Medical Culture in Latin America: Faculty from the Wake Forest University School of Medicine faculty who plan to visit Nicaragua are likely to find significant differences in facilities, staffing, and procedures. Some of these differences will be based on economics—given Nicaragua’s low per capita income, you will find facilities more Spartan and equipment less modern. But some differences will also be related to culture. Popular beliefs about disease and treatment are different than what one finds among most U.S. residents, and the distinctions are particularly marked in rural and/or less educated populations.
One important point to keep in mind is the question of Functional Health Literacy (FHL). Most studies find that Latin American immigrants in the U.S. have significantly lower FHL than the general population, which suggests that, in general, FHL levels are lower in Latin America than in the U.S. Educational attainment plays a major role in FHL, and in many parts of Latin America, especially in rural areas, educational standards are low. Nicaragua is a particularly acute example: a third of the population is illiterate, and poverty continues to be a pressing issue. Among poor and poorly educated populations, misconceptions and traditional medical practices are likely to be more prevalent.
One area where traditional beliefs are noticeable is in diagnosis. A number of medical phenomena are known by popular or folk labels in parts of Latin America. For example, many Latin Americans are familiar with empacho, which is often blamed for vomiting, diarrhea, bloating, and/or stomach cramps. It is believed that the condition results from eating too much, eating too fast, or eating the wrong combination of foods. Some home treatments, such as herbal teas and abdominal massages, do no harm, but some folk remedies present significant risks of lead poisoning. Also, symptoms of empacho may be confused with gastroenteritis, appendicitis, and other serious medical conditions. Mollera caída, or fallen fontanelle, is believed to be caused by withdrawing a nursing infant too quickly from the breast, causing the fontanelle to “sink in,” which leads to difficulties nursing. Symptoms may also include fussiness, fever, and diarrhea. Home treatment aims to correct the problem by pushing upward on the pallet, gently pulling the hair over the fontanelle, or holding the infant upside down and tapping the feet, sometimes with the head partially submerged in hot water. Apart from the health risks inherent in the treatments themselves, the symptoms of mollera caída may indicate severe dehydration. The balance of “hot and cold,” or “calor y frío,” in the body is also believed to be related to common diseases. Weather changes, consuming hot or cold food/beverages, or getting wet are sometimes believed to be the cause of fevers, coughs, and rashes. Acceptance of these folks illnesses, and others like them, may lead some Latin Americans to delay seeking medical treatment until home remedies have proven ineffective. This can result in patients presenting with more advanced symptoms. Clinicians should be careful to be sensitive and respectful regarding folk illnesses and popular home remedies. Displaying a judgmental or condescending attitude may offend a patient and reduce the likelihood of him/her returning for follow-up visits.
The doctor-patient relationship is another aspect of medical treatment that is strongly influenced by culture. When Latin Americans seek medical attention, they typically expect a higher level of interaction with their health care providers than is common in the U.S. Because the personal relationship is so vital in all areas of life (See the article on “Latin American Culture”), most Latin American patients want to develop trust with their physicians and want to know that the physician is sympathetic and interested in the patient as a person. If patients feel the physician is rushing and isn’t taking the appropriate time to get to know them, they are less likely to provide complete details about their medical condition. The lack of positive relationship may also impede complete adherence with the doctor’s instructions for treatment.
Another key element of the doctor-patient relationship is respect. Because respect and personal honor are more important to most Latin Americans than to most Americans, it is important that U.S. health care practitioners understand the expectations that are common in most Hispanic countries in the clinical environment. Patients usually have a high degree of respect for medical personnel, both because of the authority position they occupy and because of their high level of education. (See the discussion of Power Distance in “Latin American Culture.”) The other side of that, of course, is that Latin American patients feel they deserve respect and consideration as well, particularly if they are older than the health care provider. Using usted (Ud., the formal “you”) rather than tú (the informal “you”), and addressing patients formally—señora López, rather than Verónica, for example—are ways to show the sort of respect patients are accustomed to. A warm handshake, both in greeting and in farewell, and a friendly pat on the arm or shoulder also demonstrate the sincere, personal care that many Latin Americans are accustomed to.
