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Culturally Competent Nursing Care for Families: Listening to the Voices of Mexican-American Women

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Sandra K. Eggenberger, PhD, RN
Jane Grassley, PhD, RN
Elizabeth Restrepo, PhD, RN

Abstract

Mexican-Americans represent the fastest-growing minority population group in the United States. Gaining a cultural perspective of health care in the Mexican-American population necessitates listening to the voices of women because they assume primary responsibility for maintaining family health. The Transcultural Assessment Model developed by Giger and Davidhizar (2004) provides the framework for this exploration of Mexican-American women’s health care views. From this model the investigators developed an interview guide based on social organization and environmental control. Thematic analysis of interviews with six Mexican-American women revealed the importance of the family, religion, and locus-of-control in the health beliefs, attitudes, and lifestyle practices of this culture. Using the voices of Mexican-American women the investigators seek to promote an understanding of the culture as a guide for nursing care. The purpose of this article is to increase awareness of the Mexican-American cultural phenomena of social organization and environmental control which can guide the nurse to provide culturally competent care that meets the needs of Mexican-American women and their families.

Citation: Eggenberger, S., Grassley, J., Restrepo, E. (July 19, 2006). "Culturally Competent Nursing Care for Families: Listening to the Voices of Mexican-American Women". OJIN: The Online Journal of Issues in Nursing. Vol. 11 No.3.

DOI: 10.3912/OJIN.Vol11No03PPT01

Key words: culturally competent care, environmental control, family health, Mexican-American, social organization, Transcultural Assessment Model

Mexican-Americans represent the fastest-growing minority population and largest Hispanic group currently residing in the United States (Spector, 2004; U.S. Department of Commerce, 2001). In 2000, Hispanics comprised nearly one third of the Texas population with Mexican-Americans representing approximately 75% of this group (U.S. Department of Commerce, 2001). These demographics suggest a need to increase nurses’ awareness of culturally constructed concepts of health and illness and the Mexican-American culture (Burk, Wieser, & Keegan, 1995). The Centers for Disease Control rank Hispanic women in the United States as a medically underserved group that lacks access to health education and preventive health care resulting in higher rates of disease than in non-Hispanic whites (Oomen, Owen, & Suggs, 1999).

This article describes the findings of a field experience in which the authors participated as students in a doctoral multicultural nursing course. The investigation was designed to gain a cultural perspective of health care in the Mexican-American population by listening to the voices of women because they assume primary responsibility for maintaining family health (Burk et al., 1995; Purnell & Paulanka, 2005). In this article, elder Mexican-American women’s views on family life, health beliefs, and health care practices are illuminated using components of Giger and Davidhizar’s Transcultural Assessment model (2004). The authors first present a review of the extant literature describing the Mexican-American cultural beliefs and practices related to two factors in the Giger and Davidhizar model, specifically the social organization and environmental control perspectives of the culture. Next the authors review the model emphasizing the phenomena in the model especially relevant in the Mexican-American culture. Finally, they discuss the findings, addressing how each enhances the limited literature describing Mexican-American women’s cultural perspectives related to health care. The purpose of this article is to increase awareness of Mexican-American cultural phenomena and guide nurses in providing culturally competent nursing care that meets the needs of Mexican-American women and their families.

Background Literature


Becoming culturally competent has been described as a process where a nurse continually strives to effectively deliver care within the cultural context of an individual, family, and community...

A nurse who is entrusted with the care of clients and their families must recognize the value and importance of providing culturally appropriate care (Giger & Davidhizar, 2004). Between 1970 and 1980, the Mexican-American population nearly doubled, and then between 1980 and 2000, the number of individuals in this group residing in the United States nearly doubled again (Giger & Davidhizer; U.S. Department of Commerce, 2000, 2001, 2002). These statistics suggest a need for nurses to be aware of cultural phenomena in the Mexican-American population that supports culturally appropriate and competent nursing care. Although unique differences may exist within a cultural group, the acquisition of baseline knowledge related to a specific culture can begin to assist a nurse’s development of culturally competent nursing care. Becoming culturally competent has been described as a process where a nurse continually strives to effectively deliver care within the cultural context of an individual, family and community by seeking cultural awareness, knowledge, understanding, and skills (Campinha-Bacote, 2003; Purnell & Paulanka, 2005). Demonstrating knowledge and understanding of meanings of health and illness in the context of culture is crucial to developing culturally competent nursing care (Purnell & Paulanka, 2005). Giger and Davidhizar introduced the Transcultural Assessment Model in 1991 as an assessment tool for evaluating cultural variables and their effects on health and illness behaviors to provide culturally competent care. In particular, caring for the Mexican-American client requires the development of a trusting relationship built on awareness and understanding of the cultural phenomena of social organization and environmental control (Giger & Davidhizar). This awareness can be described as being at "the heart of cultural competence" (Leonard & Plotnikoff, 2000).


