UNDERSTANDING the culture of a community, that is, shared beliefs, values, and behaviors,1 helps us appreciate the meaning which the community attributes to life experiences. From a health promotion perspective, we are particularly interested in the meaning that different populations ascribe to health within their larger cultural context. Health promotion, by definition, involves influencing behaviors, attitudes, and knowledge, all of which rest on the foundation of culture.2 Thus, all health promotion activities practiced by healthcare professionals are filtered through the very unique cultural interpretation of the target group. To provide services in a way that is meaningful to the populations we serve, we need to offer choices and counsel in a way that culturally makes sense to them.
We should be concerned with cultural practices in health because research shows that such practices have a very real impact on health outcomes. Consider the example of social support. Quality of social support from family, a practice highly driven by culture, has been shown to have significant consequences for health. Among Mexican American immigrant women, social support is a major factor predicting their excellent birth weight outcomes in spite of very low socioeconomic levels and poor use of prenatal care.3 Similarly, among the elderly, health and well-being are closely tied to the availability of social support.4 Social support has also been found to be a significant mediator in the recovery process of persons with a wide range of illnesses, from depression5 to brain injury6 and to heart disease.7 Social support helps patients emotionally manage their illness, engage in required treatment behaviors, and obtain material resources. So if we wanted to understand, encourage, and foster social support for individuals and groups, we would need to recognize how social support is manifested in the cultural world these individuals belong to and how they view and assume caretaking responsibilities. As with social support, there is a wide range of family and social practices that also affect health and are uniquely negotiated on the basis of culture.
Nevertheless, there is still much misunderstanding about culture and health. The use of culture to explain health outcomes has been critiqued as resting on unexamined foundations as well as reflecting serious biases. In a review of the literature, Kao et al8 found that cultural explanations of health outcomes are still based on mainstream interpretations; furthermore, when culture is found to have an impact on health outcomes, culture itself becomes a potential object of professional intervention (rather than, for instance, focusing on better outreach strategies). Furthermore, on the basis of their analyses of current studies on Latino health, Hunt and her coauthors9 draw attention to the routine failure to account for the effect of socioeconomic inequalities in the study of the impact of culture on health, despite the fact that significant disparities in quality of care and access faced by the Latino population are well documented.10-12 Thus, it is important to have a precise conceptualization of culture, one that is holistic rather than fragmented, and one that is contextual rather than one dimensional. We need to understand the mechanisms through which culture has an impact on health behaviors and outcomes, rather than simply attribute differences in risk or outcomes to an undefined element of culture. We also need to understand correlations between culture and other hidden or underlying causes that may moderate or mediate the impact of culture.
In this article, we focus on the cultural experiences of women and their families in the Mexican American population and their relevance to health promotion, with an emphasis on family and social context. Expanding this understanding can help us reach this often significantly underserved population. Our aim is to shed light on these issues by synthesizing a wealth of research that has been conducted about Mexican American cultural perceptions of health and health behaviors and then uncovering emerging patterns. First, we attempt to provide a comprehensive view of the cultural framework of this population based on a review of recent empirical studies. We examined a wide range of studies on the health perceptions and health behaviors of Mexican Americans in relation to a variety of health matters and on their relationship with the healthcare system. We identified empirical studies by conducting a search using relevant library databases (Academic Search Premier, Web of Science, EBSCOhost Research Databases, Social Services Abstracts, Chicano Database) using the terms "health," "health perceptions," "health care," "culture," "Mexican American/Latino/Hispanic," "women," and "families." We then selected studies that investigated various aspects of specific cultural values and grouped them together. We also attempted to use studies that represented a variety of research methods, including ethnographic methods, focused individual and group interviews, and population-based surveys. Findings were drawn from studies done exclusively on Mexican Americans, but when relevant also included studies on Latinos that included the subgroup of Mexican Americans.
Second, we highlight recent innovative culturally competent practices with this population that reflect the more complex view of Mexican American culture found in the empirical research. We identified programs using various relevant library databases (PubMed, in addition to the ones listed above) as well as Internet searches for programs described on the World Wide Web using the terms "underserved populations," "minorities," "outreach," "innovative," "Mexican American/Latino/Hispanic," "women," and "families." After an extensive review of programs, we selected programs that were illustrative of creative strategies and that have been implemented within about the last decade.
