Cultural Population. Mexican Heritage. Health Care.

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People of Mexican Heritage

Chapter 18

RICK ZOUCHA and CECILIA A. ZAMARRIPA

Overview, Inhabited Localities, and Topography OVERVIEW

People of Mexican heritage are a very diverse group geo- graphically, historically, and culturally and are not easy to describe. Although no specific set of characteristics can fully describe people of Mexican heritage, some common- alities distinguish them as an ethnic group, with many regional variations that reflect subcultures in Mexico and in the United States. A common term used to describe Spanish-speaking populations in the United States, including people of Mexican heritage, is Hispanic. However, the term can be misleading and can encompass many different people clustered together owing to a com- mon heritage and lineage from Spain. Many Hispanic people prefer to be identified by descriptors more specific to their cultural heritage, such as Mexican, Mexican American, Latin American, Spanish American, Chicano, Latino, or Ladino. Therefore, when referring to Mexican Americans, use that phrase instead of Hispanic or Latino (Vázquez, 2001). As a broad ethnic group, people of Mexican heritage often refer to themselves as la raza, which means “the race.” The Spanish word for race has a different meaning than the American interpretation of race. The concept of la raza has brought people together from separate worlds to make families and is about inclu- sion (Vázquez, 2000).

HERITAGE AND RESIDENCE

Mexico, with a population of 107,449,525 (CIA, 2007), is a blend of Spanish white and Indian, Native American,

Middle Eastern, and African. Mexican Americans are descendants of Spanish and other European whites; Aztec, Mayan, and other Central American Indians; and Inca and other South American Indians as well as people from Africa (Schmal & Madrer, 2007). Some individuals can trace their heritage to North American Indian tribes in the southwestern part of the United States.

Mexico City, one of the largest cities in the world, has a population of over 20 million. Mexico is undergoing rapid changes in business and health-care practices. Undoubtedly, these changes have accelerated and will continue to accelerate with the passage of the North American Free Trade Agreement as people are more able to move across the border to seek employment and edu- cational opportunities.

Historically, people of Mexican heritage lived on the land that is now known as the southwestern United States for generations, long before the first white settlers came to the territory. By 1853, approximately 80,000 Spanish-speaking settlers lived in the area lost by Mexico during the Texas Rebellion, the Mexican War, and the Gadsden Purchase. After the northern part of Mexico was annexed to the United States, the settlers were not offi- cially considered immigrants but were often viewed as foreigners by incoming white Americans. By 1900, Mexican Americans numbered approximately 200,000. However, during the “Great Migration” between 1900 and 1930, an additional 1 million Mexicans entered the United States. This may have been the greatest immigra- tion of people in the history of humanity (Library of Congress, 2005).

Hispanics, the fastest growing ethnic population in the United States, include over 35.3 million people, or 13.2 percent of the population. Fifty-eight percent are of Mexican heritage, with an increase from 13.5 million in

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1990 to 20.6 million in 2000 (U.S. Bureau of the Census, 2001). Mexican Americans reside predominantly in California, Texas, Illinois, Arizona, Florida, New Mexico, and Colorado. However, the major concentration of Mexican Americans, totaling over 18 million, are found in the southern and western portions of the United States (U.S. Bureau of the Census, 2001). Ninety percent of Mexican Americans live in urban areas such as San Diego, Los Angeles, New York City, Chicago, and Houston, whereas less than 10 percent reside in rural areas.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Historically, many Mexicans left Mexico during the Mexican Revolution to seek political, religious, and eco- nomic freedoms (Congress, 2005). Following the Mexican Revolution, strict limits were placed on the Catholic Church, and until recently, clerics were not allowed to wear their church garb in public. For many, this restricted the expression of faith and was a minor factor in their immigration north to the United States (Meyer & Beezley, 2000). Since the “Great Migration,” limited employment opportunities in Mexico, especially in rural areas, has encouraged Mexicans to migrate to the United States as sojourners or immigrants or with undoc- umented status; the latter are often derogatorily referred to as wetbacks (majodos) by the white and Mexican American populations.

