,
malanga, peanuts, amaranth, arracacha, hichintal, legumes,
cassava, pecans, sweet potato, pumpkin, plantain, yucca.
•
Fruits: lime, banana, avocado, breadfruit,
plum, apple, berries, papaya, mango,
cherimoya, guanabana, pineapple,
melon, tamarind, quince, grapes, guava, orange,
kiwi.
•
Vegetables: kale, cactus, eggplant, turnip,
chard, squash, zucchini, onion, broccoli,
okra, spinach, lettuce, tomato,
tomatillo, sweet pepper, chilies. (Oldways
Preservation and Exchange
Trust, 2003).
Recommendation
For further information on healthy traditional
foods and the patterns of a Latin American–style diet, see the
Latin American diet pyramid at http://www.eguana.
net/organizations.php3?orgid=61&typeID=193&action=printContentItem
&itemID= 1535. (Oldways Preservation and Exchange Trust, 2003).
|
• As with other groups, after migration to the U.S.,
Hispanics/Latinos may increase
their consumption of meat and fast foods as
they acculturate. (Diversity
Resources, 2001).
v Adherence Factors
Decision-making
• La familia (family). Hispanic families
traditionally emphasize interdependence over
independence and cooperation
over competition. Therefore, family members are
likely to be involved in
the treatment and decision-making process for a patient.
Migration and
separation from family may cause stress in Hispanic patients who are
used
to making decisions in collaboration with other family members.
(Management
Sciences for Health, 2003).
Recommendation
Including family members in the consultation is
often critical to the care of the patient and may contribute to the
patient’s ability to adhere to the recommended treatment.
(Management Sciences for Health, 2003).
|
Communication
• Personalismo.
Warm, friendly providers
who take an active interest in their
patients’ lives are more likely
to earn the loyalty, respect, and confidence of their
patients. (Management Sciences for Health, 2003).
• Confianza (trust). A provider who is able to establish a bond
of confianza with his
or her Hispanic patients will find a
profound improvement in the quality of care and
in patients’
willingness to take wellness and risk-reduction advice to heart. Having
won confianza from patients, the provider may also come to
appreciate the
Hispanic view of health. (Management Sciences for Health,
2003).
Suggestion
Involve health care brokers, community outreach
workers, or promotoras to help establish trust with new
Hispanic/Latino patients. (Management Sciences for Health, 2003).
|
• Respeto (respect). Health care providers, by
virtue of their healing abilities,
education, and training, are afforded a
high level of respeto as authority figures. As
a general rule, Hispanic patients listen to what their health care providers have to
say
and value the direction and services offered. (Management Sciences for
Health, 2003).
Key Fact
Out of a sense of respeto, many Hispanic
patients tend to avoid disagreeing with or expressing doubts to
their health care providers about the treatment they are receiving.
They may even be reluctant to ask questions or to admit that they
are confused about their medical instructions or treatment.
Associated with this is a cultural taboo against expressing negative
feelings directly. This taboo may manifest itself in a patient’s
withholding information, not following treatment orders, or
terminating medical care. (Management Sciences for Health, 2003).
|
• Some Hispanic/Latino patients may avoid asking
questions to avoid appearing to
disagree with the provider, out of a sense
of respect. (Kaiser Permanente, 2001).
Recommendations
• Be as thorough as possible to minimize confusion when
explaining treatment plans
and procedures, and gently encourage
your Hispanic/Latino patients to voice any
questions or
concerns. Prompt them regularly with questions, and ask whether
they understand your diagnosis or treatment recommendations.
• When the patient talks to you, summarize what he or she
has said. Clarify and
check that the patient understands each
point before moving on.
• Encourage the asking of questions.
• For information and tools related to increasing patient
adherence, see, Provider-
Patient Interaction, Patient Adherence at http://erc.msh.org/mainpage.cfm?file=4.4.0.htm&module=provider&language=English.
|
v Complementary and Alternative Medicine
Complementary and alternative medicine (CAM) has growing
social, economic, and clinical significance in the U.S.. It is important
for providers to understand the implications of CAM for their patients:
what it is, who uses it, and why. CAM covers a broad range of healing
philosophies, approaches, and therapies that the U.S. medical community
does not commonly use, accept, or study. (Kaczmarczyk and Burke, 2003).
