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Quality Health Services for Hispanics: The Cultural Competency Component
 

I. The Basics Chapter Four: Getting to Know the Culture

Closing the cultural gap to the width of a handshake

Both distal space and touching influence the interaction. "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 competency trainings for her colleagues. "Touching, how you make eye contact, the subtle things all count," she explains.  

Key Concept

"Touching, how you make eye contact, the subtle things all count"...


Food preferences, often based on cultural and environmental exposure, affect the following of diet recommendations as preventive lifestyle practices or as an adjunct to treatment compliance. "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 — '¿Que son bagel?' (What's a bagel?)."18 		 


There are certain cultural nuances or unwritten rules that govern social interactions...there will always be individual variation from any cultural norm.


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

Key Concept:

 


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.

   
La Familia — A good starting place for any discussion of Hispanic culture is with la familia, the family.

Hispanic families also traditionally emphasize interdependence over independence, and cooperation over competition....

  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's important for the health care provider to be aware of these issues. In the interest of effective care, such policies may need to be reexamined to allow for more direct involvement of the supportive family network.

Family involvement often is critical in the care of the patient. For many, several family members and extended family members as commadres, compadres, or padrinos will accompany patients to medical visits. Often family members include the very young and very old. They will want to hear what is being said and participate in the interactions.

Thus, the patient/provider conversation may take on a different dynamic. The collective nature of the interaction must be respected by the provider who may be challenged by time constraints and his/her professional training which only focused on one on one interactions. For example, the patient may not be the one responding to the provider's questions or even the one asking questions because he/she may defer to someone in the familial group. The person conversing with the provider may be a spouse, the eldest family member, son/daughter or commadre. Often, the spokesperson will be the person who has the respect and power in the family. Most often, the speaker is the matriarch/patriarch or in many cases in the U.S., it is the more acculturated children.

If it is the children, there is a disruption in the family dynamics. The provider must be respectful and inclusive of the elders even though the younger family members may be the key mediator. The provider must understand the collective nature of this interaction to realize the patient may not be the key decision maker for symptom descriptions, treatment options or compliance.

For Hispanics the intimate confines of extended families, close-knit Hispanic communities, and traditional patriarchal 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 those younger, men from women, adults from children, teachers from students, employers from employees, and so on.

   

Key Concept

Respeto — Respeto dictates appropriate deferential behavior towards others based on age, sex, social position, economic status, and authority.


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.

  Health providers, by virtue of their healing abilities, education, and training are afforded a high level of respeto (respect) 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 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 (respect) 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 respect is not being shown.
...cannot directly ask questions about... alcoholism, domestic violence, mental health problems, and sexual practices.   Another way to demonstrate respect, the provider and other outsiders cannot directly ask questions about problems in the patient's life such as alcoholism, domestic violence, mental health problems and sexual practices. Directly asking these kind of questions may be embarrassing and challenging to the cultural practice of keeping this information within the family. This kind of information needs to be obtained through indirect questioning such as "How often does your husband go out? Have you seen ads about the use of condoms? etc."
    Along with good health care practices such as providing the patient with information about the examination, diagnosis, and treatment; listening to the patients 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.

Specific Points to Remember

  • 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).
  ...you should be more formal in your interactions with older Hispanic patients.
  • 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 a time as the patient explicitly suggests the use of the informal tu.
  A few words spoken in Spanish may become an important cue to people about your positive attitudes towards them.
  • Encourage the asking of questions. Out of a sense of respeto 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. A good general principle: if you are not sure of the culture with which you are working — use formal language and avoid slang or idioms.
   

      Health providers, as authority figures, need to take seriously the responsibility and respeto (respect) 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.

Key Concept

Personalismo — Personal rather than institutional relationships are important.

 
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 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.

The Hispanic loyalty to the individual provider also has significant implications for continuity of care. 		 


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. The 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, the eight minute visit, and physician rotations in public clinics.

  • 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.
  • 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. In an emergency situation the only way to
    immediately communicate may be nonverbal.

Over time, by respecting the patient's culture and showing a 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 may rotate in public health settings, and clinicians 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, or 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.
  • Health care brokers, community outreach workers or promotoras can play a key role in establishing trust with a new provider.
 

Key Concept

Confianza — ...a health care provider can expect to win their confianza (trust).

... the provider who is able to establish a bond of trust, ...of confianza, ...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.

 

Key Concept

Integrated Body, Mind and Espiritu (Spirit)

 

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 espiritu (spirit).

  Health symptomatology often present from the mind/body/ spirit connection. Mental health problems and life's stressors may appear as tight chest pain, shortness of breath, abdominal pain, sweats, and/or chronic illnesses, such as frequent colds or headaches.19 These symptoms have traditional labels such as sustos, peña, attaques de nervios.20 Culturally, each has a specific cause with a non-medication remedy.

Besides not having a separation of mind, body, and spirit, mental health problems are not necessarily validated, are often viewed as a sign of weakness, and may carry stigma. Consequently, physical symptoms are more of a conduit for support. The recovery process afforded physical illness may also afford respite from mental stressors.21

The physical symptoms presented in the U.S. medical system are often mislabeled as somaticizers and mistreated medically for depression.22 Duran found that low acculturated Hispanic women who were labeled with somatic complaints did not present with depression as did the high acculturated U.S. born Hispanic women.

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 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.    

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.
Hispanic patients may bring quite a broad definition of health to the clinical or diagnostic setting.  

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 practicing Catholics), 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 the culturally competent health care professional.

Any good health provider can support the following recommendations.

Key Concept

Healthy Body, Mind, and Spirit23

 

Body

  1. Do not smoke.
  2. Limit alcohol.
  3. Eat healthy meals.
  4. Exercise regularly.
  5. Listen to your body.

Mind

  1. Set limits.
  2. Learn to relax.
  3. Worry less.
  4. Give yourself time for pleasure.
  5. Nurture healthy relationships.

Spirit

  1. Do good acts.
  2. Think good thoughts.
  3. Have quiet time to yourself.
  4. Pray.
  5. Have lots of family and friends around to listen and talk with.

Key Concepts:

Familia, Respeto, Personalismo — Mind, Body, Spirit

Familia — Family

  1. Allow for several family and friends.
  2. Communicate with the group.
  3. Determine the matriarch and patriarch.
  4. Notice if the acculturated children or nonfamily members are the
    spokespeople.

Respeto — Respect

  1. Always be respectful.
  2. Explain without condescending.
  3. Address elders in traditional ways (below eye level if you're younger).
  4. Be mindful of the parents and elders in the room when the acculturated child or a health mediator is the spokesperson.
  5. Ask for questions or a description of what was first heard and experienced.
  6. Indirectly ask personal/private questions such as alcohol use, mental problems, violence, stressors, sex, etc.
  7. Ask permission to touch genitalia after explaining what you are doing and why.

Personalismo — Personal Familiarity

  1. Respect distal space and touching based on familiarity.
  2. Ask about their life (family, friends, work).
  3. Share your own life stories.
  4. Share pictures.
  5. Converse with all of the family members.
  6. Be respectful of gender, do not give an impression of being too familiar.
  7. Make personal notes in medical records to cue provider of family names or special events to discuss on the next visit.

Mind, Body, Spirit

  1. Physical symptoms of stressors, often labeled somatic complaints, may not have the same cultural meaning as the medical model and DSM IV pathology.
  2. Foster psychosocial support and reduce stressors.
  3. When appropriate, use traditional healers and remedies.