Demonstrating knowledge and understanding of meanings of health and illness in the context of culture is crucial to developing culturally competent nursing care.

Social organization includes groups in the social environment that influence cultural development, identification, and behavior. The family as a social group is of paramount concern to nurses since family relationships have special significance for Mexican-Americans (Giger & Davidhizar, 2004). Environmental control assesses the perception of a person’s ability to plan the activities that control nature and direct aspects of the environment (Giger & Davidhizar). Varying health beliefs and practices related to environmental control are shaped by a culture. In particular, examining locus-of-control, health beliefs, and folk medicine are important constructs for promoting awareness of the Mexican-American cultural group.

Social Organization: Family


Mexican-American family socialization emphasizes the needs of the whole family with an expectation of loyalty from each family member.

Authors describe the family as a significant social organization system in the Mexican-American culture (Giger & Davidhizar, 2004; Kemp, 2001; Kuipers, 1999; Niska, 1999). "The concept of familism is an all-encompassing value in the Mexican-American culture, where the traditional family is still the foundation of society" (Zoucha & Purnell, 2003 p. 267). The valuing of family considerations over individual needs permeates the literature concerning the Mexican-American family culture (Kemp; Niska). Mexican-American family socialization emphasizes the needs of the whole family with an expectation of loyalty from each family member (Burk et al., 1995; Niska). The child-rearing practices of this culture foster the growth of self-identity embedded within the milieu of the familia (family) (Giger & Davidhizar; Parke, & Buriel, 2002).


...extensive family support may result in delay in seeking health care outside of the family.

Mexican-American families rely on their extended family network and become involved in intergenerational helping networks (Niska, 1999). Strong ties extend beyond the nuclear family to a cohesive extended family of grandparents, cousins, aunts, uncles, and godparents (Keefe, Padilla, & Carlos, 1979). Niska suggested that Mexican-American family socialization cultivates multigenerational family contacts and frequent face-to-face communication within the entire family network. Close intergenerational networks often result in Mexican-American families living in close proximity with an extended family (Niska; Zoucha & Purnell, 2003).

Social support literature suggests that Mexican-Americans receive support from their nuclear and extended families during both daily events and crises (Kemp, 2001; Niska, 1999). Many decisions, including those concerning individual health care, are made by the family (Burk et al., 1995; Oomen et al., 1999). Seeking guidance with personal problems appears to be gender linked in the Mexican-American culture with older Mexican-Americans often relying on their daughters for assistance with health problems (Niska). Although the positive aspects of family support are acknowledged in the literature, extensive family support may result in a delay in seeking health care outside of the family (Zoucha & Purnell, 2003). Furthermore, family acceptance of health care initiatives may be necessary before adherence occurs (Burk et al.).

Social Organization: Male and Female Roles


...a troubling issue associated with male dominance is family violence in the Mexican-American culture, which is not an uncommon occurence.

The male in the Mexican-American culture is often viewed as the authority in the family (Burk et al., 1995). The woman is often viewed as the force holding the family together and sharing cultural wisdom (Kemp, 2001). Self-sacrifice by the woman in the Mexican-American family emerged as a theme in the literature (Burk et al.; Oomen et al., 1999). However, some authors (Zoucha & Purnell, 2003) suggested that these traditional roles are stereotypical and that women are currently assuming more authority in the Mexican-American family. Yet, a troubling issue associated with male dominance is family violence in the Mexican-American culture, which is not an uncommon occurrence (Kemp). Even though the woman has been identified as a central figure in the family, only limited literature focuses primarily on understanding the Mexican-American culture through interview data collected solely from women.

Environmental Control: Locus-of-Control


Spiritual and religious beliefs greatly influence the health and illness practices...[and] illness may be viewed as the result of misfortune or as a punishment from God...

Roman Catholicism is the predominant religion of the Mexican-American culture. The Hispanic population comprises nearly one-third of all Catholic parishioners (Schaefer, 2001). Spiritual and religious beliefs greatly influence the health and illness practices of the Mexican-American culture (Kemp, 2001). Several authors suggest that Mexican-Americans have an external locus of control because of the belief that God’s will controls everything and determines one’s health status (Berry, 1999; Burk et al., 1995; Kuipers, 1999). Furthermore, illness may be viewed as the result of misfortune or as a punishment from God for immoral behavior (Zoucha & Purnell, 2003; Zaldlivar & Smolowitz, 1994). Borrayo and Guarnaccia (2000) found that women born in Mexico showed a stronger belief in the role of chance (fate) and powerful others (physicians) in their health outcomes than women of Mexican descent who were born in the United States.