CAM
The National Center for Complementary and Alternative Medicine
(NCCAM) defines CAM as:
"a broad range of healing philosophies (schools of
thought), approaches, and therapies that mainstream Western
(conventional) medicine does not commonly use, accept, study,
understand, or make available. A few of the many CAM practices
include the use of acupuncture, herbs, homeopathy, therapeutic
massage, and traditional oriental medicine to promote well-being
or treat health conditions.
"People use CAM treatments and therapies in a variety of
ways. Therapies may be used alone, as an alternative to
conventional therapies, or in addition to conventional, mainstream
therapies, in what is referred to as a complementary or an
integrative approach.
"Many CAM therapies are called holistic, which generally
means they consider the whole person, including physical, mental,
emotional, and spiritual aspects." (Cited in U.S. DHHS,
2003a).
|
• Within the Hispanic community, an extensive practice
of traditional medicine is
carried out by curanderas, espiritistas,
or healers. In urbanized barrios, this
tradition has been carried
on in part by Hispanic pharmacists who are familiar with
both traditional treatments, such as té de manzanilla (chamomile tea), and modern
prescription medicines, such as antibiotics. Many Hispanics use
traditional medicine
in combination with other approaches. The Hispanic
view of the mind-body-spirit
continuum is a synergistic one, but it is
also quite practical. (Management Sciences
for Health, 2003).
• A combination approach may work well for your patients. The caution here is to
make sure to determine what, if any, traditional healing methods your patient is
using and to evaluate the potential adverse impact of combining a traditional
treatment with other medications. (Management Sciences for Health, 2003).
Recommendation
Validate the beliefs of Latino patients who practice traditional healing methods that current biomedical training may not support. Bear in mind that traditional practices are highly valued in Latino cultures and that a collaborative treatment approach will be most effective. (Kaiser Permanente, 2001).
|
Suggestion
Victor S. Siepina, MD, a family medicine physician, offers an ABCDE approach to speaking with patients about the use of complementary and alternative therapies and integrative health care:Ask, don’t tell
Be willing to listen and learn
Communicate and collaborate
Diagnose
Explain and explore options and preferences
(U.S. DHHS, 2003a).
|
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Sources: The Provider’s Guide to Quality & Culture
http://erc.msh.org/quallity&Culture
Management Sciences for Health
Office of Minority Health and Bureau of Primary Health Care.
v Quality & Culture Quiz
1. Cross-cultural misunderstandings between providers and patients
can lead to
mistrust and frustration, but are unlikely to have an impact
on objectively
measured clinical outcomes.
a. true
b. false
2. When the patient and provider come from different cultural
backgrounds, the
medical history obtained may not be accurate.
a. true
b. false
3. When a provider expects that a patient will understand a condition
and follow a
regimen, the patient is more likely to do so than if the
provider has doubts about
the patient.
a. true
b. false
4. A really conscientious health provider can eliminate his or her
own prejudices or
negative assumptions about certain types of patients.
a. true
b. false
5. When taking a medical history from a patient with a limited
ability to speak
English, which of the following is least useful?
a. Asking questions that require the patient to give a simple
"yes" or "no" answer,
such as "Do you have
trouble breathing?" or "Does your knee hurt?"
b. Encouraging the patient to give a description of her/his
medical situation, and
beliefs about health and illness.
c. Asking the patient whether he or she would like to have a
qualified interpreter
for the medical visit.
d. Asking the patient questions such as "How has your condition
changed over
the past two days?" or "What makes your condition
get better or worse?"
6. During a medical interview with a patient from a different
cultural background,
which is the least useful technique?
a. Asking questions about what the patient believes about her or
his illness–what
caused the illness, how severe it is, and what
type of treatment is needed.
b. Gently explaining which beliefs about the illness are not
correct.
c. Explain the "Western" or "American"
beliefs about the patient’s illness.
d. Discussing differences in beliefs without being judgmental.
7. When a patient is not adhering to a prescribed treatment after
several visits,
which of the following approaches is not likely
to lead to adherence?
a. Involving family members.
b. Repeating the instructions very loudly and several times to
emphasize the
importance of the treatment.
c. Agreeing to a compromise in the timing or amount of treatment.
d. Spending time listening to discussions of folk or alternative
remedies.
