The ethnic terms Latino or Hispanic refer to a diverse population of Latin American descent that includes many nationalities and races. Latino refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.¹ Latinos comprised nearly 16 percent of the U.S. population in 2009, making them the largest minority group.¹ By 2050, it is projected that they will comprise up to 30 percent of the U.S. population.² The three largest subgroups include Mexican Americans (about 65 percent), mostly settled in the Southwest, Puerto Ricans (9.1 percent) in the urban Northeast, and Cuban Americans (3.5 percent) in Florida.³ However, these demographics are rapidly shifting as Latino populations are increasingly integrated into suburban and rural communities throughout America. About 23 percent of Latinos in the United States live in poverty.²

There is ample evidence that Latinos, especially those of Mexican and Central American origin, face significant obstacles to obtaining health care, especially language barriers.⁴ Many hospitals and offices lack trained interpreters and rely on ad hoc interpretation by bilingual staff or even the children of patients. Lack of third party reimbursement for professional interpreter services exacerbates this problem. Adding to the language barrier is the pitfall of false fluency, when physicians mistake the meaning of a Spanish word because of unfamiliarity with cultural or linguistic subtleties.⁴ Another barrier is inability to afford health insurance; nearly one-third of Latinos (30.7 percent) lack coverage.⁵ Yet another barrier stems from cultural mistrust coupled with a predisposition to seek alternative care first, thus delaying conventional treatment. Many Latinos are accustomed to self-treating because most pharmaceuticals are available without prescription in their home countries. Recent immigrants may face additional obstacles to care, including illegal immigration status (fears of deportation), illiteracy, and a radically different set of health beliefs.

A consequence of these problems is a marked disparity in the quality of care that Latino patients receive. In a 2002 report from the Institute of Medicine, more than 175 studies were cited to document this disparity.⁶ In an attempt to address this problem, the National Standards for Culturally and Linguistically Appropriate Services (CLAS) were released in 2001 by the Office of Minority Health of the U.S. Department of Health and Human Services.⁷ Fourteen guidelines were published, which were organized around three main themes: culturally competent care, language access services, and organizational supports. Culturally competent care necessitates cross-cultural training, which is increasingly included in medical education, but with the realization that cultural competency is a lifelong learning process rather than an end in itself.⁸

Health Issues

SPECIAL MEDICAL CONCERNS

Latinos have disproportionately higher rates of obesity and diabetes mellitus (Table 1).^9–14 Approximately 43 percent of Mexican Americans older than 20 years are obese, compared with 33 percent of the non-Latino white population.¹² Diabetes and hypertension are closely linked with obesity; 11.8 percent of Latinos older than 20 years have type 2 diabetes (13.3 percent of Mexican Americans), making it the foremost health issue in this population.¹⁴ A higher-calorie diet, a more sedentary lifestyle, and genetic factors contribute to this problem. Because of less access to health care, Latinos with diabetes are often diagnosed later and have a greater risk of complications.^15,16 Despite these unfavorable health and socioeconomic statistics, overall mortality is lower than would be expected—an anomaly termed the Hispanic paradox.¹⁷ Latinos live an average of 2.5 years longer than non-Latino whites (to 80 years, seven months of age) and 7.7 years longer than non-Latino blacks.¹ It is not known what protective factors exist, but immigrant hardiness, social integration, and diet may have a role.¹ Raising awareness about the consequences of obesity is necessary in Latino communities, especially because being somewhat overweight (gordito) can be considered healthy. Mexican Americans are much less likely to be treated for hypertension than non-Latino whites (35 versus 49 percent).¹¹ Targeted public health campaigns are needed for hypertension, diabetes prevention, and weight control.

Many Latino immigrants experience tremendous stress once they are in the United States. Emotional distress often presents with headaches (dolor de cabeza) or other physical symptoms instead of depressed mood.⁹ Consequently, a high index of suspicion is needed to recognize adjustment reactions or depression. Neurocysticercosis, a leading cause of seizures in Mexico, and pulmonary tuberculosis are more common in Latino immigrants.¹⁰ Interferon gamma–release assay blood testing for tuberculosis is now preferred over tuberculin skin testing in immigrants with a history of bacille Calmette-Guérin vaccination because of a high rate of false-positive results with skin testing (although skin testing is still recommended for children younger than five years).¹³ Publicized fears of contagion from illegal immigration may be overblown. Despite a lack of U.S. studies, a Norwegian study found that although immigrants from tuberculosis-endemic regions did bring more strains of tuberculosis with them, they did not significantly contribute to the spread of tuberculosis within the resident population.¹⁸

HEALTH CARE BELIEFS AND FOLK ILLNESSES

Non-Latino physicians may be perplexed by references to folk healing and illness in Latino patients. Latino healing traditions include curanderismo in Mexico and much of Latin America, Santeria in Brazil and Cuba, and espiritismo in Puerto Rico.¹⁹ Curanderos, traditional healers, distinguish between “hot” and “cold” illnesses (Table 2²⁰ ) and occasionally between natural and unnatural (sorcery-related) diseases.^19,20 Patients may seek out the care of brujos or brujas (wizards or witches) for the latter conditions. Other healing specialties include yerberas (herbalists), hueseros (bone setters), parteras (midwives), and sobradores (similar to physical therapists).²¹

