Transcript Health Problems in Mexican Immigrants:

The Role of Context and Culture in the
Healthcare of Mexican Immigrants
Maria de Jesus Diaz-Perez, PhD
Salud Family Health Centers
Fort Lupton, CO
Outline:
• Context of Mexican immigration
– History
– Changing demographics
• Why culture?
– How body works
– How people get sick
• Culture bound syndromes
– How they cope with illness
• Therapeutic networks
Hispanics in the U.S.
• Largest ‘minority’
group
• Ethnicity, not race
• Diverse population
– 15 countries
represented
– 66% are of Mexican
heritage
Latinos in the United States
According to 2010 US Census, 50.5 million of Americans
are Latino, making up 16% of the population
– Mexicans represent 65.5% of Latinos in this country
– About 36% of Mexican origin Latinos are foreign born
Immigrants
– First generation: Born in Mexico and came to the US
when they were older than 12 years of age
– Second generation: Born in the US from at least one
immigrant parent and/or came to the US before or at 12
years of age
Mexican Immigrants
• Mexican population is one of the five largest immigrant
groups in almost every state in the United States.
• By 2006, 14 states had populations of Mexican immigrants
over 100,000
• Colorado has an estimated number of 268,000 Mexican
immigrants.
• Despite slower growth in immigration in recent years,
states like North and South Dakota, New Hampshire,
West Virginia, and Maine, had an increase of Mexican
population over a 100 times from 2000 to 2007 .
What is the right label?
• Hispanic?
• Latino?
• Chicano?
History of Mexican Immigration
• 1942 – 1964
– Bracero Program
• 1964 – 1986
– Start of undocumented
immigration
• 1986 – Now
– Era of
misguided
legislation
Bracero Program:
1942 - 64
•
•
•
•
Federal program to subsidize growers
Immigrants worked in agriculture
Immigrants were documented
Many agricultural workers lived in
‘camps’
Era of undocumented immigration:
1964-86
• Characteristics of immigration:
–
–
–
–
Increasingly undocumented
Stable flow
Circular movement of male workers
Identifiable, predictable patterns
• Most immigrants worked in seasonal
agricultural jobs
• Most immigrants lived in ‘camps’
Era of Misguided Legislation:
1986 - Present
• 1986
– Immigration Reform and Control Act
(IRCA)
• 1996
– Illegal Immigration Reform and Immigrant
Responsibility Act (IIRIRA)
• What is next?
1986: Immigration Reform
and Control Act
(IRCA)
1. Employer
Sanctions
2. Border control
enforcement
3. Amnesty
Program
Goal: Reduce
undocumented
immigration
1996: Illegal Immigration Reform
and Immigrant Responsibility Act
(IIRIRA)
• Welfare reform
to exclude
immigrants
• Federal actions
to deny means
tested programs
to immigrants
Goal: Reduce
undocumented
immigration
• State actions to
restrict services
to immigrants
Increased risks of
injury and death
IRCA and IIRIRA
Geographic
diversification
Shift toward
permanency
Ever increasing
migration,
worsening living
conditions
Declining wages
How successful has this legislation
been in stemming the flow of
undocumented immigrants?
New destinations
2000 – 2007: Main,
New Hampshire,
Western Virginia had
over a 100 times MX
population increases
Mexican population
increased from 14 to 18
times in the 90’s: Alabama,
Tennessee, Kentucky, North
and South Carolina
Leite, P., Angoa, M., Rodriguez, M. (2009). La emigración Mexicana a Estados Unidos:
balance de las últimas décadas. Situación demográfica. México: CONAPO.
New origins
Mexican Migration Today
•
•
•
•
Longer times in U.S.
Many different types of employment
New receiving communities
Feminization and urbanization of
migrant populations
Characteristics of Mexican
Immigrants
•
•
•
•
•
56% men, 44% women
Median age: 35
60% had less than high school education
Most had a job in Mexico
Most are married and might travel with
or without family
• 40% come from rural Mexico
Factors Against Immigration
600
500
400
300
200
100
98
•
•
•
•
•
No jobs
High anti-immigrant sentiment
Federal raids
State laws
Very dangerous to cross
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
0
96
94
92
90
88
86
Yearly immigration
US employment rate
Mexican Immigrants
in the U.S.
• Come for economic reasons – to work!
• Many of them want to be in the U.S.
temporarily
• Mexico and their villages remain part of
the psychic present, not a lost past
The double standard of
Mexican migrants
• Perceived as someone to be proud of for
taking the risk of going north and work in a
hostile environment.
• In the US they are considered “illegal
aliens”.