8. When a patient who has not adhered to a treatment regimen states
that s/he
cannot afford the medications prescribed, it is appropriate to
assume that
financial factors are indeed the real reasons and not
explore the situation further.
a. true
b. false
9. Which of the following are the correct ways to communicate with a
patient
through an interpreter?
a. Making eye contact with the interpreter when you are speaking,
then looking
at the patient while the interpreter is telling the
patient what you said.
b. Speaking slowly, pausing between words.
c. Asking the interpreter to further explain the patient’s
statement in order to get
a more complete picture of the patient’s
condition.
d. None of the above.
10. If a family member speaks English as well as the patient’s
native language, and is
willing to act as interpreter, this is the best
possible solution to the problem of
interpreting.
a. true
b. false
11. Which of the following statements is true?
a. People who speak the same language have the same culture.
b. The people living on the African continent share the main
features of African
culture.
c. Cultural background, diet, religious, and health practices,
as well as language,
can differ widely within a given country or
part of a country.
d. An alert provider can usually predict a patient’s health
behaviors by knowing
what country s/he comes from.
12. Which of the following statements is not true?
a. Friendly (non-sexual) physical contact is an important part
of communication
for many Latin American people.
b. Many Asian people think it is disrespectful to ask questions
of a health
provider.
c. Most African people are either Christian or follow a
traditional religion.
d. Eastern Europeans are highly diverse in terms of customs,
language and
religion.
13. Which of the following statements in not true?
a. The incidence of complications of diabetes, including
lower-limb amputations
and end-stage renal disease, among the
African-American population is double
that of European Americans.
b. Japanese men who migrate to the U.S. retain their low
susceptibility to
coronary heart disease.
c. Hispanic women have a lower incidence of breast cancer than
the majority
population.
d. Some Native Americans/American Indians and Pacific Islanders
have the
highest rate of type II diabetes mellitus in the world.
14. Because Hispanics have a lower incidence of certain cancers
than the majority of
the U.S. population, their mortality rate from
these diseases is correspondingly
lower.
a. true
b. false
15. Minority and immigrant patients in the U.S. who go to traditional
healers and use
traditional medicines generally avoid conventional
Western treatments.
a. true
b. false
16. Providers whose patients are mostly European-American, U.S.-born,
and
middle-class still need to know about health practices from
different world
cultures.
a. true
b. false
17. Which of the following is good advice for a provider attempting
to use and
interpret non-verbal communication?
a. The provider should recognize that a smile may express
unhappiness or
dissatisfaction in some cultures.
b. To express sympathy, a health care provider can lightly touch
a patient’s arm
or pat the patient on the back.
c. If a patient will not make eye contact with a health care
provider, it is likely
that the patient is hiding the truth.
d. When there is a language barrier, the provider can use hand
gestures to bridge
the gap.
18. Some symbols—a positive nod of the head, a pointing finger, a
"thumbs-up"
sign—are universal and can help bridge the
language gap.
a. true
b. false
19. Out of respect for a patient’s privacy, the provider should
always begin a
relationship by seeing an adult patient alone and drawing
the family in as
needed.
a. true
b. false
20. In some cultures, it may be appropriate for female relatives to
ask the husband
of a pregnant woman to sign consent forms or to explain
to him the suggested
treatment options if the patient agrees and this is
legally permissible.
a. true
b. false
21.Which of the following is not true of an organization that
values cultural
competence:
a. The organization employs or has access to professional
interpreters that speak
all or at least most of the languages of its
clients.
b. The organization posts signs in different languages and has
patient education
materials in different languages.
c. The organization tries to hire staff that mirror the ethnic
and cultural mix of its
clients.
d. The organization assumes that professional medical staff do
not need to be
reminded to treat all patients with respect.
22. A female Muslim patient may avoid eye contact and/or physical
contact
because:
a. She doesn’t want to spread germs.
b. Muslim women are taught to be submissive.
c. Modesty is very important in Islamic tradition.
d. She doesn’t like the provider.
