Hispanic/Latino Cultural Competencies and Healthcare

Hispanic/Latino culture has certain cultural nuances or unwritten rules that govern social interactions. These unstated rules may impact the way in which individuals perceive, seek, and receive services. Common cultural characteristics for Hispanic/Latinos in the United States include family, or la familia; respeto or respect; personalismo; confianza or trust; and espiritu or spirit.

La familia (family): Family involvement often is critical in the health care of the patient. Traditionally, Hispanic/Latinos 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/Latino people frequently consult with other family members and often ask them to come along to medical visits. Hispanic/Latino 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.

Respeto (respect): For Hispanic/Latinos the intimate confines of extended families, close-knit Hispanic/Latino communities, and traditional patriarchal networks are mediated by respeto (respect). Respeto implies a mutual and reciprocal deference. Respeto dictates appropriate deferential behavior towards others based on age, sex, social position, economic status, and authority. Older adults expect respect from those younger, men from women, adults from children, teachers from students, employers from employees, and so on.

Personalismo: Hispanic/Latinos tend to stress the importance of personal relationships, which is why so many Hispanic/Latinos continue to rely on community-based organizations and clinics for their primary care. Hispanic/Latinos 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 Rivas with, "Buenos Días, Señora Rivas. 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.

Confianza (trust): Over time, by respecting the patient's culture and showing personal interest, a health care provider can expect to win a patient’s confianza (trust). When there is confianza,    Hispanic/Latinos will value the time they spend talking with their health care providers and believe what they say. Confianza means that the provider will have their best interests at heart.

Espiritu (spirit), body, and mind: Health care professionals often work within the structures of mainstream medicine, which provides separate physical and mental health care. Hispanic/Latino culture, on the other hand, tends to view health from a more synergistic point of view. This view is expressed as the continuum of body, mind, and espiritu (spirit).

Strengths and Protective Factors in Hispanic/Latino/Latino Families and Communities

This section highlights some of the cultural characteristics that transcend historical and cultural differences among the many Hispanic/Latino populations living and working in the US. These characteristics serve as strengths and protective factors for Hispanic/Latino patients, their families, and their communities.

La familia (family): Hispanic/Latino 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. Including family members in the consultation is often critical to the care of the patient and may contribute to a patient’s ability to adhere to the recommended treatment.

Respeto (respect): 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/Latino patients tend to look forward to what the health care provider has to say and value the direction and services.

Confianza (trust): The provider who is able to establish a bond of trust or confianza, with his or her Hispanic/Latino 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 a patient, the provider may also come to appreciate the Hispanic/Latino view of health. Remember that with confianza there is compliance (adherence). Health care brokers, community-outreach workers, or promotoras can play a key role in establishing trust with a new provider.

• Personalismo: Warm, friendly, and personal providers who take an active interest in the patient’s life are more likely to earn the loyalty, respect, and confidence of their clients.
• A network of hundreds of local community-based organizations has emerged in almost every Hispanic/Latino community in America. For the past 30 years, these organizations have acted as frontline advocates for and providers of Hispanic/Latino health care and social services.
• Within the Hispanic/Latino community there is an extensive practice of traditional medicine carried out by curanderas, espiritistas, or healers. In urbanized barrios this tradition has been carried on in part by Hispanic/Latino pharmacists, familiar with both traditional treatments like té de manzanilla (chamomile tea) as well as modern prescription medicines such as antibiotics. Many Hispanic/Latinos will use traditional medicine in combination with other approaches.

Challenges to Health and Well-Being of Hispanic/Latino/Latino Communities

Hispanic/Latinos share a range of sociocultural characteristics that can impact their health status within the United States. Many cultural factors impact favorably on their health status, and these can be considered strengths and protective factors.

Distance from family and inter-generational family conflict

Migration and separation from family may cause stress in Hispanic/Latino patients who are used to making decisions in collaboration with other family members. The values of young immigrant workers or couples newly arrived in the United States may clash with those of other family members. 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.

Patient concerns about respect

Out of a sense of respeto many Hispanic/Latino 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.

The desire for personalismo in the provider-patient relationship

When asked in focus groups where they received their medical care, the majority of Hispanic/Latinos named their personal health care provider rather than their health care institution. Hispanic/Latino loyalty to the individual provider has significant implications for continuity of care. If a health care professional leaves a health center for another in close proximity, their Hispanic/Latino patients may follow him/her to the new setting. If the health professional leaves the area however, their Hispanic/Latino patients may 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, the eight-minute visit, and physician rotations in public clinics.

The need for confianza (trust)

Confianza is increasingly difficult to achieve these days due to the dramatic changes occurring in the health care system. For example, long-term provider-patient relationships are less common as physicians rotate in public health settings, clinicians are limited in the amount of time they can spend with each patient, and health maintenance organizations and other institutions reduce their coverage and treatment of the poor. Yet patient confianza in the provider is central for identifying and treating health concerns and encouraging patient adherence to recommended treatment.

Mental Health

Hispanic/Latino patients may view mental health problems as a sign of weakness, and these problems may carry stigma. Consequently, physical symptoms may be a more appropriate conduit for support. Hispanic/Latinos have a high incidence of mental health problems, particularly depression, anxiety, and substance abuse. A major contributing factor involves the stressors of cultural transition caused by immigration, acculturation, and biculturalism. These stressors are often manifest in feelings of irritability, anxiety, helplessness, and despair. Hispanic/Latinos may mourn the loss of family, friends, language, and culturally determined values and attitudes. These reactions are not signs of individual pathology, but rather normal responses to the often-disruptive process of change.