Of undocumented immigrants in the United States, an estimated 6 million are from Mexico (Van Hook, Bean, & Passel, 2005). Before the Immigration Reform and Control Act of 1986, hundreds of thousands of Mexicans crossed the border, found jobs, and settled in the United States. Although the numbers have decreased since 1986, border towns in Texas and California still experience large influxes of Mexicans seeking improved employment and educational opportunities. The tide of illegal immigration to the United States has increased, as evidenced by the apprehension of Mexicans attempting to enter the United States annually, with estimates of 250,000 to 300,000 peo- ple entering illegally (Passel, 2004).

Even though the economy of Mexico has grown, the buying power of the peso has decreased and inflation rates have increased faster than wages; thus, 43 percent of the population continues to live in poverty (CIA, 2007). Recent Mexican immigrants are more likely to live in poverty, more pessimistic about their future, and less edu- cated than previous immigrants. Many Mexicans are among the very poor, with little hope of improving their economic status. Between the years 1999 and 2000 in the United States, the poverty rate for Hispanics was 22.6 per- cent (U.S. Bureau of the Census, 2001).

EDUCATIONAL STATUS AND OCCUPATIONS

Many second- and third-generation Mexican Americans have significant job skills and education. By contrast, many, especially newer immigrants from rural areas, have poor educational backgrounds and may place lit- tle value on education because it is not needed to

obtain jobs in Mexico. Once in the United States, they initially find work similar to that which they did in their native land, including farming, ranching, mining, oil production, construction, landscaping, and domes- tic jobs in homes, restaurants, and hotels and motels. Economic and educational opportunities in the United States are attainable, which allows immigrants to pur- sue the great American dream of a perceived better life (Kemp, 2001). Many Mexicans and Mexican Americans work as seasonal migrant workers, who may relocate several times each year as they “follow the sun.” Sometimes, their unwillingness or inability to learn English is related to their intent to return to Mexico; however, this may hinder their ability to obtain better paying jobs (Fig. 18–1).

The mean educational level in Mexico is 5 years. Until 1992, Mexican children were required to attend school through the sixth grade, but since the Mexican School Reform Act of 1992, a ninth-grade education is required. However, great strides have been made in educational standards in Mexico, which now reports a 92 percent lit- eracy rate among its population (CIA, 2007). A common practice among parents in poor rural villages is to educate their children in what they need to know. This group often finds immigration to the United States to be their most attractive option. For many Mexicans, high school and a university education is unavailable and, in many cases, unattainable.

Hispanics are the most undereducated ethnic group in the United States, with only 57 percent aged 25 years or older having a high school education, compared with 88.4 percent for non-Hispanic whites. However, that number increased from 43 percent to 57 percent complet- ing high school from 1993 to 2000 (U.S. Bureau of the Census, 2001). Some migrant worker camps have free or low-cost bilingual educational programs to assist Mexican Americans in learning to read and write in both lan- guages. Only 10.6 percent of Mexican Americans aged 25 years or older have a college degree. However, the number of Hispanics who completed 4 years of college doubled between 1990 and 2000 (U.S. Bureau of the Census, 2001).

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FIGURE 18–1 A migrant worker camp on Maryland’s eastern shore. The Sanchez family (discussed in the Case Study on line) lives in such a camp, as do many Mexican American farm workers in the United States.

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Communication DOMINANT LANGUAGE AND DIALECTS

Mexico is one of the largest Spanish-speaking countries in the world, with over 80 million speaking the language. The dominant language of Mexicans and Mexican Americans is Spanish. However, Mexico has 54 indige- nous languages and more than 500 different dialects (Spanish Language, 2007). Knowing the region from which a Mexican American originates may help to iden- tify the language or dialect the individual speaks. For example, major indigenous languages besides Spanish include Nahuatl and Otami, spoken in central Mexico; Mayan, in the Yucatan peninsula; Maya-Quiche, in the state of Chiapas; Zapotec and Mixtec, in the valley of Oaxaca; Tarascan, in the state of Michoacan; and Totonaco, in the state of Veracruz. Many of the Spanish dialects spoken by Mexican Americans have similar word meanings. However, the dialects of Spanish spoken by other groups may not have the same meanings. Because of the rural isolationist nature of many ethnic groups and the influence of native Indian languages, the dialects are so diverse in selected regions that it may be difficult to understand the language, regardless of the degree of flu- ency in Spanish.