23. Which of the following statements is not true:
a. Diet is an important part of both Islam and Hinduism.
b. North African countries have health care systems that suffer
because of
political problems.
c. Arab people have not historically had an impact on the medical
field.
v Quality & Culture Quiz Answers
1. False Low levels of cultural competence can impede the
process of making an
accurate diagnosis, cause the provider to order
contraindicated medication, and
reduce patient adherence to recommended
treatment.
2. True Because of language and cultural barriers, the patient
may not understand
the questions or may be reluctant to report symptoms;
in turn, the provider may
misunderstand the patient’s description of
symptoms.
3. True This is an adaptation of the "Pygmalion
theory" which has proven that
students generally live up—or down—to
the expectations of their teachers.
(Rosenthal and Jacobson 1968).
4. False Most of us harbor some assumptions about patients,
based on race,
ethnicity, culture, age, social and language skills,
educational and economic
status, gender, sexual orientation, disability/ability, and a host of other
characteristics. These assumptions are often unconscious and so deeply rooted
that even when an
individual patient behaves contrary to the assumptions, the
provider
views this as the exception to the rule. A conscientious provider will
not
allow prejudices to interfere with making an accurate diagnosis and
designing an
appropriate treatment plan.
5. Answer: a. While it may seem easier to ask questions that
require a simple "yes"
or "no" answer, this
technique seriously limits the ability of the patient to
communicate information that may be essential for an accurate history and
diagnosis.
The most effective way to put the patient at ease and to ensure that
the
patient provides essential information about his or her symptoms is to
combine two types of questions: 1) open-ended questions such as
"Tell me about
the pain in your knee" and 2) more directed
questions, such as "What makes the
pain get better or worse?"
Always get a qualified interpreter when possible.
6. Answer: b. Although the provider may be tempted to correct
the patient’s
different beliefs about illness, this may lead the
patient to simply withhold his/her
thoughts in the future and interfere
with building a trusting relationship. It is more
effective to be nonjudgmental about differences in beliefs. The provider should
keep in
mind two goals: 1) the patient should reveal her/his medical history and
symptoms to help the provider make an accurate diagnosis, and 2) the
patient
should develop trust in the provider’s medical advice and be
willing and able to
adhere to that advice. To accomplish these goals, it
is essential to treat the
patient with respect, openly discussing
differences in health beliefs without
specifying "correctness"
or "incorrectness."
7. Answer: b. Non-adherence can be the result of many
different factors that may
require a variety of interventions. Simply
repeating the instructions may not
address the real issues that are
keeping the patient from adhering to the regimen.
In fact, repetition of
instructions may be inappropriate and quite offensive if the
patient has
a communication disability. Family members can provide
valuable support.
It may also be necessary to set small, realistic goals in order to
achieve long-term behavioral change. Finally, an understanding of the
patient’s
beliefs about other remedies may offer valuable clues to
her/his reluctance to
adhere to treatment.
8. False In addition to exploring payment options with the
patient, it is important for
the provider to inquire about cultural and
psychological factors that may impede
adherence to the prescribed treatment regimen.
9. Answer: d. Although it may seem natural to look at the
interpreter when you are
speaking, you want the patient to feel that you
are speaking to her/him, so you
should look directly at her/him, just as you would if you were able to speak
her/his language. It is best to
speak in a normal tone of voice, at a normal pace,
rather than pausing between words. Because of differences in grammar and
syntax, the
interpreter may have to wait until the end of your sentence before
beginning to interpret. Do pause after one or two sentences to allow the
interpreter to speak. When you need further information, or need to
clarify what
the patient has said, clearly tell the interpreter what
you
want asked of
the patient. Although you may ask the interpreter to add
his or her
opinion of what the patient really meant, try to get as close
as possible to the
patient’s actual words and intent.
10. False This is an inappropriate responsibility for families
to take on and may
actually place the provider in violation of the Civil
Rights Act of 1964 and the
August 30, 2000 Office for Civil Rights (OCR) Policy Guidance. The rationale for
using professional interpreters is
clear. Professional interpreters have been
trained to provide accurate,
sensitive two-way communication and uncover
areas of uncertainty or
discomfort. Family members are often too emotionally
involved to
tell the patient’s story fully and objectively, or lack the
technical
knowledge to convey the provider’s message accurately.
