4.

Getting to Know 
The Hispanic/Latino Culture

In working with Hispanic patients language can be such an obvious barrier, challenge, and point of identity that it can sometimes obscure other critical more subtle aspects of cross-cultural understanding. There are certain cultural nuances or unwritten rules that govern social interactions. These unstated rules can impact the way in which individuals perceive, seek, and receive services. These essential cultural aspects can involve interactions as simple as conversational gambits and spatial (physical space) relationships, along with larger institutional issues such as family visiting hours, patient education, and measuring individual responses to pain. Being aware and understanding the cultural context for these interactions can be a tremendous asset to you as a health care professional, and in your ability to deliver effective care.

"We’re a touching people. If you’re more than a handshake distance from your customer or patient you’re too far," says a Mexican American pharmacist and state legislator who has conducted cultural proficiency trainings for her colleagues. "Touching, how you make eye contact, the subtle things all count," she explains. "Diet is another example. Back in the early 1980s I’d try and help my patients adjust their diet to their medications. But the American Diabetes Association at the time had nothing on the Latino diet. They had a mainstream diet plan, and a supplement on a Jewish diet, but nothing my Hispanic patients in their 60s and 70s could use. They weren’t about to start eating brussels sprouts and cod for the first time in their lives. One older woman I remember looked at the material and asked me - ‘¿Qué es un bagel?’ (What’s a bagel?)."

Common cultural characteristics for Hispanics in the United States include: family, respeto or respect, personalismo, and confianza. This chapter will give a brief description of each these cultural concepts. It is important to note that there will always be individual variation from any cultural norm.

La Familia

A good starting place for any discussion of Hispanic culture is with la familia, the family. Traditionally, Hispanics include many people in their extended families, not only parents and siblings, but grandparents, aunts, uncles, cousins and compadres, close friends and godparents (padrinos) of the family’s children. When ill or injured, Hispanic people frequently consult with other family members and often ask them to come along to medical visits. Hispanic extended families and the support role they play for patients may run counter to certain institutional rules, such as hospital policies that limit patients to two visitors. In the interest of effective care, such policies may need to be reexamined to allow for more direct involvement of the supportive family network.

Hispanic families also traditionally emphasize interdependence over independence, and cooperation over competition, and are therefore far more likely to be involved in the treatment and decision making process for a patient. This level of involvement may not always be possible. Migration and separation from family may stress the values of young immigrant workers or couples newly arrived in the United States. Similarly, teenagers who quickly acculturate to the United States and the manners of their peers may demand to be treated as individuals and show signs of typical adolescent conflict with their parents and other relatives who maintain traditional values and customs. Because such stresses to family functioning may have significant health implications, it is important for the health care provider to be aware of these issues.

Respeto

For Hispanics the intimate confines of extended families, close-knit Hispanic communities, and traditional networks are mediated by respeto (respect). Respeto dictates appropriate deferential behavior towards others based on age, sex, social position, economic status, and authority. Older adults expect respect from youngsters, women from men, men from women, adults from children, teachers from students, employers from employees, and so on.

Health 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 tend to look forward to what the health care provider has to say and will value their direction and services. One way some Hispanics show respect is to avoid eye contact with authority figures. This respectful behavior should not be misinterpreted as a sign of disinterest. At the same time the health care provider is expected to look directly at the patient, even when communicating through an interpreter.

Respeto implies a mutual and reciprocal deference. The Hispanic adult patient expects the provider to treat him/her with returned respect and may terminate treatment if they perceive that that respect is not being shown.

Along with good health care practices such as providing the patient with information about the examination, diagnosis, and treatment; listening to the patient’s’ concerns; and, taking their individual needs into consideration while planning treatment, there are some additional steps you as a health care provider can take to assure the respect of your Hispanic patients.

• If you’re a younger provider, even though you will be awarded respect as an 
   authority figure, you should be more formal in your interactions with older 
   Hispanic patients. Formality should not be taken to mean coldness or distance, 
   but rather politeness. It is polite to address Hispanic adults as Señor (Mr.), Don 
   (Sir), Señora (Mrs.), or Doña (Madam).

