Abstract
Individuals of Latino descent are one of the fastest growing groups in the United States. They also experience multiple health disparities. To effectively treat individuals from these cultures, several issues should be considered. Assessing the degree of an individual’s acculturation and tailoring interventions to be more compatible with a patient’s cultural values are important steps to be taken.
‘Latinos experience significant health disparities and are less likely to receive medical care than other groups in the United States.’
Between 2000 and 2010, the fastest growing group in the United States was the Latino population, which, with an increase of 15.2 million, accounted for more than half of the total US population growth. 1 Additionally, it is estimated that the Latino population of the United States will increase from 14% (42 million) in 2005 to 29% (128 million) of the national population in 2050. 2 Latinos experience significant health disparities and are less likely to receive medical care than other groups in the United States. 3 Furthermore, Latinos are more likely to experience poverty and face harsher socioeconomic hardships compared with other racial groups. 4 Poverty has been shown to negatively affect the ability of individuals to make changes within one’s environment. 5
Many within-group differences exist in terms of education, family, social and health values, beliefs, and practices for Latinos. 6 A major factor that accounts for these differences is the amalgamation of traditional cultural values and aspects of an assimilated culture. This has been termed acculturation. 7 As discussed by Larsen et al, 8 there is a clear need to consider acculturation as a continuum. Depending on the country of origin, generation status, preferred language, and socioeconomic status, individuals may have significantly different levels of acculturation. 6 Taking into account an individual’s level of acculturation is important when tailoring health care recommendations. Several significant factors to be considered in cultural tailoring of health care services include familismo, personalismo, simpatía, and modestia.
Cultural Values
Familismo
Many Latino cultures promote the value of collectivism, which emphasizes the importance of the group before the individual. 9 Familismo is a core value that includes the commitment to support family members both emotionally and financially, reliance on family for help, and deferring to family for how one should think or behave. 9 This core value may manifest itself in the patient–physician relationship in several ways. For example, patients may not independently make decisions regarding their health and may instead rely on input and advice from multiple family members before deciding on a course of action. 10 Consistent with the value machismo, men are traditionally considered the decision makers in the family while women are primarily responsible for taking care of the family.11-13 Additionally, Latina women typically possess the most health care knowledge and have been shown to facilitate behavior change within the family. 14 As a result, the primary female caretaker should be included in discussions regarding lifestyle interventions for their family members in order to improve adherence.12,15 However, when the primary female caretaker of a family is the patient and the focus of a lifestyle intervention, special consideration should be given to how to effectively intervene. Depending on how strongly the patient identifies with the value of familismo, this value may prevent Latinas from focusing on their health care needs. Specifically, Latinas who have stronger beliefs consistent with familismo may be less adherent to lifestyle changes (ie, reduced caloric intake, step goals, and treatment session attendance). 16 In order to address this issue, health care providers (HCPs) should focus on the impact of the patient’s health on her ability to care for the needs of the family. This message is likely more salient to many Latina women and may be one way to improve adherence. Overall, identifying key family members who may be involved in supporting the individual in their behavior change and engaging them in the decision-making and treatment process is an important cultural consideration.
Personalismo
Close personal and intimate relationships are deeply valued in many Latino cultures. 11 Many Latino patients expect to form a close relationship with their HCP.11,17-19 To establish a personal connection with patients, HCPs should inquire about their patients’ families and significant life events. 20 Additionally, establishing physical contact with patients through handshakes may assist with creating a warm and friendly atmosphere.17,21 A lack of personalismo can have a negative impact on patient adherence. 15 Anecdotally, HCPs have reported a lack of adherence from Latino patients until the patient feels that the HCP genuinely cares about them and is recommending treatment options based on their concern for them as an individual. 11 Overall, establishing close and personal relationships with Latino patients will help create a physician–patient working alliance which is likely to improve outcomes.
Simpatía
Simpatía is a cultural value that emphasizes politeness and deference to others in order to avoid conflict. 20 Having strong beliefs consistent with simpatía may make it difficult for patients to openly discuss potential barriers to treatment with their HCP. Failure to realistically explore barriers to treatment with patients may have a negative impact on treatment adherence. Family social events can represent significant challenges for many patients. For example, within the Latino culture, there is pressure for overindulgence in social events. The value of simpatía may make it difficult for individuals to decline offerings of food and it is important that HCPs carefully discuss realistic ways that the patient can navigate these situations.22,23 Being aware of the social pressure that many Latinos feel to avoid conflict should help HCPs to better identify potential barriers to treatment and assist the patient with planning for these situations.
Modestia
Modesty is highly valued by many Latino individuals. Latina women, especially older women, may be very conservative with regard to physical exposure.11,20 This may present a significant barrier to many forms of physical activity that involve exercising in public or where they can be observed by others such as walking or going to the gym. When recommending a physical activity intervention to Latina patients, HCPs should assess the patients’ comfort level for various forms of physical activity. Attending a women’s only gym or developing a home-based physical activity routine may be options for very modest patients.
Identifying and Working With Cultural Barriers: The LEARN Method
The LEARN technique is a heuristic for a cross-cultural interviewing technique that can be easily remembered and used to identify and address cultural barriers in clinical practice.24,25
Listen with empathy to the patient’s perception of the problem and potential barriers to treatment.
Explain or reflect back your understanding of the problem and barriers.
Acknowledge any similarities and differences in your and the patient’s perceptions.
Recommend options for treatment.
Negotiate a plan of action.
Conclusions
One of the most significant barriers to addressing cultural barriers to treatment with patients is lack of awareness of cultural differences. Increasing awareness of core values common among Latinos with more traditional beliefs will help improve HCPs’ ability to engage patients in the behavior change process and assess potential barriers to treatment to engaging in lifestyle change. Providing culturally relevant treatment to patients has important implications in the promotion of adherence and improved outcomes.