Radio and television programs broadcasting in Spanish in both the United States and Mexico have helped to standardize Spanish. For the most part, public broadcast communication is primarily derived from Castilian Spanish. This standardization reduces the difficulties experienced by subcultures with multiple dialects. When speaking in a nonnative language, health-care providers must select words that have relatively pure meanings in the language and avoid the use of regional slang.

Contextual speech patterns among Mexican Americans may include a high-pitched, loud voice and a rate that seems extremely fast to the untrained ear. The language uses apocopation, which accounts for this rapid speech pattern. An apocopation occurs when one word ends with a vowel and the next word begins with a vowel. This creates a tendency to drop the vowel ending of the first word and results in an abbreviated, rapid- sounding form. For example, in the Spanish phrase for How are you?, ¿Cómo está usted? may become ¿Comestusted?. The last word, usted, is frequently dropped. Some may find this fast speech difficult to understand. However, if one asks the individual to enun- ciate slowly, the effect of the apocopation or truncation is less pronounced.

To help bridge potential communication gaps, health- care providers need to watch the client for cues, para- phrase words with multiple meanings, use simple sen- tences, repeat phrases for clarity, avoid the use of regional idiomatic phrases and expressions, and ask the client to repeat instructions to ensure accuracy. Approaching the Mexican American client with respect and personalismo (being friendlike) and directing questions to the domi- nant member of a group (usually the man) may help to facilitate more open communication. Zoucha and Husted (2002) found that becoming personal with the client or

family is essential to building confidence and promoting health. The concept of personalismo may be difficult for some health-care professionals because they are socialized to form rigid boundaries between the caregiver and the client and family.

CULTURAL COMMUNICATION PATTERNS

Whereas some topics such as income, salary, or invest- ments are taboo, Mexican Americans generally like to express their inner beliefs, feelings, and emotions once they get to know and trust a person. Meaningful conver- sations are important, often become loud, and seem dis- organized. To the outsider, the situation may seem stress- ful or hostile, but this intense emotion means the conversants are having a good time and enjoying each other’s company. Within the context of personalismo and respeto, respect, health-care providers can encourage open communication and sharing and develop the client’s sense of trust by inquiring about family members before proceeding with the usual business. It is important for health-care providers to engage in “small talk” before addressing the actual health-care concern with the client and family (Zoucha & Reeves, 1999).

Mexican Americans place great value on closeness and togetherness, including when they are in an in-patient facility. They frequently touch and embrace and like to see relatives and significant others. Touch between men and women, between men, and between women is accept- able. To demonstrate respect, compassion, and under- standing, health-care providers should greet the Mexican American client with a handshake. Once rapport is estab- lished, providers may further demonstrate approval and respect through backslapping, smiling, and affirmatively nodding the head. Given the diversity of dialects and the nuances of language, culturally congruent use of humor is difficult to accomplish and, therefore, should be avoided unless health-care providers are absolutely sure there is no chance of misinterpretation. Otherwise, inap- propriate humor may jeopardize the therapeutic relation- ship and opportunities for health teaching and health promotion.

Mexican Americans consider sustained eye contact when speaking directly to an older person to be rude. Direct eye contact with teachers or superiors may be inter- preted as insolence. Avoiding direct eye contact with superiors is a sign of respect. This practice may or may not be seen with second- or third-generation Mexican Americans. Health-care providers must take cues from the client and family.

TEMPORAL RELATIONSHIPS

Many Mexican Americans, especially those from lower socioeconomic groups, are necessarily present oriented. Many individuals do not consider it important or have the income to plan ahead financially. The trend is to live in the “more important” here and now, because mañana (tomorrow) cannot be predicted. With this emphasis on living in the present, preventive health care and immu- nizations may not be a priority. Mañana may or may not

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really mean tomorrow; it often means “not today” or “later.”