Risk Factors for Health and Mental
Health Problems in Migrant
Populations
Family Separation
Trauma during crossing
Undocumented residency
Discrimination
Poor labor conditions
Poverty
Isolation
Overcrowded, inadequate housing
Lack of knowledge of English
Caring for Mexican
Immigrants
Characteristics of Rural
Mexico
•
•
•
•
•
•
High rates of unemployment
Mostly Catholic
Traditional gender roles
Low levels of education
Limited availability of basic services
Social marker: POVERTY
Influence of Culture
• Rural Mexicans have limited access to formal
health services
• Mexican immigrants to U.S. maintain cultural
behaviors
• Beliefs and behaviors remain unchanged until
the immigrants get familiar with the new
culture and feel comfortable dealing with the
new health system
Culture
“An integrated pattern of human behavior that
includes thoughts, communications, languages,
practices, beliefs, values, customs, courtesies,
rituals, manners of interacting, and roles,
relationships and expected behaviors of a
racial, ethnic, religious or social group; and the
ability to transmit the above to succeeding
generations”.
Why Does Culture Matter?
• The functioning of the body
• How people get sick
• Whether people seek help and the type of help
they seek
• How much stigma they attach to different
illnesses
• Culture also influences the meanings that
people assign to their illness
The Functioning of the Body
• Balance and imbalance
– Balance dependent on external forces
How people get sick:
Culture-Bound Syndromes
• A symptom complex occurring in a specific
geographic distribution, associated with
certain unique environmental circumstances
and cultural beliefs
• Idioms of Distress:
– Ways in which different cultures express,
experience, and cope with feelings of distress
Mexican Culture Bound Syndromes
• Culturally specific
• More common in rural Mexico
• Contain somatic and psychological
components
– Mind-body split does not exist
Mexican Traditional Healers
• Curandero(a)
• Sobador(a)
• Yerbero(a)
• Espiritista
• Brujo(a)
Mexican Cultural Syndromes
•
•
•
•
•
•
Nervios
Susto
Mal de Ojo
Empacho
Mollera Caida
Aire
Nervios
• Etiology:
– An attempt to re-establish balance between
personal and social aspects of life
– May be a coping strategy in which women
are temporarily freed from demands until
they recover their social balance
– Does not always indicate presence of
psychopathology
Nervios
• Epidemiology:
– More common in women
• Symptoms:
– Multiple somatic complaints: headaches,
sleep difficulties, trembling
– Large number of emotional symptoms:
crying spells, anxiety
Nervios
• Treatment:
– Many people seek medical treatment
– Usually resolves with time
– Patient usually doesn’t expect meds
• Note:
– Similar to anxiety or mood disorders
– The word “Nervios” has two meanings
Comorbidity of “Nervios” with Mood and
Anxiety Disorders among Mexican Rural
Population
35
30
32.7
27.9
25
20
15
10
7.1
9.5
Any mood
disorder
Any anxiety
disorder
5
0
Women
Men
Salgado de Snyder, VN, Diaz-Perez, MJ, & Ojeda, V. (2000). The prevalence of nervios and associated
symptomatology among inhabitants of Mexican rural communities. Culture, Medicine and Psychiatry, .
Susto
• Etiology:
– Caused by a sudden fright
– Soul is dislodged from the body and can be
lost
• Epidemiology:
– Crosses all age, sex, and socioeconomic
groups
Susto
• Symptoms:
–
–
–
–
–
–
Multiple somatic complaints,
Appetite disturbances,
Sleep disturbances,
Feelings of low self worth, sadness
Weight loss
Can cause diabetes
Susto
• Treatment:
– Determined by severity of illness
– Herbal teas for mild cases
– Ritual ‘sweeping’ in more severe cases (limpia,
barrida)
• Best performed by a curandero but can be performed
by family member or other traditional healer
• focused on cleansing the body so the soul can return
Mal de Ojo
• Etiology:
– Occurs when a weak person is stared at by a
person with strong vision (‘vista fuerte’)
– This glance makes the weaker person’s spirit
‘sick’
– Requires cultural belief in the ‘evil eye’
– Usually caused inadvertently
Mal de Ojo
• Epidemiology:
– More common in children
• Symptoms:
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–
–
–
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Fitful sleeping, insomnia
Crying without apparent cause
Diarrhea, vomiting, fever
Headaches
Appetite loss
Mal de Ojo
• Prevention:
– Touch
– Wearing a red yarn, buck-eyes, or pink coral
bracelets
– Avoid direct eye contact
• Treatment:
– Ritual healing necessary to treat it
– Usually administered by family
– Directed at drawing sickness out of patient
• Egg treatment
Mal de Ojo
• Touch all children that you look at,
particularly in an admiring way
• Be careful about too direct eye contact