An individual’s locus-of-control influences compliance with both prevention and treatment measures. Because personal efforts do not determine health outcomes for those with an external locus-of-control, Mexican-Americans may not participate in healthy lifestyle activities (Zoucha & Purnell, 2003). Older women who perceived little control over determining their health outcomes were less likely to participate in health-promoting activities such as exercise (Lucas, Orshan, & Cook, 2000). However, several other studies have found that Hispanic women measure higher on internal locus-of-control than on external locus-of-control (Bundek, Marks, & Richardson, 1993; Duffy, 1997; Duffy, Rossow, & Hernandez, 1996). For example, in a study of locus-of-control and cancer screening, elderly Hispanic women scored higher on internal control followed by belief in powerful others; belief in chance had the lowest scores. Mexican-American women with an internal locus-of-control were more likely to seek and pay attention to health information and to participate in health promotion activities such as performing monthly breast self-examination, eating a healthy diet, or exercising regularly (Bundek et al.; Duffy; Duffy et al; Higgins & Learn, 1999).

Environmental Control: Health Beliefs


Many Mexican-Americans may not be able to describe exactly why they use certain treatments for a particular condition because the classification of diseases has been handed down...

Mexican-American health care beliefs are derived from cultural and historical perspectives that may influence an individual’s inclination to seek medical attention or comply with a prescribed health regimen (Zaldívar & Smolowitz, 1994). The perceptions that good health is a result of luck or reward and that disease or illness represent punishment from God for some transgression are pervasive in Mexican-American culture (Kemp, 2001; Kuipers, 1999; Spector, 2004). Some Mexican-Americans sustain the belief that health represents a balance between the forces of hot, cold, wet, and dry (Kemp; Taylor, 1985; Spector). The cause of illness is often believed to be an imbalance among forces of hot and cold, not related to temperature, but to the description of the substance involved (Spector). According to this belief, an illness labeled as hot should be treated with a cold substance, while a disease identified as cold should be treated with a hot substance (Spector). Many Mexican-Americans may not be able to describe exactly why they use certain treatments for a particular condition because the classification of diseases has been handed down from generation to generation (Taylor). Generally speaking, there is a belief that a hot food should not be combined with another hot food, but should be eaten only with cold foods. For example, when a woman delivers a baby, a so-called hot experience, she must eat cold foods to restore balance. Treatment for a condition may also include prayers and offerings, application of herbs, both hot and cold, as well as suggestions and practical advice (Kuipers).

Both physical and mental illness may be considered as an imbalance between the individual and the environment. Emotional, spiritual, and social factors influence health with disease resulting from hot and cold imbalances (Kemp, 2001). The Mexican-American population often views the mind and body as one, interdependent in states of both health and illness (Zaldívar & Smolowitz, 1994).

Environmental Control: Folk Medicine


Magico-religious practices are very common in this culture and even more prevalent when a serious illness or disease develops.

Mexican-Americans may use folk medicine in minor illnesses as an alternative to scientific medical practice or as an "adjunct" to conventional medical treatment (Burk et al., 1995). The folk remedies of Mexican-Americans are derived from the influences of the Roman Catholic Church and the Mexican Indians, and include herbal remedies, use of amulets, and rituals performed by folk practitioners (Burk et al.; Kuipers, 1999; Spector, 2004). Common herbs used during illness are mint tea, chamomile tea, tamolindo, and cinnamon (Teresa Recio, personal communication, June 1, 2001).

Magico-religious practices are very common in this culture and even more prevalent when a serious illness or disease develops (Spector, 2004; Zoucha & Purnell, 2003). These practices may involve shrines, medals, candles, prayers and healers. The curandera, a traditional healer in the Mexican-American culture, focuses on the physical, mental, spiritual, and social aspects of the ill person. The person may consult the curandera either prior to or concurrent with accessing professional medical care (Burk et al, 1995; Kuipers, 1999; Zoucha & Purnell, 2003).

Theoretical Framework

Provision of culturally appropriate nursing care is enhanced by assessing cultural phenomena (Giger & Davidhizar, 2004) and valuing an individual’s health beliefs and health care practices within the context of his or her unique culture (Purnell, 2002). The Transcultural Assessment Model developed by Giger and Davidhizar provided the framework for this exploration of Mexican-American women’s health care views. This model includes six cultural phenomena of communication, space, time, biological variations, social organization, and environmental control. These phenomena vary among cultural groups and influence health status and views. The authors decided to focus this investigation on social organization and environmental control since these are strong phenomena in the Mexican-American cultural system and significantly influence the health of Mexican-American population.