Symptoms are often interpreted differently based on cultural presuppositions. Posttraumatic shock or anxiety may be attributed to susto (“soul loss”) rather than posttraumatic stress disorder. Abdominal pain may be attributed to empacho, or food stuck in the intestine. A child's failure to thrive may be attributed to mal de ojo (“evil eye”), a hex conveyed by an envious glance. Table 3 lists some common Latino folk illnesses, their symptoms, and treatment.¹⁹ Therapies for these conditions may seem odd, but most are harmless, with a few exceptions. Azarcon and greta (lead salts) and azogue (mercury) compounds, which are sometimes given for teething or empacho, are contraindicated.²² Some injuries have occurred with curandero treatment of caida de la mollera (“fallen fontanel”). However, it may be more likely to mistakenly suspect child abuse than to actually encounter it in patients who use traditional treatments.²³

Herbal therapies play a major role in Latino folk medicine, so knowing the Spanish names of common herbs can be helpful (eTable A). A large selection of herbal teas are available from botanicas or yerberas in most Latino neighborhoods. Herbs often have hot or cold properties; hot herbs are used to treat cold conditions, and vice versa. A mother might use cooling herbs to treat diaper rash, a hot condition. She might also stop giving her infant vitamins, because they are a hot therapy.²⁴ It is often possible to safely accommodate conventional and alternative treatments (in reasonable doses) if potential conflicts or interactions are identified in advance. Web-based resources are available to assist physicians in understanding Latino health beliefs (Table 4).

Patients should be asked if they use alternative therapies, because it is not likely that such information will be volunteered. Latinos' belief in alternative treatment is affected by many factors, including education, socioeconomic class, and time spent in the United States (acculturation). First-generation immigrants are likely to seek out curanderos, whereas their children may scoff at the idea. Physicians cannot assume that all Latinos share these beliefs; many do not. America is rapidly changing as a “cultural collision” between Latino and white culture transforms lives on both sides of the border. Exposure to U.S. media is changing traditional Latino perceptions of health, diet, and body image, even as non-Latino Americans are influenced by Mexican cuisine and culture.

Approaches to Care

CULTURAL VALUES

Latino culture has several normative values that must be recognized in clinical settings. These include simpatía (kindness), personalismo (friendliness), and respeto (respect).²⁵ Simpatía emphasizes politeness and conflict avoidance. Personalismo, a personal connection, can be achieved by asking about the patient and his or her family. Because people stand closer to each other in most Latino cultures, physical proximity is also perceived as being more personable. Respeto implies attentive concern for the patient and respect of his or her personhood and age, especially if the patient is older. Older patients should be addressed as señor or señora rather than by their first names. Using don or doña with the given or full name indicates even greater respect for older patients.

Addressing patients properly can be another challenge. Double or hyphenated Latino surnames may seem complicated, with the father's name preceding the mother's. Additionally, when a woman gets married, her husband's name may be appended to her father's name. After immigration, some Latios adopt American naming conventions, but others do not. When in doubt, the best policy is to ask the patient how he or she would like to be addressed.²⁶

The cultural value of modestia (modesty), which is related to respect, is often neglected.²⁷ Latinos may be conservative in this area, and physical exposure should be negotiated as the examination warrants. A chaperone is often appreciated if a same-sex physician is not available. Although patients of all cultural backgrounds warrant kindness, a personal connection, and respect, the consequences of omitting these traditional values may be more problematic with Latinos.

CROSS-CULTURAL INTERVIEW

Cross-cultural interviewing can be facilitated by following specific guidelines, and several mnemonics have been developed for use by physicians. In the LEARN model, which is illustrated in the Case Study below,^28,29 the physician should first sympathetically listen to the patient's perception of the problem, explain his or her perception of the problem to the patient, acknowledge and discuss any differences and similarities between the two views, recommend a treatment plan, and negotiate agreement.³⁰ Use of the LEARN technique identifies and helps resolve any cultural differences that may arise.

TEACH BACK AND PATIENT ACTIVATION

Conveying medical instructions to patients with limited English skills can be frustrating. For literate patients, it may be helpful to write things down, even if this must be done in English rather than Spanish. These instructions can be studied by the patient or translated when time permits. Spanish language handouts are a better option. However, the most useful technique is “teach back” or “show me”: having patients repeat their care instructions until they do it correctly. The extra time necessary for this technique is justified by the prospect of much better understanding and adherence.³¹

Patients should be actively involved in their care rather than passively acquiescing to instructions. Such “patient activation” or motivation for change is more challenging in foreign-born Latinos, but may be achieved through active dialogue and discussion.³² Hopeful involvement in the care plan should replace fatalism or resignation.

A CARING ENVIRONMENT

Medical practices and hospitals should strive to create an environment that is warm and welcoming to Latino patients. Bilingual posters and medical literature are an important starting point. Spanish language handouts are available from several Internet sources.³³ Recruiting Latino physicians and staff, and recognizing Latino holidays at the office (e.g., Cinco de Mayo), will open many doors to the Latino community.³⁴ Office staff, as well as physicians, should be instructed in basic cultural sensitivity (Table 5).^34,35 Hospitals can include culturally appropriate foods in their menus.

Developing cultural sensitivity to Latino patients entails recognizing and appreciating their diversity. As with any patient, Latinos should be treated as individuals first, while exploring possible cultural distinctions. Bridging such cultural gaps, wide or narrow, will result in better physician-patient relationships and more effective care.