Some Mexicans and Mexican Americans perceive time as relative rather than categorically imperative. Deadlines and commitments are flexible, not firm. Punctuality is generally relaxed, especially in social situations. This con- cept of time is innate in the Spanish language. For exam- ple, one cannot be late for an appointment; one can only arrive late! In addition, a few immigrants from rural envi- ronments in which adhering to a strict time clock is unimportant may not own a clock or even be able to tell time.

Because of their more relaxed concept of time, Mexican Americans may arrive late for appointments, although the current trend is toward greater punctuality. Health-care facilities that use an appointment system for clients may need to make special provisions to see clients whenever they arrive. Health-care providers must care- fully listen for clues when discussing appointments. Disagreeing with health-care providers who set the appointment may be viewed as rude or impolite. Therefore, some Mexican Americans will not tell you directly that they cannot make the appointment. In the context of the discussion, they may say something like “my husband goes to work at 8:00 a.m. and the children are off to school, then I have to do the dishes . . . .” The health-care professional should ask: “Is 8:30 a.m. on Thursday okay for you?” The person might say yes but the health-care professional must still intently listen to the conversation and then possibly negotiate a new time for the appointment. In the conversation, the client may give clues that they will not arrive at the intended time, because it is important to save face and avoid being rude by saying they will not arrive on time.

FORMAT FOR NAMES

Names in most Spanish-speaking populations seem com- plex to those unfamiliar with the culture. A typical name is La Señorita Olga Gaborra de Rodriguez. Gaborra is the name of her father, and Rodriguez is her mother’s sur- name. When she marries a man with the surname Guiterrez, she becomes La Señora (denotes a married woman) Olga Guiterrez de Gaborra y Rodriguez. The word de is used to express possession, and the father’s name, which is considered more important than the mother’s, comes first. However, this full name is rarely used except on formal documents and for recording the name in the family Bible. Out of respect, most Mexican Americans are more formal when addressing nonfamily members. Thus, the best way to address Olga is not by her first name but rather as Señora Guiterrez. Titles such as Don and Doña for older respected members of the community and family are also common. If using English while communicating with people older than the nurse or health-care provider, use titles such as Mr., Ms., Miss, or Mrs., as a sign of respect.

Health-care providers must understand the role of older people when providing care to people of Mexican heritage. To develop confidence and personalismo, an ele- ment of formality must exist between health-care providers and older people. Becoming overly familiar by

using physical touch or addressing them by first names may not be appreciated early in a relationship (Kemp, 2001). As the health-care professional develops confi- dence in the relationship, becoming familiar may be less of a concern. However, using the first name of an older client may never be appropriate (Zoucha & Husted, 2000).

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

The typical family dominance pattern in traditional Mexican American families is patriarchal, with evidence of slow change toward a more egalitarian pattern in recent years (Grothaus, 1996). Change to a more egalitar- ian decision-making pattern is primarily identified with more educated and higher socioeconomic families. Machismo in the Mexican culture sees men as having strength, valor, and self-confidence, which is a valued trait among many. Men are seen as wiser, braver, stronger, and more knowledgeable regarding sexual matters. The female takes responsibility for decisions within the home and for maintaining the family’s health. Machismo assists in sustaining and maintaining health not only for the man but also with implications for the health and well- being of the family (Sobralske, 2006).

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

Children are highly valued because they ensure the con- tinuation of the family and cultural values (Locke, 1999). They are closely protected and not encouraged to leave home. Even compadres (godparents) are included in the care of the young. Each child must have godparents in case something interferes with the parents’ ability to ful- fill their child-rearing responsibilities. Children are taught at an early age to respect parents and older family mem- bers, especially grandparents. Physical punishment is often used as a way of maintaining discipline and is some- times considered child abuse in the United States. Using children as interpreters in the health-care setting is dis- couraged owing to the restrictive nature of discussing gender-specific health assessments.

