Susto,Coraje,y Fatalismo : Cultural-Bound Beliefs and the Treatment of Diabetes Among Socioeconomically Disadvantaged Hispanics

Abstract

Hispanics are disparately affected by diabetes. Treating socioeconomically disadvantaged Hispanics is challenging due to economic and cultural barriers. Health care providers must understand that cultural beliefs about medicine and disease may have an impact on how diabetes treatment is viewed. Concepts such as susto (fright), coraje (anger), and fatalismo (fatalism) are common cultural beliefs. If these beliefs are not well understood by the health care provider, recommendations for treatment are likely to be discarded. To dismantle cultural barriers between the patient and the health care provider, there are several strategies that a health care provider can implement. For instance, a health care provider must develop trust with the patient. The health care provider could also engage a family member or promotora or promotor (community health worker) in the conversation. Furthermore, if the cultural barriers are significant, the patient may be best served by receiving treatment from someone with a better understanding of his or her background. Thus, a referral may be appropriate.

‘Hispanics are disparately affected by diabetes with a prevalence rate of 12% compared with 7% in non-Hispanic whites.’

Diabetes affects a total of 30 million adults and prediabetes affects an additional 84 million individuals. ¹ Medical expenditures associated with diabetes were $176 billion in 2012, and that number does not take into consideration cost associated with reduced earnings and productivity. ² For that reason, lifestyle modifications that include physical exercise, diet, and diabetes self-management have been proposed to assist people make long-term behavior change as discussed in the current issue by Galaviz et al. ³

Hispanics are disparately affected by diabetes with a prevalence rate of 12% compared with 7% in non-Hispanic whites. ¹ Preventing and treating diabetes among Hispanics, especially among those who are low income, is challenging in part due to the fact that 1 in 5 Hispanics lack health insurance, which is double the rate than the general population. ⁴ The lack of access and availability of health care, along with significant language barriers, prevents many Hispanics from receiving timely and adequate health care.

Behavior change strategies can be applied to prevent diabetes in high-risk populations. In order to increase the likelihood that these interventions can have a meaningful impact among socioeconomically disadvantaged Hispanics, cultural beliefs about medicine and disease that may be deeply rooted in people’s lives should be understood. For example, concepts such as susto (fright), coraje (anger), and fatalismo (fatalism) are common cultural beliefs cited that can affect how the causality and treatment of diabetes are viewed. ⁵ While it is important to note these cultural beliefs are common among some socioeconomically disadvantaged Hispanics, caution should be taken when grouping individuals together under a term such as Hispanics. Hispanic is a label used to group individuals whose ethnic backgrounds are from Spanish-speaking countries but are in fact a heterogeneous group that vary in their cultural beliefs in relation with disease. The purpose of this article is to provide a brief overview of some beliefs that could affect treatment outcomes among socioeconomically disadvantaged Hispanics taking into consideration the importance of health care providers to attend to the individual patient. By attending to the individual patient, rather than treating Hispanics as a homogeneous group, erroneous assumptions in treatment can be reduced. ⁶

Emotional Causation

Several emotions are believed to cause diabetes among Hispanics. ⁷ Susto (fright) is defined as a condition of intense emotion felt after experiencing a traumatic event, such as a car accident or the death of a child that—according to tradition—makes the soul leave the body. ⁸ After experiencing susto, it may take from days to years for symptoms of diabetes to develop. For example, individuals of Mexican decent living in rural Washington State thought that susto could be caused by family fights, the use of drugs, or by the spirit of the deceased. Reported cold sweats, vomiting, and diarrhea are among the symptoms. In rural Guatemala, some individuals have been shown to believe that being exposed to air drafts could precipitate susto, and mentioned headaches and sweating among the symptoms. Susto can be healed by praying, taking herbs, visiting a curandero (folk healer), drinking holy water with herbs, or talking with a psychologist.^9,10 Not only are the treatments for susto varied, different groups do not view treatment for this the same. In one study, the only group that believed that susto could be healed by itself were Mexicans living in South Texas. Others believe that susto could be prevented by being calm, or overweight, and that the young and strong individuals are less affected. ¹¹ To further complicate this issue, susto is viewed differently based on location (South Texas, Mexico, and Guatemala), and some evidence suggests that this belief may begin to disappear once in contact with a different culture.