• Even if you do not speak Spanish, greeting a patient with "Buenos dias" (good 
   morning)  or "Buenas tardes" (good afternoon) suggests that you have respect 
   for the Spanish language. These few words become an important cue to people 
   about your positive  attitudes towards them as too often Hispanics sense hostility 
   and disdain for their limited use or lack of English. If you speak some Spanish, it 
   is important to remember to always use the formal usted (you) until such time as 
   the patient explicitly suggests the use of the informal tú (you).

• Encourage the asking of questions. Out of a sense of respeto (respect) many 
   Hispanic patients tend to avoid disagreeing or expressing doubts to their health 
   care provider in relation to the treatment they are receiving. They may even be 
   reluctant to ask questions or admit 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.

Health providers, as authority figures, need to take seriously the responsibility and respeto conferred on them by many Hispanic patients. They need to explain all medical procedures and treatments thoroughly, and to ascertain through careful questioning whether the patient has fully understood the explanations and instructions he/she has received.

Personalismo

Hispanics tend to stress the importance of personalismo–personal rather than institutional relationships, which is why so many Hispanics continue to rely on community-based organizations and clinics for their primary care. Hispanics expect health providers to be warm, friendly, and personal, and to take an active interest in the patient’s life. For example a health provider, even one with a limited time schedule for patient visits, might greet Señora Díaz with, "Buenos Días, Señora Díaz. How are you doing today? How did your daughter’s graduation go?" Such a greeting implies personalismo, conveying to the patient that the provider is interested in her as a person and will help put the patient at ease before an exam or medical procedure.

When asked in focus groups where they received their medical care, the majority of Hispanics responded by naming their personal health care provider rather than their HMO or other health care institution. Hispanic loyalty to the individual provider also has significant implications for continuity of care. If a health care professional leaves a health center for another in close proximity, their Hispanic patients are likely to follow him/her to the new setting. If the health professional leaves the area however, their Hispanic patients may frequently stop treatment, unless the provider has made introductions to the new health care provider and established a transitional relationship between them based on personalismo.

Unfortunately, personalismo tends to conflict with the health system’s trend towards managed care and away from individualized practices and long-term provider/patient relationships. It is a loss many in the health care system are feeling.

The Hispanic patient’s desire for closeness to their health care provider is more than the content of their verbal exchanges; it also has to do with physical space. When interacting with others Hispanics typically prefer being closer to each other in space than non-Hispanic whites do. When non-Hispanic providers place themselves at their customary two feet or more distance away from their Hispanic patients, they may be perceived as not only physically distant but wrongly be thought of as uninterested and detached. Such perceptions can be overcome by sitting closer, leaning forward, giving a comforting pat on the shoulder, or other gestures that indicate an interest in the patient.

Confianza

Overall, Hispanics tend to be highly attuned to others’ non-verbal messages. Non-Spanish speaking providers should be particularly sensitive to this tendency when establishing a relationship with patients who speak only Spanish. Over time, by respecting the patient’s culture and showing personal interest, a health care provider can expect to win their confianza (trust). When there is confianza Hispanics will value the time they spend talking with their health care providers and believe what they say because confianza means that the provider will have their best interests at heart.

Unfortunately confianza is increasingly difficult to achieve these days due to the dramatic changes occurring in the health care system, i.e., long-term provider-patient relationships are less common, physicians and others are limited in the amount of time they can spend with each patient, and HMOs and other institutions reduce their coverage and treatment of the poor. And yet despite these and other obstacles, the provider who is able to establish a bond of trust, confianza, with his or her Hispanic patient will find a profound improvement in the quality of care-giving and willingness of the patient to take wellness and risk-reduction advice to heart. Having won confianza from your patients you may also find yourself coming to appreciate the Hispanic view of health. Remember that with confianza there is compliance.

While today’s health care professionals work within the structures of mainstream medicine, providing separate physical and mental health care, Hispanic culture tends to view health from a more synergistic point of view. This view is expressed as the continuum of body, mind, and espíritu (spirit).