FAMILY GOALS AND PRIORITIES V I G N E T T E 1 8 . 1

Mr. Perez is a 76-year-old Mexican American who was recently diagnosed with a slow heartbeat requiring an implanted pacemaker. Mr. Perez has been married for 51 years and has 6 adult children (three daughters aged 50, 48, and 42; three sons aged 47, 45, and 36), 11 grandchil- dren; and 2 great grandchildren. The youngest boy lives three houses down from Mr. and Mrs. Perez. The other children, except the second-oldest daughter, live within 3 to 10 miles from their parents. The second-oldest daughter is a registered nurse and lives out of state. All members of the family except for Mr. Perez were born in the United States. He was born in Monterrey, Mexico, and immigrated to the United States at

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the age of 18 in order to work and send money back to the family in Mexico. Mr. Perez has returned to Mexico through- out the years to visit and has lived in Texas ever since. Mr. Perez is retired from work in a machine shop. Mr. Perez has one living older brother who lives within 5 miles. All mem- bers of the family speak Spanish and English fluently.

The Perez family is Catholic, as evidenced by the religious items hanging on the wall and prayer books and rosary on the coffee table. Statues of St. Jude and Our Lady of Guadalupe are on the living room table. Mr. and Mrs. Perez have made many mandas (bequests) to pray for the health of the family, including one to thank God for the healthy birth of all the children, especially after the doctor had discouraged them from having any children after the complicated birth of their first child. The family attends Mass together every Sunday morning and then meets for breakfast chorizo at a local restaurant frequented by many of their church’s other parish- ioner families. Mr. Perez believes his health and the health of his family are in the hands of God.

The Perez family lives in a modest four-bedroom ranch home that they bought 22 years ago. The home is located in a predominantly Mexican American neighborhood located in La Loma section of town. Mr. and Mrs. Perez are active in the church and neighborhood community. The Perez home is usually occupied by many people and has always been the gathering place for the family.

During his years of employment, Mr. Perez was the sole provider for the family and now receives social security checks and a pension. Mrs. Perez is also retired and receives a small pension for a short work period as a teacher’s aide. Mr. and Mrs. Perez count on their nurse daughter to guide them and advise on their health care. Mr. Perez visits a curandero for medicinal folk remedies. Mrs. Perez is the provider of spir- itual, physical, and emotional care for the family. In addition, their nurse daughter is always present during any major surg- eries or procedures. Mrs. Perez and her daughter the nurse will be caring for Mr. Perez during his procedure for a pace- maker.

1. Explain the significance of family and kinship for the Perez family.

2. Describe the importance of religion and God for the Perez family.

3. Identify two stereotypes about Mexican Americans that were dispelled in this case with the Perez family.

4. What is the role of Mrs. Perez in this family?

The concept of familism is an all-encompassing value among Mexicans, for whom the traditional family is still the foundation of society. Family takes precedence over work and all other aspects of life. In many Mexican fami- lies, it is often said “God first, then family.” The dominant Western health-care culture stresses including the client and family in the plan of care. Mexicans are strong propo- nents of this family care concept, which includes the extended family. By including all family members, health- care providers can build greater trust and confidence and, in turn, increase compliance with health-care regimens and prescriptions (Wells, Cagle, & Bradley, 2006).

Blended communal families are almost the norm in lower socioeconomic groups and in migrant-worker

camps. Single, divorced, and never-married male and female children usually live with their parents or extended families, regardless of economics. Extended kinship is common through padrinos, godparents who may be close friends are usually considered family members (Zoucha & Zamarripa, 1997). Thus, the words brother, sister, aunt, and uncle do not necessarily mean that they are related by blood. For many men, having children is evidence of their virility and a sign of machismo.

When grandparents and older parents are unable to live on their own, they generally move in with their children. The extended family structure and the Mexicans’ obliga- tion to visit sick friends and relatives encourage large num- bers to visit hospitalized family members and friends. This practice may necessitate that health-care providers relax strict visiting policies in health-care facilities.

Social status is highly valued among Mexican Americans, and a person who holds an academic degree or position with an impressive title commands great respect and admiration from family, friends, and the com- munity. Good manners, a family, and family lineage, as indicated by extensive family names, also confer high sta- tus for Mexicans.