CULTURAL RESPONSES TO HEALTH
Mexican American culture has been characterized in the literature by a relatively accepted framework of values: familism, respeto and simpatia (respect and congeniality), curanderismo (folk healing), religiosity/spirituality, and the importance of language, among the most important. Recent research suggests a richer, more dynamic conceptualization of the cultural interpretations of health in this population than a simple list of terms can provide. Our review of the literature focuses on 3 dimensions of this complexity: (1) how cultural expectations and beliefs are shared and work complementarily in the family and the larger social context; (2) how cultural beliefs can be a source of tension and stress with significant consequences for health; and (3) how cultural characteristics can be less central than other variables when it comes to dealing with the healthcare system, such that healthcare use patterns more accurately mirror problems related to access and availability of resources and concerns with quality of care. Based on illustrative cases, this section elaborates on how each of these scenarios plays out.
Shared cultural expectations: Beliefs about social support vis-a-vis caretaker behaviors
Familism, a strong sense of family care and obligation, is considered an important Mexican American cultural value. However, familism is based on relationships between family members. That is, to understand the concept of familism, it is necessary to examine how the family as a unit incorporates this value. A review of empirical studies shows that it is shared expectations by family members that facilitate the realization of familism. One area in which research on Mexican American familism has been developed in depth is the case of social support and aging. Bringing together studies on familism and aging reveals the complex dynamics related to expectations of social support from family on the part of elderly members vis-a-vis a sense of responsibility for caregiving on the part of family members.
Familism is part of the health perceptions of Mexican American elderly people and has consequences for their health outcomes, according to several studies. Ethnographic research shows that older Latina women view health not as the absence of illness; rather, they see the decline of health as natural and anticipated.13 Thus, they embody a perspective that McCarthy et al call collectivist, in that health and illness are connected to an interdependence with family-elderly expect care from family as they become more frail. This is in contrast to a non-Latino White individualist perspective, in which, according to the study, loss of health is perceived as the loss of one's independence and becoming a burden on family. Thus, among Latino elderly, positive perceptions of aging and responses to health problems are significantly dependent on a high level and quality of social support from children and other family members. For immigrants, positive perceptions are influenced by the extent to which such cultural expectations from their home country are maintained.14 On the other hand, Latino elderly who do not have strong family support may also lack needed professional care. A study based on US national survey data showed that, given similar needs, Latino elderly with disabilities who were isolated and lacked family support were less likely to take advantage of paid in-home long-term care services. However, when children lived nearby, the elderly had a higher probability of receiving services.15
Given the importance of social support for health among Mexican American and other Latino elderly, what sense of responsibility do their caregivers feel? This is a particularly significant issue for women, who tend to take caregiving roles. What research on caregivers shows is that, indeed, familism leads to family taking care of elderly, even when it is a burden.16 The provision of social support by caregivers decreases the probability of institutionalization of Latino elderly.17 However, decisions about caregiving are tempered by various factors. For instance, despite the durability of familism, serious impairment, such as advanced age, disability in activities of daily living, and cognitive impairment, can overwhelm a family support network, perhaps resulting in institutionalization. Consequently, Latino caregivers negotiate tensions between the cultural demands of family caregiving and the practical demands of their individual circumstances. In the case of elderly with dementia, placement is seen as a last resort, taken when caregivers lack adequate support, when their own health is poor, and when patient behavior becomes problematic.18 However, even when a family member must be institutionalized, caretakers remain deeply involved in his or her daily care. Another strategy used in some Mexican American communities is for caregivers to rely on adult day care, which allows them to keep their elderly family members living at home and out of nursing homes. According to the Texas Department of Aging and Disability Services,19 the majority (60%) of the entire state's licensed adult day care facilities are concentrated in South Texas, an area with the highest concentration of Latinos in the state.
Managing tensions between cultural values and competing pressures
In some situations, cultural values create tensions for Mexican Americans in the face of competing pressures such as unfulfilled support, poverty, or stigma. One form of tension can be observed when family members need to seek help outside the family. In families, nurturing involves relying on immediate and extended family for emotional and material support as well as for information. Meanwhile, relying on coworkers, neighbors, and health and social service professionals can be minimal.20 Because of the importance placed on strong reliance on family, when family support is weak or problematic, family members' needs are sometimes left unfulfilled. In-depth ethnographic interviews show that women who do not receive the family support they need experience feelings of emotional imbalance as well as physical ailments.21
In the same way, structured interviews with caregivers (most of whom were women) of Alzheimer's patients showed that stronger adherence to Latino cultural values of family support and a reluctance to seek outside help-even when they were aware of the availability of services and support groups-led to greater incidence of depression and stress.22 Certainly, in spite of the burden that family members may place on themselves, family support alone cannot compensate for the lack of access to resources. For example, a study conducted by Sherraden and Barrera23 of pregnant Mexican immigrant women in Chicago showed that although family support generally improves birth outcomes, it does not protect women living in extreme poverty. Thus, efforts of caretakers in very disadvantaged families may be undermined and fail to serve as a protective mechanism against health problems.