Provision of culturally appropriate nursing care is enhanced by assessing cultural phenomena and valuing an individual's health beliefs and health care practices...

The cultural phenomenon of social organization, according to Giger and Davidhizar (2004), includes groups in the social environment that influence cultural development and identification. The family, an important aspect of the social organization phenomenon, strongly influences cultural behavior through a process of socialization or enculturation of children and group members (Giger & Davidhizar; Niska, 1999). These learned cultural behaviors guide individuals through life situations, events and health practices. Understanding family from a cultural perspective is a significant element in providing nursing care to Mexican-Americans since Giger and Davidhizar identify the family as being most valued in this culture.

Environmental control is defined by Giger and Davidhizar (2004) as the ability of persons within a particular cultural heritage to plan activities that control their environment as well as their perception of one’s ability to direct factors in the environment. Kuipers’ (1999) discussion of this model, in relation to Mexican-American culture, emphasized the construct of environmental control with a focus on locus-of-control, health beliefs, and folk medicine. Locus-of-control explains the way in which individuals, within their cultural environment, perceive their ability to control what happens to them and to their health. Health may be viewed as being dependent on outside forces or their own actions (Bundek et al., 1993). Beliefs about health and illness, which are components of environmental control, affect health practices, use of health resources, and a person’s response to experiences of both health and illness (Giger & Davidhizer, 2004; Northam, 1996). A third component of environmental control, folk medicine, includes alternative therapies such as using herbs and teas or visiting a cultural folk healer, a curandero.

Methodology

Mexican-American women were selected from two senior citizens centers located in two predominately Mexican-American neighborhoods in a major metropolitan city in Texas. Recent demographic trends indicated that the Hispanic population comprises 39% of the total population of the city, an 11% increase since 1990 (Peek, 2001; U.S. Department of Commerce, 2001).

Protection of Participants

Permission to conduct the investigation was obtained from the Institutional Review Board of the researchers’ academic institution. The initial step in recruitment of eligible participants was obtaining permission from the manager of the senior citizen centers. Women who expressed an interest in engaging in dialogue about their health and health practices were included in the interview process. Informed consent was obtained from women who volunteered to participate in the study. Participants were given the opportunity to ask questions before agreeing to participate and reminded that they were free to stop the interview at any time.

Participants

A convenience sample of six bilingual women was selected from those who demonstrated a willingness to engage in an interview. The age of participants ranged between 64 and 84 years with a mean of 71 years. All participants indicated that they were Mexican-Americans and had been born in the United States. Each woman was interviewed individually by one of the investigators for approximately one hour. The investigators sought the wisdom and perspectives of mature women who had extensive and rich experiences with family health practices and concerns.

Cultural Phenomena Interview Guide

A semi-structured interview guide was used to ascertain each woman’s perspective of health beliefs (see Table ). The investigators developed the interview guide based on the extant literature related to Mexican-American culture and the Transcultural Assessment Model by Giger and Davidhizar (2004). This model provided a framework with which to focus on cultural phenomena that impact health care delivery and support exploration of an individual's cultural context. The cultural phenomena of social organization and environmental control provided the foundation for the development of the interview guide questions that focused on the family, locus-of-control, health beliefs, and folk medicine.

The investigators gave the questions to a content expert in multiculturalism to evaluate the effectiveness of the interview questions in ascertaining participants’ views of health beliefs. Questions were modified based on the expert’s feedback. Four investigators conducted the interviews. To ensure consistency in conducting the interviews, the investigators used role play with one another to rehearse the interview format.

Table. 1:  Interview Guide

Social Organization

  1. Tell me about your family.
    Follow up:
    1. Nuclear & extended family relationships
    2. Traditions & rituals
    3. Beliefs

  2. What are the important things to teach children?
    Follow up:
    1. Health/Sickness
    2. Growing up

  3. When a person is sick do you think the person can make themselves well?

  4. What do you teach your family/children about being __________(Mexican? Hispanic?)

Environmental Control

  1. Who or what do you think has control over a person’s health? (When a person is sick do you think the person can make himself well?)

  2. What do you think makes a person sick?

  3. Do you know anyone who has been to a folk healer or used folk medicine or remedies?

Health Beliefs

  1. What does being healthy mean to you?

  2. What does a healthy person look like to you?
    Follow up:
    1. Do you think you are a healthy person?
    2. When a person says you’re healthy, what does that mean?