The centrality of the family means that patients are more likely to bring family members with them to a consultation than are U.S. patients. In addition, patients in Latin America tend to seek more involvement from their families in medical decisions. It is important for clinicians to respect patient’s wishes if they bring family members to a medical visit or want to consult with family members before making a decision about care.
Modesty is another cultural difference between Latin America and the U.S. that has a noticeable impact in the clinical environment. Latin Americans traditionally have greater reluctance to discuss issues like sex, sexually transmitted diseases, genital issues, abortion, and domestic violence. They may also feel more uncomfortable in uncovering or even speaking about their own private parts. The reluctance to talk about these kinds of issues is particularly acute in the case of a female patient who is dealing with a male doctor; in surveys, Latinas usually express much higher preference for female health care providers than American women do. Also, having a patient describe his/her condition by referring to a chart or picture may help.
Some cultural researchers caution that achieving cultural competence should not be reduced to printing out a “fact sheet” or memorizing a list of supposed “cultural beliefs.” Rather, health care providers should focus on becoming familiar with the individual patient’s level of FHL and strive to understand not only the specific condition that prompted the visit but also lifestyle or other issues that may be contributing factors, and any home treatments the patient may already have tried. Practitioners can sensitively inquire whether a patient has been using herbal or home remedies, suggest replacing harmful treatments with safer ones that fit within the patient’s belief system, and recommend conventional treatments as needed.
Before concluding this discussion of medical culture, it will be helpful to include some observations about the health care system in Nicaragua. During the time when the Sandinistas were in power (1979-90; See “Nicaragua—History”), the government placed great emphasis on improving medical care for poor and rural Nicaraguans. Despite the modest gains made during that period, however, medical care in Nicaragua remains very rudimentary. Basic medical attention is available in many of the smaller cities and towns, but treatment for many serious conditions is either unavailable or only available in Managua. Dengue fever, malaria, and other tropical diseases remain common, particularly in the Atlantic coastal region, and tap water is not safe to drink. In terms of access to quality care, government employees participate in a fairly good state-run health system, but the rich go to private hospitals or seek health care out of the country, and the vast majority of the population only has access to public clinics, which are generally under-funded and under-staffed.
Brice, Jane, H., et al. “Health Literacy among Spanish-Speaking Patients in the Emergency Department.” Journal of the National Medical Association 100.11 (Nov. 2008): 1326-32.
Britigan, Denise H., Judy Murnan y Liliana Rojas-Guyler. “A Qualitative Study Examining Latino Functional Health Literacy Levels and Sources of Health Information.” Journal of Community Health.
(Online publication, available in PubMed).
Cortés-Gallo, Gabriel, et al. “La cura del empacho: una práctica común y peligrosa.” Boletín médico del Hospital Infantil de México 50.1 (1993): 44-47.
Flores, Glenn. “Culture and the patient-physician relationship: Achieving cultural competency in health care.” Journal of Pediatrics 136.1 (Jan 2000): 14-23.
Julliard, Kell, et al. “What Latina Patients Don’t Tell Their Doctors: A Qualitative Study.” Annals of Family Medicine 6.6 (Nov-Dec 2008): 543-49.
Lopez, Rebecca. “Use of Alternative Folk Medicine by Mexican American Women.” Journal of Immigrant Health 7.1 (Jan 2005): 23-31.
Saha, Somnath, José J. Arbelaez y Lisa A. Cooper. “Patient-Physician Relationships and Racial Disparities in the Quality of Health Care.” American Journal of Public Health 93.10 (Oct 2003): 1713-19.
Sobralske, Mary. “Machismo sustains health and illness beliefs of Mexican American men.” Journal of the American Academy of Nurse Practitioners” 18.8 (Aug 2006): 348-50.
Zink, Therese. “Antibiotics, Por Favor.” Minnesota Medicine (Nov 2007). http://www.minnesotamedicine.com/PastIssues/November2007MinnesotaMedicine/PerspectiveNovember2007/tabid/2341/Default.aspx
U.S. State Department travel information on Nicaragua (See “Medical Facilities and Health Information” )-- http://travel.state.gov/travel/cis_pa_tw/cis/cis_985.html