ALTERNATIVE LIFESTYLES

Twenty-six percent of Mexican families in the United States live in poverty, and many are headed by a single female parent. This percentage is lower than that for other minority groups in the United States (U.S. Bureau of the Census, 2001). Because the Hispanic cultural norm is for a pregnant woman to marry, Mexicans are more likely to marry at a young age. Yet, common law marriages (unidos) are frequently practiced and readily accepted, with many couples living together their entire lives.

Although homosexual behavior occurs in every soci- ety, The Williams Project reported that five states (California, Texas, New York, Florida, and Illinios) have the highest number of same-sex Latino couples, totaling 100,796, living together in the United States (Gates, Lau, & Sears, 2006). Newspapers from Houston, Texas; Washington, D.C.; and Chicago, Illinois, report on the efforts of Hispanic lesbian and gay organizations in the areas of HIV and AIDS (La SIDA in Spanish) and life part- ner benefits. In Mexico, antihate groups raised serious concerns about killings of homosexual men, causing many to remain closeted (Redding, 1999). In Mexico, machismo plays a large part in the phobic attitudes toward gay behavior. Larger cities in the United States may have Ellas, a support group for Latina Lesbians; El Hotline of Hola Gay, which provides referrals and information in Spanish; or Dignity, for gay Catholics. Health-care providers who wish to refer gay and lesbian clients to a support group may use such agencies.

Workforce Issues CULTURE IN THE WORKPLACE

In the United States, Hispanics are the most underrepre- sented minority group in the health-care workforce.

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Although over 13 percent of the American population is of Hispanic origin, only 1.8 percent of registered nurses are from Hispanic heritage (National Sample Survey of Registered Nurses, 2004). Cultural differences that influ- ence workforce issues include values regarding family, pedagogical approach to education, emotional sensitiv- ity, views toward status, aesthetics, ethics, balance of work and leisure, attitudes toward direction and delega- tion, sense of control, views about competition, and time.

People educated in Mexico are likely to have been exposed to pedagogical approaches that include rote memorization and an emphasis on theory with little prac- tical application taught within a rigid, broad curriculum. American educational systems usually emphasize an ana- lytical approach, practical applications, and a narrow, in- depth specialization. Thus, additional training may be needed for some Mexicans when they come to the United States.

Because family is a first priority for most Mexicans, activities that involve family members usually take prior- ity over work issues. Putting up a tough business front may be seen as a weakness in the Mexican culture. Because of this separation of work from emotions in American culture, most Mexican Americans tend to shun confrontation for fear of losing face. Many are very sensi- tive to differences of opinion, which are perceived as dis- rupting harmony in the workplace. People of Mexican heritage find it important to keep peace in relationships in the workplace.

For many Mexicans, truth is tempered by diplomacy and tact. When a service is promised for tomorrow, even when they know the service will not be completed tomor- row, it is promised to please, not to deceive. Thus, for many Mexicans, truth is seen as a relative concept, whereas for most European Americans, truth is an absolute value and people are expected to give direct yes and no answers. These conflicting perspectives about truth can complicate treatment regimens and commit- ment to the completion of work assignments. Intentions must be clarified and, at times, altered to meet the needs of the changing and multicultural workforce.

For most Mexicans, work is viewed as a necessity for survival and may not be highly valued in itself, whereas money is for enjoying life. Most Mexican Americans place a higher value on other life activities. Material objects are usually necessities and not ends in them- selves. The concept of responsibility is based on values related to attending to the immediate needs of family and friends rather than on the work ethic. For most Mexicans, titles and positions may be more important than money.

Many Mexicans believe that time is relative and elastic, with flexible deadlines, rather than stressing punctuality and timeliness. In Mexico, shop hours may be posted but not rigidly respected. A business that is supposed to open at 8:00 a.m. opens when the owner arrives; a posted time of 8:00 a.m. may mean the business will open at 8:30 a.m., later, or not at all. The same attitude toward time is evidenced in reporting to work and in keeping social engagements and medical appointments. If people believe that an exact time is truly important, such as the

time an airplane leaves, then they may keep to a schedule. The real challenge for employers is to stress the impor- tance and necessity of work schedules and punctuality in the American workforce.