  3. How do you keep yourself healthy?

  4. What do you do differently from your ancestors to stay healthy?

  5. What do you do when you are sick?

  6. Who do you talk to when you are sick?

  7. Where do you get your health information?

Data Collection

The investigators obtained consent from participants to take notes during the interview. Participants’ most significant responses were written verbatim by the individual investigator during each interview. Course faculty recommended to the interviewers that audio recorders not be used in order to encourage open and honest dialogue with elder Mexican-American participants.

Methodological Rigor

Establishing trustworthiness by meeting the criteria of credibility, transferability, dependability, and confirmability is of paramount importance to ensure quality in qualitative inquiry (Lincoln & Guba, 1985). Credibility is evidenced by the extended interview time of 60 minutes which provided sufficient time with each of the women to develop the rapport and trust needed to conduct an accurate and in-depth face-to-face interview. The triangulation of investigators and peer debriefing with colleagues provided additional insights and facilitated refinement of the analysis by the investigators to support credibility. Transferability is evidenced by the in-depth data obtained as evidenced by the extensive supporting quotations included in this article. Findings corroborated the experiences of interviewers who had previously cared for a significant number of patients from the Mexican-American population to meet the criteria of transferability. Dependability is evidenced by peer debriefing with colleagues providing additional insights to the investigators. A method of data analysis that included individual and group analysis also strengthens the findings and meets the criteria of dependability. Confirmability is evidenced by detailed field notes that were recorded after each interview providing a description of the interview, the setting, and interviewer’s thoughts and feelings and were used to substantiate the theme analysis.

Literary Context of Interview Data

Investigators analyzed participants’ responses, searching for recurrent patterns in the data that highlighted cultural themes (Gillis & Jackson, 2002) related to social organization and environmental control. Data analysis began by each investigator reviewing her interview data and notes to identify themes. Next, the team of investigators met to determine universal patterns in all six interviews (Gillis & Jackson, 2002). Exemplary statements that depicted the themes were then identified in each of the interviews. This thematic analysis revealed that social organization and environmental control are important constructs to understanding Mexican-American culture.

Using interview data and a review of literature, the investigators analyzed these two cultural phenomena and developed implications for nursing care. Literature and participants’ statements that support an awareness of the constructs of social organization and environmental control in the Mexican-American culture are included in the findings from this data analysis.

Social Organization: Family


The significance of the family group in the Mexican-American culture emerged from the data.

The significance of the family group in the Mexican-American culture emerged from the data. The importance of the extended and nuclear family as a significant social organization system (Kuipers, 1999) was illuminated throughout all interviews. The concept of familism, as discussed by the authors Zoucha & Purnell (2003), was supported by the words of all women in this exploration. Niska (1999) indicates that Mexican-American families rely on intergenerational helping networks. The following excerpts from interviews illustrate and validate the importance of the extended family in the Mexican-American culture:

    "I was there to help raise my three grandchildren ...while my children worked"

    "Whatever you do you always have your mother…your family"

    "I am very happy with my children...my boys and girls are doing ok"

    "We always do things together" [referring to siblings]

The influence of the family was a dominant theme throughout the interviews and literature related to Mexican-American culture. The need for collective achievement of the nuclear and extended family was evident in the words of participants who described their families growing in togetherness and supporting family members. Findings illuminated the participants’ families reliance on their family members to solve problems or meet their individual and family needs.

Strong ties extend beyond the nuclear family to a cohesive extended family of grandparents, cousins, aunts, uncles, and godparents (Keefe et al., 1979). Niska (1999) suggested Mexican-American family socialization cultivates multigenerational family contacts and frequent face-to-face communication within the entire family network. Close intergenerational networks often result in Mexican-American families living in close proximity with an extended family (Niska; Zoucha & Purnell, 2003). The following interview data validated these strong extended family ties discussed in the literature:

    "Grandmother lived next door to us."

    "Sunday is primarily to be with my children and grandchildren. "

    "My mother and sister live in this town also….we get together on holidays."

Interview data confirmed social support literature suggesting that Mexican-Americans receive support from their nuclear and extended families during health care situations (Kemp, 2001; Niska, 1999). The nuclear and extended families of these Mexican-American women in this inquiry were involved in health care and personal decisions. Furthermore, guidance and decision in health care and family are often gender-linked with women having a key role in these issues:

    "I took care of my Mom for nine years before she died."

    "My children moved close to me so that I could help them when they were young."

    "I talk to my daughters " (referring to health questions)

    "My family would help me get to the doctor or the hospital."