In other instances, adherence to cultural values can impel Mexican Americans to hide aspects of their lives that they may feel their families will not accept. For example, Latino parents with children who have been diagnosed with attention-deficit/hyperactivity disorder can be stigmatized by their families and often keep their child's condition a secret because their child's behavior does not fulfill cultural expectations that children should exhibit good manners (respeto).24 It is important to note that such families do generally seek information and professional treatment. In other cases, the consequences of secrecy in the face of disapproval can be damaging. For example, a large multimethod study showed that gay Latino men who come from families who are intolerant of homosexuality reported feeling that they must hide their homosexual relationships to remain connected to their families. As a result, although they have the knowledge and skills to engage in healthy sexual behaviors, they often resort to anonymous encounters and other unsafe sexual practices.25
Overriding concerns with access and quality when dealing with the healthcare system
In some situations, cultural factors seem to be less important for Mexican Americans than securing needed healthcare as well as the quality of that care. This may reflect the fact that people make use of healthcare to the extent that they have access to it. Latino healthcare perceptions are similar to those of non-Latino Whites and Blacks, such as concerns about humanistic care from healthcare professionals and being treated with dignity, while other elements are specific to Mexican American patients.26 Mexican Americans, non-Latino Whites, and non-Latino Blacks perceive the same factors affect the quality of their medical encounters: physician sensitivity to alternative medicine, ethnic concordance of physician and patient, and discrimination based on health insurance coverage, social class, and age. Some issues relevant to Mexican Americans are also of concern to Blacks, including spirituality, family, and ethnic-based discrimination. Latino-specific issues include language and immigration.
An in-depth ethnographic study of how Mexican American women perceived prenatal care showed that they defined culturally congruent healthcare in ways that reflected relatively universal expectations of genuine concern and thoughtful and professional care. Mexican Americans emphasized themes that reflected the importance of personal processes of healthcare (respeto/ respect, caring, understanding, and patience). For women with limited English, the availability of Spanish-speaking healthcare providers was an additional concern.27 Aside from these general issues, people also cared about the inclusion of family in healthcare decisions and attention to spirituality.28
Issues of access surfaced in a variety of qualitative studies on Mexican American healthcare utilization. Caregiver lack of knowledge about Alzheimer's disease, rather than culturally related beliefs, was the major reason for Mexican Americans' failure to seek an assessment for an elder. In addition, more problematic than language or ethnic differences was physicians' failure to recognize the disease.29 The lower rate of use of skilled home care nursing services by Latino elderly has been shown to be associated with various barriers. Although expectations related to familism and preference for traditional remedies play a role, barriers also include expectations of discrimination, lack of knowledge about services, and lack of health insurance.30 Many Mexican American elderly face problems of access, including lack of transportation, to obtain health and social services in general.31
Mexican American cultural practices do influence healthcare use, but the relationship is complex. Of particular importance in the Mexican American population is curanderismo, folk-healing practices, which continues to be an important aspect of Mexican American culture. Often incorporating a religious component, curanderismo encompasses spiritual and emotional elements beyond the physiologic components of health.32 A review of ethnographic studies conducted across the life span reveals how Mexican Americans consistently integrate cultural strategies, such as curanderismo, with conventional health methods and Western medicine in everyday life, which means that people do not view curanderismo and modern medicine as incompatible. One study33 showed that in raising their children, mothers maintained family health by providing good nutrition, exercise, and regular preventative healthcare. Although they used traditional Mexican teas, soups, or rubs, they also relied on over-the-counter medications and medical diagnosis to treat illness. Use of cultural healers was minimal. Mexican American elderly research subjects, according to a study conducted by Applewhite,34 did not rely solely on curanderismo to maintain family health but also sought assistance from modern medicine when they experienced more serious or chronic illness, even when they grew up with a tradition of curanderismo and maintained that tradition when raising their own children.