Stressors

Several stressors are related to social adjustment to the dominant culture which affect several generations of Hispanic/Latinos. Three stressors are:

• Acculturative stress, most typically felt by immigrants who are faced with the turmoil of leaving their homeland and adapting to a new society.
• Socioeconomic stress, often experienced by ethnic minorities who feel disempowered because of inadequate financial resources and limited social class standing.
• Minority stress, which refers to the tensions that minorities encounter resulting from racism.

Alcohol and substance abuse

Another lifestyle issue facing the Hispanic/Latino community is excessive alcohol use that can, over time, cause serious medical problems, as well as increase the more immediate risk of accidents and violence. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), Hispanic/Latinos vary markedly in their prevalence of substance abuse, alcohol dependence, and need for illicit drug abuse treatment. Relative to the total population, Mexicans and Puerto Ricans have high prevalence of illicit drug use, heavy alcohol use, alcohol dependence and need for illicit drug abuse treatment. In contrast, Caribbeans, Central Americans, and Cubans have low prevalence and South Americans, and other Hispanic/Latinos have prevalence similar to the total US population.

Principles for Culturally Competent Health Services for Hispanic/Latino/Latino Families and Communities

Culture plays a key role in our ability to influence behavior in a patient. We cannot afford to let cultural barriers limit our ability to meet the needs of our patients, or reduce their opportunity to benefit from the services we can provide. Perhaps nowhere are cultural differences more sharply drawn than in our approaches and definitions of health and healthy living. By deepening our understanding of culture we can strengthen the promise of high-quality primary health care that is accessible, effective, and cost efficient for all patients.

Involve family members: Hispanic/Latino families traditionally emphasize interdependence over independence and cooperation over competition. Family members are more likely to be involved in the treatment and decision-making process for a patient. Allow for several family and friends to participate in a consultation, and communicate with the group. The patient may not be the key decision-maker for describing symptoms, deciding among treatment options, or complying with recommended treatment. Determine the matriarch and patriarch, and notice if the acculturated children or non-family members are the spokespeople.

Show respect: Always be respectful, and explain without condescending. Health providers, as authority figures, need to take seriously the responsibility and respeto conferred on them by many Hispanic/Latino patients. One way Hispanic/Latinos show respect is to avoid eye contact with authority figures. Do not misinterpret this respectful behavior as a sign of disinterest. Address elders in traditional ways (such as below eye level if you’re younger than they are), and be mindful of parents and elders when an acculturated child or a health mediator is the spokesperson. The older Hispanic/Latino adult patient may terminate treatment if he or she perceives that respect is not being shown.

Get personal: Hispanic/Latinos typically prefer being closer to each other in space than non-Hispanic/Latino whites do. When non-Hispanic/Latino providers place themselves two feet or more distance away from their Hispanic/Latino patients, they may be perceived as not only physically distant but also uninterested and detached. Overcome such perceptions by sitting closer, leaning forward, giving a comforting pat on the shoulder, or other gestures that indicate an interest in the patient.

Encourage the asking of questions: Out of a sense of respeto, many Hispanic/Latino patients will avoid disagreeing with or expressing doubts to their health care provider about the treatment they are receiving. They may be reluctant to ask questions or admit they are confused about instructions or treatment. There 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.

Respect traditional healing approaches: In recent years, there has 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. Hispanic/Latino patients may combine respect for the benefits of mainstream medicine, tradition, and traditional healing, with a strong religious component. They may bring a broad definition of health to the clinical or diagnostic setting. Respecting and understanding this view can prove beneficial in treating and communicating with the patient. It is also culturally competent.

• Some Hispanic/Latino people believe that disease is caused by an imbalance between hot and cold principles. Health is maintained by avoiding exposure to extreme temperatures and by consuming appropriate foods and beverages. Examples of "hot" diseases or states are pregnancy, hypertension, diabetes, and indigestion. "Cold" disease examples include menstrual cramps, pneumonia, and colic. The goal of treatment is to restore balance. "Cold" diseases are treated with "hot" remedies, and vice versa. Inter- and intra-group variations exist with regard to beliefs about the hot and cold theory of disease.
• Traditional medicine in most Hispanic/Latino countries has an extensive list of folk remedies. Examples include using garlic to treat hypertension and cough; chamomile to treat nausea, gas, colic, and anxiety; a purgative tea combined with stomach massage to cure lack of appetite, stomach pains, or diarrhea; and peppermint to treat dyspepsia and gas.
• Providers may encounter the concept of a bilongo or hex, for which the proper diagnosis and treatment require consulting a santero/santera or healer.
• The evil eye (mal de ojo) appears in several Hispanic/Latino cultures. In children, it is thought to cause vomiting, fever, crying, and restlessness. It is believed to be brought on by an admiring look from a person with a strong eye. It can be diagnosed and treated with a barrida (Puerto Rico) or limpia (Mexico)—a sweeping of the body with eggs, lemons, and bay leaves, accompanied by prayer.

Used with permission from: Management Sciences for Health