    "Grandmother gave us the stuff….Every Saturday night she would bathe us... and get ready for church".

    "I talk to my Mom when I am sick..."

Sustaining physical and emotional attachment to family members and family as a whole provided the women participants with physical, social, and economic support. The close proximity of family members allowed participants to turn to their family for guidance with health concerns and issues.

Social Organization: Male and Female Roles

The role of the Mexican-American woman includes the responsibilities of providing a nurturing family environment and maintaining the health of the children and the family. The older woman in the Mexican-American culture often serves as the role model for other females in the family regarding childcare and family activities (Burk et al., 1995). The following interview data illustrate the role of Mexican-American women in the family:

    "I raised my children…that was my job"

    "I have finished my job... They have a good house and clothes and money..."

    "The children were the most important..."

    "Mom taught us."

The continuity of the family in the Mexican-American culture was evident as the women described helping their children grow and family remain healthy. Women expressed their pride in the family endeavors and their role in nurturing children.

Self-sacrifice by the woman in the Mexican-American family emerged as a theme in the interview data and in the literature (Burk et al., 1995; Oomen et al., 1999). The common perception of the traditional role of the Mexican-American woman is that of a submissive wife and a mother who places the needs of the family above all else (Burk et al..; Kemp, 2001). Even though authors (Zoucha & Purnell, 2003) suggest gender roles in today’s family appear to be changing, the voices of women in this inquiry highlighted the idea that familism remains deeply ingrained in their culture (Burk et al.). The male is often viewed as the power figure in the family, as exemplified in these women’s voices:

    "My husband made all the decisions."

    "He wanted me to stay at home."

    "I thought I had to put up with it."

    "...my mother was very strict about being submissive. The man runs the household."

    "My father said school was not for women...My father did not let us dance"

The dominant role of men and submissive role of women in the Mexican-American culture may contribute to the issue of family violence, a significant concern for nurses. All interview participants described an emotional experience of violence against women occurring in their families:

    "My father was mean…I had to bale so much cotton per day ...my Dad made sure of that...he would whip me"

    "I thought I had to put up with it" [referring to abusive husband]

    "My father made my mother suffer….all she could do was work"

The connection of male and female roles in these Mexican-American participants emerged from the cultural beliefs of male dominance and female sacrificing and bearing the burdens for the family. The father has a dominant role in decision making as the head of the household and the mother has primary responsibility of raising the children in the family. A Mexican-American woman’s priority is family cohesiveness and the family often stays together with the traditional cultural expectations superseding individual needs and wants.

Environmental Control: Locus-of-Control

Faith and church permeate the daily family and community life of Mexican-Americans (Kemp, 2001). Several authors (Berry, 1999; Burk et al.; Kuipers, 1999) suggest that Mexican-Americans often perceive lives and health as being under the control of God. The construct of an external locus of control appeared to be a predominant theme in the women interviewed in this investigation. The following excerpts from interviews revealed the strength of religious beliefs in the lives of the women and a pervasive sense of God’s influence on their health:

    "Grandma said a prayer over that [illness]. We would feel better right away"

    "God can help me. If you believe you’ll get better, you will, right away"

    "It’s all up to God"

    "Whatever God says, that’s what will happen"

    "I pray and then I feel better...I tell it to God and then I feel better"

    "When God wants me I am ready"

During times of illness and crisis, Mexican-American women may rely on religion and their families. A serious illness may be viewed as an act of God and seeking out a health care professional may be a last resort and may occur only in the terminal stage of illness (Zoucha & Purnell, 2003). One of the women discussed an illness experience in her family that clearly supported the existence of this view of illness and treatment by health care professionals:

"My husband wouldn’t go to the doctor. He went once when we were married…he wouldn’t have the tests the doctor ordered. He died in the hospital of lung cancer (two months after diagnosis)."

Women who participated in this study appeared to have beliefs that physicians were powerful others (Borrayo & Guarnaccia, 2000) that influenced their health outcomes. Participants in this study who indicated they had regular contact with a physician voiced that this medical advice served to influence and control their health:

    "Go every month for doctor’s visit [to keep healthy], and go to specialist as needed"

    "Now I do just what the doctor tells me and if he does not give it to me or approve it, I won’t take it"

    "I have a good doctor. The doctor told me to decrease my salt and eat baked, broiled, or boiled"

    "I call doctor and go to doctor [when I am sick]"

    "I go to the doctor when I’m sick"

An internal locus of control seemed to also emerge from the interview data as women participants described how they believed they could influence their own health. While believing that God had a great deal of control over their lives and health, women participants suggested that they also attributed health outcomes to their actions:

    "Myself [when asked who has control over a person’s health]…if you don’t take care of yourself ain’t nobody else going to do it"

    "I made up my mind to lose that fat when I retired. I can do something about it [my health]"

    "I like to take care of myself"

    "I decreased my salt, increased my fruit and vegetables and started to walk three miles a day"

    "I eat healthy: six small meals with vegetables and grain"

    "I got into a program from M.D. Anderson [local cancer center] that did a class…learned to fix our meals with no fat"

    "I try to get the right information…I like to read anything on health or watch TV"

    "I read Prevention Magazine"

    "I have started making tortillas with corn oil instead of lard and altering the traditional to a more healthy traditional diet"

In summary, women participants described both external and internal locus of control. Women participants described the strength of religious views and power of health care providers indicating an external locus of control. Yet, their beliefs that health can be maintained by diet and other practices indicated a simultaneous value of personal control.

Environmental Control: Health Beliefs

Although there is extensive literature (Higgins & Learn, 1999, Kemp, 2001, Kuipers, 1999, Spector, 2004) describing a Mexican-American belief that health occurs when there is a balance between forces of hot, cold, wet, and dry, this theme did not emerge in the interview data. Kemp stated that individuals may not be willing to share with health care professionals their belief in hot and cold. All of the women interviewed were born and raised their families in the United States, suggesting a high degree of acculturation, which may serve to limit cultural beliefs related to hot and cold (Pachter, 1994).

Environmental Control: Folk Medicine


...common herbs used by Mexican-Americans during illness are mint tea, chamomile tea, tamolindo, and cinnamon.

A blending of folk medicine with traditional Western medicine emerged from the interviews of the elderly Mexican-American women. Some of the common herbs used by Mexican-Americans during illness are mint tea, chamomile tea, tamolindo, and cinnamon (Teresa Recio, personal communication, June 1, 2001). The use of folk remedies by some of the women’s mothers and grandmothers was discussed in the interviews:

    "When I was a child my mother would put kerosene and sulfur on us for mosquito bites but I don’t do that now."

    "My mother would give us cinnamon tea for stomach aches."

    "We used leaves in my family". (It was noted that during this portion of the interview she crossed arms over her chest and appeared uncomfortable.)

    "We used mint… cut it, boiled it and drank it."

    "When I call my mother and I am not feeling well she always tells me to make some kind of herbal tea, which will make me feel better."

    "[Grandmother] gave us teas when we were sick, chamomile tea and cinnamon tea. She had a garden and grew her herbs. I have grown some tea herbs in my yard that grandmother used [This information required a great deal of probing]

Illnesses are often treated with herbs and remedies communicated through women in the family. Literature suggests that these beliefs may at times lead to the underutilization of western medicine health services (Giger & Davidhizar, 2004). Furthermore, interview data supported the literature indicating women in the Mexican-American culture often bear the primary responsibility for communicating folk remedies, such as use of herbs or roots, to the next generation.

When asked about a folk healer, only one woman answered in the affirmative; however, nonverbal behaviors suggested the women were hesitant or perhaps afraid to acknowledge the use of curanderas in their health practices.

    "I go sometimes and I’ve tried it."

    "I don’t go any more."

Mexican-Americans living in the United States may be hesitant to express their beliefs in folk practitioners because of their perception that these beliefs conflict with traditional medicine.

Discussion


Listening to the voices of Mexican-American women who can share their rich history in the cultural phenomena of social organization and environmental control can support culturally competent care.

Thematic analysis of data (Gillis & Jackson, 2002) from interviews with six Mexican-American women revealed the importance of family, religion, and locus-of-control in the health beliefs, attitudes, and lifestyle practices in this culture. Listening to the voices of Mexican-American women who can share their rich history in the cultural phenomena of social organization and environmental control can support culturally competent care. Knowledge of this culturally relevant information and the significance of these cultural phenomena in daily life can be a starting point in delivering nursing care that is congruent with the Mexican-American culture and can promote optimal health outcomes in women and families from this specific cultural group (Purnell & Paulanka, 2003).

Women participating in this study as well as women presented in the literature have described the significance of the family and extended family relationships in the Mexican-American culture (Giger & Davidhizar, 2004; Niska, 2001; Purnell & Paulanka, 2005). Familism, including intergenerational relationships, emerged as a recurring theme in the lives of the women participants in this investigation. Similar to the findings of Niska, the importance of children in a family’s growth was supported by words of women in this investigation. Culturally competent care would, therefore, include a focus on the significance of the client’s family and extended family (Giger & Davidhizar, 2004; Purnell & Paulanka, 2005).