with patients you don’t know well
• Always shake hands with everyone in the
room
Empacho
• Epidemiology:
– Most common in children, but can occur in
any age group
• Symptoms:
– Bloating, vomiting, constipation,
stomachache, anorexia
Empacho
• Etiology:
– A bolus of food sticking to stomach wall
– Eating against own will
– Caused by improper diet
•
•
•
•
Poorly cooked food
Too much milk or cheese
Changing infant formula too fast
Swallowing saliva
Empacho
• Treatment
– Sobadora
• Folk practitioner specializing in musculoskeletal
treatments
– Lift and pinch skin around the spinal cord
– Rubbing stomach with olive oil, massaging
calves, drinking purgative teas or chamomile
(manzanilla)
Empacho
• Concerns:
– Certain home remedies (caseros) contain
lead and mercury
Mollera Caida
Mollera Caida
• Etiology:
– Sunken fontanelle
– Caused by incorrect care of the child (letting
the child fall, pulling the child off the bottle
too quickly, etc)
Mollera Caida
• Epidemiology:
– Occurs exclusively in infants
• Symptoms:
– Diarrhea, persistent crying, appetite loss,
sleeplessness
– May be fatal
Mollera Caida
• Treatment
– Most people seek traditional or home
remedies, rather than medical care
– Goal is to push the fontanelle back out
•
•
•
•
Push up on the palate
Hold child upside down
Suck on fontanelle
Put poultices on fontanelle
Mollera Caida
• Symptoms are the same as acute
gastroenteritis with dehydration
– Symptoms can be treated with rehydration
– BUT the dehydration is caused by the
sunken fontanelle, not the other way around
Aire
• Etiology:
– Thought to be caused by sudden
temperature change
• Epidemiology:
– Affects people of all ages
Aire
• Symptoms:
– Headaches, dizziness, body aches, fatigue,
chest discomfort
– Adults: muscular spasms and facial
paralysis
– Children: ear ache
• Treatment:
– To blow warm smoke into the ear (children)
– Cupping to loosen the muscles (adults)
– Most people seek medical treatment
Coping Styles
• Culture relates to how people cope with
everyday problems and more extreme types
of adversity
• Spirituality and Religion
Influence of Culture
• Familismo
– Importance of family over individual
– Respect for elders
– Family needs to be included in treatment decisions
• Fatalismo
– Our fate is out of our control
– Coping mechanism
– Can lead to non-compliance if not addressed
Therapeutic Networks
• Simultaneous use of multiple forms of therapy
– Popular sector
– Folk sector
– Professional sector
• Based on availability, payment, and on how
the sick person explains the origin of ill health
• What makes sense
• Use different sources of care at the same time
or in sequence
Barriers to Health Care Utilization
• Economic barriers
– Poverty
– Lack of medical insurance
• Language
• Low literacy
• Cultural Background
• Immigration Status
– fear, lack of knowledge of programs available,
and concern over repercussions to their
immigration status
• Discrimination
Health Care Quality Survey,
Commonwealth Fund
• Minorities more likely to report being treated
with disrespect or being looked down upon in
the patient-provider relationship
•
•
•
•
Asians: 20.2%
Latinos: 19.4%
African Americans: 14.1%
Whites: 9.4%
Blanchard & Lurie (2004)
Intracultural Variations
• Intersection of life experiences/cultural
processes
• Variation occurs among individuals
–
–
–
–
–
in the same setting,
across generations,
between genders,
across geographic settings, and
rural and urban settings
Culture Counts
• Patient’s culture
• Clinician’s culture
– Western medicine
– Emphasizes body/mind separation
– Evidence-based
Model for Cross-Cultural Care:
A Patient-Based Approach
Awareness
of Cultural
and Social
Factors
Elicit
Factors
Negotiate
Models
Implement
Management
Strategies
Includes building trust and double checking clinical decisions to
avoid stereotyping
Tools and skills necessary to provide quality
care to any patient
Recommendations to Service Providers
• Maximize already existing personal and social
resources:
– Religion
– Culture
– Family
– Social networks
– Personal
Source: Salgado de Snyder, V. N., y cols. (1998). Pathways to mental health services among
inhabitants of a Mexican village with high migratory tradition to the U.S. Health and Social Work,
23(4), 249-261.
Final comments
Don’t forget context
• Come for economic reasons – to work!
• Increased violence and trauma
• Increased anti immigrant sentiment:
discrimination
Don’t forget culture: Culture goes both ways
From Nelida’s Story
• What is Nelida’s message?
• What are the cultural understandings that
people of Los Molinos have regarding water
boiling?
• What are the conflicts between the message
and cultural beliefs?
• What would you do to help Nelida
communicate her message more
effectively?