Within the last century, health and illness have been approached through a variety of treatments, each with its own philosophical base. Some have been based on empirical science (mainstream medicine), some believe disorders linked to the musculoskeletal system can be corrected by physical manipulations (osteopathy), some developed treatments based on the belief that minute doses of drugs that mimic diseases can be used to treat diseases (homeopathy). Still other approaches continue to base states of health on a purely spiritual belief system (Christian Science). In addition there is an extensive practice of traditional medicine carried out by curanderas, espiritistas, or healers within the Hispanic community. In urbanized barrios this tradition has been carried on in part by Hispanic pharmacists, familiar with both traditional treatments like té de manzanilla (chamomile tea) as well as placing a strong value on the use of modern prescription medicines such as antibiotics. In recent years there has also been a dramatic increase of interest on the part of mainstream medicine in researching and identifying many of the healing properties and pharmaceutical potentials of traditional medicines.

Webster’s New University Dictionary defines synergy as, "1. The action of two or more organisms to achieve an effect of which each is individually incapable." and "2. The theological doctrine that regeneration is effected by a combination of human will and divine grace." The Hispanic view of the mind, body, spirit continuum is a very synergistic one, but also quite practical.

Combining respect for the benefits of mainstream medicine, tradition and traditional healing, along with a strong religious component from their daily lives (over 77% of Hispanics in the United States are Catholic), Hispanic patients may bring quite a broad definition of health to the clinical or diagnostic setting. Respecting and understanding this view can prove beneficial both in treating and communicating with the patient, as well as useful for all health care professionals .

 

 

Copyright The National Alliance for Hispanic Health
1501 16th Street, NW
Washington, D.C . 20036

Names

· Children are often named after relatives or religious figures. The middle name
  is followed by the father’s last name, which is followed by the mother’s last
  name. Traditionally, wives keep their maiden names and add on their 
  husband’s names in the following form:maiden name, followed by "of" (de),
  followed by husband’s last name.

· Some Hispanic surnames are not Spanish. The founding father of Chile was
  named O’Higgins, and the presidents of Peru, Argentina and Chile have been
  Fujimori (Japanese), Menem (Syrian) and Aylwin (Welsh). Family Structures

· Familismo–Hispanics/Latinos tend to view the family as a primary source of
  support. Families are broadly defined, close knit, and emotionally and
  financially supportive. Family often includes  non-blood-related persons,
  including compadrazgos (when a couple baptizes the child of another). Some
  non-Hispanics interpret these family characteristics negatively as over - 
  involvement or dependence.

· The eldest male is typically the authority figure, and gender roles are
  traditional.

· Important decisions are made by the whole family, not the individual.

· Elders often provide childcare so that children and spouses can work.

· In traditional Colombian families, children are highly protected and very
  dependent on their parents. They are expected to live with their parents
  until they marry. Punishment is often emphasized over positive rewards.
  Children are taught to avoid confrontations with their parents and older
  persons, and to be obedient, respectful, and shy.

Communication and Social Interaction

· Personalismo–This refers to the tendency of Hispanics to place utmost value
  on individuals as opposed to institutions. They tend to trust and cooperate
  with individuals they know personally, and many dislike impersonal and formal
  structures. Hispanic customers may identify a health worker by name rather
  than by job title or institution. In a professional situation, many expect
  formality in address (Mrs. X), but also personalismo (how are your kids doing
  in school?).The quality of a social interaction is often seen as more important
  than length.

· Respeto–The special consideration and respect that should be shown to
  elders and authority figures within the community. When speaking Spanish,
  elders should be addressed as usted, not tu.

· Simpatía–This describes many Hispanics’ preference for smooth social
  relations based on politeness and respect, as well as avoidance of
  confrontation and criticism. Overt disagreement is not considered appropriate
  behavior. Some expect offers of gifts or food to follow a pattern of offer,
  refusal, insistence, and final acceptance, so receivers do not appear greedy
  or givers insincere.

· Many Hispanics are characterized by warm, friendly, and affectionate
  relationships. Personal space is close and frequently shared with family
  members or close friends.