...a culturally competent nurse would elicit family participation during patient teaching and family support for the patient in health care decision-making.
Honoring the significance of family values and roles is an important component of the nursing care of and consultation with Mexican-American women. In particular, a culturally competent nurse would elicit family participation during patient teaching and family support for the patient in health care decision-making. Using language and expressions familiar to the Mexican-American family may increase family adherence to health teaching and treatment protocols (Purnell & Paulanka, 2005). Nurses should expect and support the presence of extended family and their participation during a loved one’s hospitalization.

Interview findings revealed the theme of male dominance in Mexican-American family dynamics. Cultural competence would suggest that the health care provider include the male in the family in health care decision-making (Purnell & Paulanka, 2005). Though screening for domestic violence is critical in women of every race, ethnicity, and age group, culturally competent nursing care would demand particular attention to screening for domestic violence in women of Mexican-American heritage.

Developing nursing care that recognizes both external and internal locus of control may result in effective health outcomes in the Mexican-American culture. Participants in this study expressed both internal and external locus-of-control in their health beliefs which differed from the information given by Giger and Davidhizar (2004) that Mexican-Americans were more likely to believe in an external locus of control. Assessing a client for health locus-of-control can provide information critical to the design of a nursing approach to health care teaching.


Conveying an accepting attitude toward herbal therapies, folk medicine, and folk healers may result in an honest relationship with a sharing of information to support health outcomes.
If a female client indicates a strong belief that God’s will determines her health, the nurse, honoring that belief, might seek the support of the woman’s church community in promoting a healthy lifestyle (Giger & Davidhizar). Recognizing that not all Mexican-American women function from an external locus-of-control, the nurse would affirm and support each woman’s efforts to protect her health and provide health information as needed.

Nurses and other health care professionals who have an appreciation of the folk medicine used by this culture can better help the Mexican-American client reveal her cultural perspective. Recognition that Mexican-American women may use folk remedies learned from their mothers and grandmothers or seek the advice and care of a curandera, while denying either or both of these activities, is crucial to cultural competence in the nursing care of clients of this heritage. Conveying an accepting attitude toward herbal therapies, folk medicine, and folk healers may result in an honest relationship with a sharing of information to support health outcomes.

Conclusions


Knowledge of and respect for the health care beliefs of Mexican-American clients and their families create a therapeutic alliance that improves health outcomes...

"A culturally sensitive health care system is one that is not only accessible, but also respects the beliefs, attitudes, and cultural lifestyles of its patients" (Pachter, 1994, p. 692). Giger and Davidhizar’s Transcultural Assessment Model (2004) provided the framework for this study of Mexican-American women’s views on family life, health beliefs and health care practices. Awareness of the Mexican-American cultural phenomena of social organization and environmental control can help nurses establish trust, develop rapport, determine health care resources, and develop care that will be acceptable to individuals of this culture. Knowledge of and respect for the health care beliefs of Mexican-American clients and their families create a therapeutic alliance that improves health outcomes through increased understanding of healthy lifestyle practices and therapeutic interventions (Giger & Davidhizar). Understanding the cultural phenomena of social organization and environmental control in the lives of women and their families guides the nurse in providing flexible, culturally appropriate health care that meets the needs of Mexican-American families.

Authors

Sandra K. Eggenberger, PhD, RN
E-mail: Sandra.eggenberger@mnsu.edu

Sandra K. Eggenberger, PhD, RN is a Professor at Minnesota State University, Mankato School of Nursing. She teaches family nursing courses and concepts of cultural competence care to undergraduate and graduate nursing students. Sandra's experiences include conducting family research studies aimed at advancing family nursing knowledge.

Jane Grassley, PhD, RN
E-mail: JGrassley@mail.twu.edu

Jane Grassley, PhD, RN is an Assistant Professor at Texas Woman's University, Denton, Texas. Jane was a lactation consultant at St. Paul University Hospital, which served a large and diverse population of Mexican-American women. She was responsible for meeting the lactation needs of diverse populations, primarily Mexican-American.

Elizabeth Restrepo, PhD, RN
E-mail: ElizabethRestrepo@texashealth.org

Elizabeth Restrepo, PhD, RN is a clinical consultant/data analyst for Texas Health Resources in Arlington, Texas. She has significant obstetrical experience with Mexican-American women in Texas. Elizabeth is responsible for analysis of clinical data and for multiple research and education studies in the clinical setting.

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© 2006 OJIN: The Online Journal of Issues in Nursing
Article published July 19, 2006


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