11. Answer: c. The only assured similarity among people from
around the world who
come to you for care is the fact that they are
your patients and they hope to be
treated with respect and with
concern for their individual health needs. As a
health care
practitioner, it is important to have a basic under-standing of your
patients’ cultures—and to recognize the similarities and
differences among
people from the same region of the world and the
same country. Differences in
cultures within a region can be
pronounced. Each patient is the product of many
cultural forces. People from the same continent, the same country, the same
part of the
country, and even the same city, may have major differences in
cultural heritage, traditions, and language, as well as differences in
socioeconomic status, education, religion, and
sexual orientation. It
is the
combination of all of these factors that make up a
person’s
"culture."
12. Answer: c. A large percentage of Africans are Muslims,
most of them living in North
and West Africa, but there are also many
Muslims in East Africa.
13. Answer: b. The longitudinal NI-HON-SAN study and
Honolulu Heart Program
showed that dietary changes contributed to a
significant increase in coronary heart
disease among Japanese men who
migrated to Hawaii and California. It highlighted
the role that
environmental factors can play in counteracting predispositions to
disease.
14. False Despite the lower rate of breast, oral cavity,
colorectal, and urinary bladder
cancers among Hispanics, their
mortality rate from these cancers is just as high as
that of the rest
of the population.
15. False In the U.S., some individuals from minority and
immigrant groups use
traditional treatments before turning to
conventional Western medicine, or use both
concurrently.
16. True A growing number of people from majority U.S.
cultures are turning to
traditional medicines as part of their health
care strategies. Providers should be
aware of any such practices that
may affect their patients’ health.
17. Answer: a. Although smiling is an expression of
happiness in most cultures, it
can also signify other emotions. Some
Chinese, for example, may smile when they
are discussing something sad or uncomfortable. The other pieces of advice
are incorrect. The use
and interpretation of body language depends entirely on
the patient’s culture and personal preferences. What is appropriate in one culture
may be embarrassing or offensive in another culture. Interpersonal
greeting
behaviors, for example, vary widely from one culture to
another. Beliefs about
touching are also highly variable, with some
cultures placing a high value on
physical contact, and others
believing that physical contact of any kind is a sign
of intimacy.
Similarly, some cultures perceive direct eye contact as a sign
of respect, while in other cultures, eye contact with
elders and
authority figures
is to be avoided. Hand gestures in particular can
lead to serious
misunderstandings. For example, the "ok"
sign, widely used in the U.S., is the
symbol for coins or money in
Japan. In several other cultures, the gesture
represents a bodily
orifice and is highly offensive.
18. False Each of these symbols has a very different meaning
in different cultures, and
may be offensive.
19. False In many of the world’s cultures, an individual’s
health problems are also
considered the family’s problems, and it is
considered threatening to exclude family
members from any medical
interaction. The provider should ask the patient whether
she/he would
prefer to be seen alone or with the family. It should be the provider’s
goal to help the patient to express her/his true preference about
this, without
offending any family members. The provider might ease
any tension around this issue
by assuring family members that they
will be asked to return to the examining
room in a short time.
20. True In many cultures, men are not involved in the
activities surrounding pregnancy
or childbirth. Yet they maintain the
responsibility for making decisions and giving
permission for
treatment, medication, and hospital stays. A female relative may have
to intervene between the provider and the husband.
21. Answer: d. Even the most conscientious, committed staff
who have been trained in
cultural competence may need periodic
reminders. In a busy practice, it is easy for
providers to seek shortcuts, slipping into assumptions about the diverse populations
they
serve and failing to take the time needed to fully understand the health
beliefs
and values of each patient.
22. Answer: c. Modesty is a very important aspect of a Muslim’s
life. Handshakes
between unrelated men and women are inappropriate
according to Islamic norms.
In addition, eye contact will often be
avoided, especially in mixed-gender situations.
23. Answer: c. Health and healing has been a part of Arab
tradition since the earliest
historical recordings. Not only has Arab
medicine been in existence for over one
thousand years, but Arab medical
texts and practices were very influential in the
development of Western
medical tradition.
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