· Some Hispanics may get agitated or emotional when nervous or frightened.
  They may communicate intense emotion and appear quite animated in
  conversations–a behavior that is sometimes misperceived by non-Hispanics
  as being "out of control." Latinos’ voice pitch and inflections are sometimes
  misinterpreted as confrontational. Many are very loud and outspoken in
  expressing pain.

· Many Hispanics, particularly if they were not raised in the US, may avoid
  direct eye contact with authority figures or in awkward situations.

· Many will nod affirmatively but not necessarily mean agreement. Silence may
  mean failure to understand and embarrassment about asking or disagreeing.

· Many may understand English better than they can speak it, especially under
  stress.

· Modesty and privacy are important. Stigmatized health issues should be
  discussed through an interpreter and not family members. When a family
  member is used as interpreter, if the issue is personal, try to use a family
  member of the same gender. Sexuality issues are hard to discuss. Often the
  word for sex (sexo) is not even used–tener relaciones (to have relations) is
  used instead.

Time Orientation

· Time and punctuality may be flexible. Social gatherings are often expected to
  start later than the announced time.

· Many Hispanics are averse to a hurried pace, especially given the
  expectation of personalismo.

· 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.

· 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.

· 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.

Concept of Health

• Health is generally viewed as: being and looking clean; being able to rest and
  sleep well;feeling good and happy; having the ability to perform in one’s
  expected role as mother / father, worker, etc. In Puerto Rico, the phrase
  llenitos y limpios (clean and not too thin) is used.

• A person’s sense of bienestar (well-being) is thought to depend upon a
  balance in emotional,  physical, and social arenas. Imbalance may produce
  disease or illness. Some attribute physical illness to "los nervios", believing
  illness results from having experienced a strong emotional state. Thus, they
  try to prevent illness by avoiding intense rage, sadness, and other emotions.
  Depression is not talked about openly; a person may say, "I am sad" (triste).

• Eating well and drinking fruit juices are common health promotion practices.
  Exercise is often not perceived as a health promotion practice and is
  discouraged during illness. As with other issues, this will vary by educational
  level.

• Individuals may not seek help until they are very sick.

• Hispanic cultures view illnesses, treatments, and foods as having "hot" or
   "cold" properties, although how these are ascribed may vary by country.
   Some consider health as the product of balance among four body humors
   (blood and yellow bile are "hot", phlegm and black bile are "cold"). One would
   balance a hot illness with cold medications and foods, etc. This might
   result in not following a doctor’s advice to drink lots of fluids for a common
   cold, if one believes such drinks add more coldness to body. Instead, hot
   liquids (teas, soups, broth) could be recommended. Colombians often use
   meat broth instead of chicken soup when sick; also drink agua de panela
   (unprocessed sugar and water) for respiratory/flu symptoms.

• Prevention strategies could build on this concern for balance – e.g., adopt a
  balanced diet to prevent diabetes and other diseases associated with
  overweight.

• Some common illnesses and their accepted causes:

Ataque – severe expression of shock, anxiety, sadness

Bilis – vomiting , diarrhea, headaches, dizziness, migraine, nightmares, loss of appetite, inability to urinate, brought on by livid rage and revenge fantasies. Believed to stem from bile pouring into bloodstream in response to strong emotion.

Empacho – lack of appetite, stomachache, diarrhea, vomiting, caused by poorly digested or uncooked food. Treated by massaging the stomach and drinking purgative tea, or by azarcon or greta, medicine that has been implicated in some cases of lead poisoning.

Mal de ojo (evil eye) – Vomiting, fever, crying, restlessness, brought on by an admiring or covetous look from a person with an evil eye. Children susceptible. Preventable by wearing particular jewelry.

Pasmo – tonic spasm of voluntary muscle; chronic cough or stomach pain; arrest of child’s growth and development, all brought by exposure to cold air when body is overheated.

Susto (fright) – anorexia, insomnia, hallucinations, weakness, painful sensations, brought on by traumatic experiences. Treatment may include a barrida (spiritualistic cleansing by sweeping body with eggs, lemons, bay leaves), herb tea, prayer.

Asthma may be called fatiga by Puerto Ricans.



Source: Rhode Island Department of Health
Providence, RI

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