TOWARD A MORE CULTURALLY COMPETENT PRACTICE
Various innovative culturally competent strategies to promote health and healthcare access in this population have been developed that reflect the complex ways that Mexican American women and their families integrate cultural practices within their social context. These strategies work by reconceptualizing culture as a strength rather than as a barrier, promoting community-level outreach methods, and increasing healthcare access by tackling system barriers.
Reconceptualizing culture as a strength
Research literature about cultural considerations in healthcare for different cultural groups has often focused on culture as a barrier to healthcare. For instance, familism, respeto and simpatia, curanderismo, and the use of the Spanish language have been described as barriers that are so embedded in Mexican American culture that it is difficult for the healthcare system to respond effectively.30,31,35 More responsive approaches treat these cultural attributes as strengths, not barriers, and consider them as part of the larger experience of this population. Thus, such interventions are adjusted to meet the range of cultural responses to health found in this population.
Recent research literature presents strategies to draw on the cultural characteristic of familism as a useful tool in reaching underserved Mexican American women and their families. Fleury et al36 found that emphasis on enduring relationships with kin across generations can be used to encourage Mexican Americans to make behavior changes that benefit their health. This is illustrated in a program called Cuidando El Corazon (Taking Care of the Heart), which focused on the benefits to the family of losing weight. Similarly, Wagner37 presents a strategy that promotes healthcare utilization to Mexican Americans by encouraging individuals to care for themselves for the good of the family. SEARCH, an outreach program in rural Louisiana designed to improve the health status of migrant farm workers, took this idea and provided health education to migrant children; reaching the children would inevitably reach the entire family.38
The use of promotoras, or lay community educators, is another way to use family-orientedness. Promotoras are drawn from the Mexican American community, speak Spanish, and meet regularly with residents of impoverished areas to encourage participation in education, health, job training, human services, housing, and youth and elderly programs.39 In Arizona, a Spanish diabetes education program called La Diabetes y La Union Familiar (Diabetes and Family Unity) provides diabetes education in the homes of Latino families. This program uses promotoras to provide interventions that target the entire family by focusing on family support, communication, and family health behaviors.40
Healthcare professionals can also use respeto and simpatia as principles to guide their communication with Mexican American patients. Mexican American women in one ethnographic study related their desire to have unhurried interactions with healthcare providers, social greetings, and gentleness of technique.41 The women considered these strategies to be signs of respect because the healthcare professionals demonstrated a willingness to listen to their interpretation of what was happening to them and to include them in the treatment process. Another qualitative study that looked at Latina women's perceptions of the quality of their prenatal care indicated that they were less likely to perceive their prenatal care as patient-centered than were non-Latina women.42 The authors suggest group prenatal care (which involves having 8 to 12 women participate in a series of structured 2-hour educational prenatal sessions) so that Latina women can have prolonged interactions with their physicians in addition to their customary appointments. At the same time, because Latinos have a high degree of respect toward authority figures, the role of physicians is especially important for promoting healthcare screening for Latina women and their families. A review of published studies that examined factors influencing breast and cervical cancer screening in Latina women found that physician recommendation was a key cue to action for Latina women.43
Because Mexican Americans who continue to value folk healing tend to use it in combination with modern medical treatment, depending on the illness, offering folk care can draw individuals into professional care.34 One innovative strategy combines these 2 forms of treatment in order to increase the use of the healthcare system: a nurse-curandera, a bilingual nurse trained in folk healing who can provide the benefits of allopathic healthcare with the benefits of using practices that promote patient and family involvement in the healing process.44 The nurse-curandera uses her scientific knowledge to evaluate the safety of a folk remedy or treatment and refers clients to other healthcare providers when appropriate.