ISSUES RELATED TO AUTONOMY

Many Mexican Americans respond to direction and dele- gation differently from European Americans. Many newer immigrants are used to having traditional autocratic managers who assign tasks but not authority, although this practice is beginning to change with more American- managed companies relocating to Mexico. A Mexican worker who is not accustomed to responsibility may have difficulty assuming accountability for decisions. The indi- vidual may be sensitive to the American practice of check- ing on employees’ work.

Mexicans who were born and educated in the United States usually have no difficulty communicating with others in the workplace. When better-educated Mexican immigrants arrive in the United States, they usually speak some English. Newer immigrants from lower socioeco- nomic groups have the most difficulty acculturating in the workplace and may have greater difficulty with the English language.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Because Mexican Americans draw their heritage from Spanish and French peoples and various North American and Central American Indian tribes and Africans, few physical characteristics give this group a distinct identity. Some individuals with a predominant Spanish back- ground might have light-colored skin, blond hair, and blue eyes, whereas people from indigenous Indian back- grounds may have black hair, dark eyes, and cinnamon- colored skin. Intermarriages among these groups have created a diverse gene pool and have not produced a typical-appearing Mexican.

Cyanosis and decreased hemoglobin levels are more difficult to detect in dark-skinned people, whose skin appears ashen instead of the bluish color seen in light- skinned people. To observe for these conditions in dark- skinned Mexicans, the practitioner must examine the sclera, conjunctiva, buccal mucosa, tongue, lips, nailbeds, palms of the hands, and soles of the feet. Jaundice, like- wise, is more difficult to detect in darker-skinned people. Thus, the practitioner needs to observe the conjunctiva and the buccal mucosa for patches of bilirubin pigment in dark-skinned Mexicans.

DISEASES AND HEALTH CONDITIONS

Common health problems most consistently docu- mented in the literature for both people from Mexico and Mexican Americans are difficulty in assessing and utiliz- ing health care, malnutrition, malaria (in some places), cancer, alcoholism, drug abuse, obesity, hypertension,

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diabetes, heart disease, adolescent pregnancy, dental dis- ease, and HIV and AIDS (Kemp, 2001). In Mexican American migrant-worker populations, infectious, com- municable, and parasitic diseases continue to be major health risks. Substandard housing conditions and employment in low-paying jobs have perpetuated higher rates of tuberculosis in Mexican Americans. Intestinal parasitosis, amoebic dysentery, and bacterial diarrhea (Shigella) are common among Mexican immigrants (Kim- Godwin, Alexander, Felton, Mackey, & Kasakoff, 2006).

Newer Mexican immigrants from coastal lowland swamp areas and from some mountainous areas where mosquitoes are more prevalent may also have a higher incidence of malaria. People from high mountain terrains may have increased red blood cell counts on immigration to the United States (Centers for Disease Control and Prevention [CDC], 2006). Health-care providers must take these topographic factors into consideration when per- forming health screening for symptoms of anemia, lassi- tude, failure to thrive, and weight loss among Mexican immigrants.

Cardiovascular disease is the leading cause of death and disability in minority populations, including Mexican Americans (Kurian & Cardarelli, 2007). However, current research shows that despite the adverse cardiovascular risk profile, including the incidence of obe- sity, diabetes, and untreated hypertension, Mexican Americans have a lower rate of coronary heart disease mortality than nonwhite Hispanics (Pandey, Labarthe, Goff, Chan, & Nichaman, 2001). Cardiovascular risk fac- tors are influenced by behavioral, cultural, and social fac- tors. Mexican Americans have the highest prevalence of no leisure time physical activity (Kurian & Cardarelli, 2007). In addition, poor health, low social support, lack of educational and occupational opportunities, low access to health care, and discrimination contribute to the risk factors associated with cardiovascular disease (Kemp, 2001).