Coraje is also mentioned as causative of diabetes. ¹² Coraje is defined as the emotion resulting from long-term experience of social struggles or “moral indignation.” ¹³ Being usually angry or experiencing family violence make the person feel coraje, which may in turn cause diabetes. Whether physical, verbal, or emotional, interpersonal abuse has also been viewed by patients as a causal factor in the development of diabetes, both in men and women. ¹³

Fatalism

Fatalismo (fatalism or the belief that things happen because it is people’s fate) has been related to the origin and outcomes of diabetes in 2 different ways. ¹¹ Researchers have predominantly seen religious beliefs related to fatalism (as a form of punishment for past sins). ¹⁴ At the same time, many Hispanics use religion as a form of support that assists them to endure the disease. This may not only be a cultural belief but also grounded in life circumstances. Real economic barriers suffered by the most undeserved individuals (eg, lack of health insurance, financial burden of treating diabetes) may leave people with the sense that there is not much they can do, even if they do not believe that their lives are shaped by fate. ¹⁵

Treatment Considerations

A better understanding of underlying beliefs can help the health care professional in many ways. Without understanding some of the issues that may be viewed as instrumental in the development of disease, recommendations for treatment are likely to be discarded. Additionally, some patients may never discuss these core issues without a prompt. For example, in one study, participants only referred to susto or coraje when they were specifically asked. ¹⁶ When the patients have strong cultural beliefs, there are several strategies that a provider can use to break the cultural barrier.

Developing Trust

Of utmost importance is the establishment of a relationship of trust with patients, especially when cultural differences may act as a barrier. ¹⁷ Patients have shown higher preferences for providers who are warm, empathetic, and listen with genuine interest. Individuals not only value the medical information they receive but also the emotional characteristics of the provider. ¹⁶ Directly asking about the cultural beliefs of the Hispanic patient opens the possibility of talking about stressful experiences and emotional aspects of the patient’s life that could act as a barrier for the prevention and treatment of diabetes. ¹⁶ The time spent in such a conversation is likely to increase the patients’ trust in the health care provider, improving their readiness for behavior change.

Promotores and Family Members

Additional strategies that can be used to break the cultural barrier between patients and health care providers include inviting a family member, engaging bilingual and bicultural promotora or promotor (community health worker), or involving a peer coach. Involving a family member is important, not only because familismo is a Hispanic cultural trait that promotes family ties but because lack of support from the family has been reported as a barrier for successful self-management. ¹⁸ A study by Sorkin et al ¹⁹ showed that an intervention including obese women who attended with an obese or overweight daughter had greater weight loss and better adherence to healthy eating patterns than in the group of obese women who attended alone. Peer coaches may assist in behavior change by role modeling and providing both information and emotional support.^20,21 These coaches do not need to be experts to be effective either. For example, coaches with a lower sense of self-efficacy have been shown to help their assigned clients more than those with higher self-efficacy, probably due to feeling more empathy. ²¹

Referral

Typically, the concept of referring a patient to another provider is associated with feelings of failure as a health care provider. The purpose of referring to another care provider does not imply that one does not have the skills required to appropriately treat a condition. In some cases, a referral is appropriate because of a poor “match” between the health care provider and the patient. As discussed, some patients will have belief structures that make it difficult for the clinician to fully understand the core issues that are related to the disease or disorder being treated. In these cases, the patient may be best served by receiving treatment from someone with a better understanding of his or her background. Health care professionals should regularly assess key barriers to treatment. If it is determined that the patient–health care provider match is not a good one, a referral may be appropriate.

Summary and Conclusions

A health disparity is clearly seen in that Hispanics have higher rates of diabetes than non-Hispanic whites. The treatment of diabetes in some socioeconomically disadvantaged Hispanics may be improved by including cultural beliefs about the disease. Specifically, strong emotions in the form of susto and coraje may be viewed as causative factors in the development of diabetes, while fatalism may deter individuals from diabetes management. Health care providers should be ready to assess for these beliefs and incorporate them into treatment. Additionally, other supports in the form of family members or peer coaches may help bridge any cultural gaps that exist between the patient and the health care provider. In cases where the provider-patient match is affecting treatment, a referral to a health care provider with a better understanding of the cultural belief system may be considered.