Promoting community-level outreach methods
A key approach to reaching Mexican American women and their families is to go through community channels, given that Mexican Americans most often receive service-related information through informal sources, such as family, friends, and neighbors.31 One program in Indiana had a bilingual Spanish-English outreach coordinator visit community centers, churches, and health clinics to present information to Latina women and men about a variety of cancers.45 Other community outreach strategies include doing intensive home visits using bilingual, bicultural nurse extenders who provide information to improve families' skills and increase knowledge46 or using nurse-community health advocates to help increase Latino immigrant families' access to healthcare.47 Partners in Health, a community outreach program, established faith-based and healthcare partnerships to reach women with a message about using cancer clinical screening services.48 In Canada, a group called Latin American Women Support Organization, or LAZO, integrated lay health promotion and participatory research to reach isolated women.49 LAZO trained bilingual women to collect data about their community's needs and provide health education to their peers. Recent strategies also included using mobile health units to reach Mexican immigrants in Colorado and other states.50
Outreach programs in a variety of health areas have been restructured to reach Mexican Americans and often encourage reflection on the impact of culture on their health. One outreach program that targets Latina women is Mujeres Unidas Contra el Sida, Women United Against AIDS.51 This program provides bilingual/bicultural support groups in San Antonio, Tex, for women who have been HIV-infected or affected. It conducts small group presentations and focus groups for Latinas and their families in their homes and other settings where participants can feel comfortable to share in open discussions. They provide education and discussions concerning HIV/AIDS and ways in which Latino parents can best educate their children. A similar strategy is used by Hermanos de Luna y Sol, Brothers of the Moon and Sun, a program targeting Spanish-speaking Latino gay/bisexual men in San Francisco.52 The program seeks to provide a culturally appropriate HIV risk-reduction intervention for participants by promoting critical awareness of social and cultural forces that impact and shape their social and sexual lives. Participants are invited to explore tensions that arise as a result of conflicting cultural expectations from their families (and community) and their ability to lead fulfilling lives as homosexual men.
Increasing healthcare access through information dissemination
Finally, in an effort to increase access to healthcare among underserved Mexican Americans, some other innovative strategies focus on addressing barriers in the healthcare system, rather than focusing on perceived cultural barriers. For example, Ross53 suggests educating the Mexican American population in California on the status of state policies on eligibility for healthcare benefits. He explains that many Mexican immigrants, legal or illegal, do not trust the US healthcare system as a result of the passage of Proposition 187, a 1994 law to prohibit healthcare services for undocumented individuals. (The law was overturned in 1998.) Ross adds that Latinos often are unaware of existing programs to address their healthcare needs.
Another study that focused on education to improve access was piloted in Los Angeles with predominantly immigrant Latina women. The study used a model called SAFe (Screening Adherence Follow-Up), which incorporated health education, counseling, and systems navigation information to influence patient behavior.54 The study educated participants on navigating through the healthcare system so as to empower them to seek follow-up services after an abnormal Papsmear test. Findings for this pilot study included adherence ranging from 83% to 93% of women coming to at least 1 follow-up examination, depending on the type of diagnosis.
Language is an essential part of patient communication within the healthcare system and thus serves as a bridge to healthcare access and quality care for Mexican American women and their families. In recognition of the shortage of Spanish-speaking healthcare professionals, efforts to create ways of increasing language proficiency are under way. For example, in North Carolina, the statewide Area Health Education Center began a Spanish immersion workshop for healthcare professionals. This agency also maintains a Web-based resource of printed materials and videos in Spanish.55
Clearly, an understanding of the cultural factors influencing the healthcare practices of Mexican American women and their families goes beyond simply identifying cultural traits. It is essential to understand how culture plays out in the social context of this population in conjunction with other factors that may affect their interactions with the healthcare system. Although Mexican American cultural values can be consistent with family and social expectations, it is important to recognize that in other situations, pressures in the environment may be at odds with these cultural values and thus cause tensions. This can help explain why in some cases cultural values (eg, familism) seem to play a beneficial role in health but not in others.56 Moreover, cultural values do not determine Mexican Americans' healthcare decisions as much as do issues of access. As a result, an individual's location at the intersection of gender, race and ethnicity, acculturation, and socioeconomic status plays a key role in shaping his or her cultural responses to health.57
Innovative healthcare interventions reflect this more complex understanding of Mexican American culture, resulting in greater cultural competence and congruence. All in all, successful strategies invite healthcare professionals to integrate cultural factors into health promotion activities by adjusting to the needs of families. Specifically, health practitioners need to collect and value as crucial psychosocial information that incorporates cultural aspects of women and their families, including level of acculturation, family support, and material needs.58 Healthcare providers may at times facilitate existing cultural patterns of responding to health problems that fare successfully within families. At other times, they may need to provide alternative sources of support and information when cultural tensions may leave individuals vulnerable to health risks as a result of lack of informal social supports. Finally, while being attentive to cultural concerns, healthcare providers may need to improve access to the healthcare system by offering information about services, eligibility, and application procedures.59