Mexican Americans have five times the rate of diabetes mellitus, with an increased incidence of related complica- tions, as that in European American cohort groups. In addition, health-care professionals working with Mexican immigrants and Mexican Americans should offer screen- ing and teach clients preventive measures regarding pesti- cides and communicable and infectious diseases because many of these people work with chemicals and live in crowded housing conditions.

VARIATIONS IN DRUG METABOLISM

Because of the mixed heritage of many Mexican Americans, it may be more difficult to determine a thera- peutic dose of selected drugs. Several studies report differ- ences in absorption, distribution, metabolism, and excre- tion of drugs, including alcohol, in some Hispanic populations. The mixed heritage of Mexican Americans makes it more difficult to generalize drug metabolism. Few studies include only one subgroup of Hispanics; therefore, health-care providers need to consider some notable differences when prescribing medications. Hispanics require lower doses of antidepressants and experience greater side effects than non-Hispanic whites.

High-Risk Behaviors Alcohol plays an important part in the Mexican culture. Many of this group’s colorful lifestyle celebrations include alcohol consumption. Men overall drink in greater pro- portion than women, but this trend is changing owing to acculturation. Mexican American women are consuming more alcohol than their mothers or grandmothers (Collins & McNair, 2002).

Because of these drinking patterns, alcoholism repre- sents a crucial health problem for many Mexicans. More- acculturated Hispanics consume more alcoholic beverages than non-Hispanic whites, possibly expecting alcohol to make them more socially acceptable and extroverted. Low acculturation and distorted self-image problems have spe- cial implications for nursing and health care.

Marijuana is the number-two drug used by Mexican Americans because it is readily available in their native land and easily accessible from people who work in farm- ing and ranching occupations. Some adults who can afford drugs use cocaine and heroin, and the younger population uses inhalants (Eden & Aguilar, 1989).

The trend toward decreasing cigarette smoking in the United States is extending to the Mexican American cul- ture, in which cigarette smoking rates have steadily declined for both men and women between 1990 and 2004 (CDC, 2007). However, the reported decrease in cig- arette smoking rates for Mexican American men and women should not promote a sense of complacancy for nurses and health-care professionals.

HEALTH-CARE PRACTICES

Responsibility for health promotion and safety may be a major threat for those of Mexican heritage accustomed to depending on the family unit and traditional means of providing health care. Continuing disparities in health and health-seeking behaviors have been reported in sev- eral studies. Lower socioeconomic conditions and accul- turation are responsible for Latina women being over- weight, exhibiting hypertension, experiencing high cholesterol levels, and having increased smoking behav- iors (Kemp, 2001). Latino men are less likely to have can- cer screening or physical examinations than their non- Latino white counterparts. High-risk health behaviors such as drinking and driving, cigarette smoking, sedentary lifestyle, and nonuse of seat belts increase with fewer years of educational attainment. Through educational programs and enforcement of state laws, more Mexicans are begin- ning to use seat belts; however, it is still common to see their children traveling unrestrained in automobiles.

Nutrition MEANING OF FOOD

As in many other ethnic groups, Mexicans and Mexican Americans celebrate with food. Mexican foods are rich in color, flavor, texture, and spiciness. Any occasion—births, birthdays, Sundays, religious holidays, official and unofficial holidays, and anniversaries of deaths—is seen as a time to

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celebrate with food and enjoy the companionship of fam- ily and friends. Because food is a primary form of social- ization in the Mexican culture, Mexican Americans may have difficulty adhering to a prescribed diet for illnesses such as diabetes mellitus and cardiovascular disease. Health-care professionals must seek creative alternatives and negotiate types of foods consumed with individuals and families in relation to these concerns.

COMMON FOODS AND FOOD RITUALS

The Mexican American diet is extremely varied and may depend on the individual’s region of origin in Mexico. Thus, one needs to ask the individual specifically about his or her dietary habits. The staples of the Mexican American diet are rice (arroz), beans, and tortillas, which are made from corn (maíz) treated with calcium carbon- ate. However, in many parts of the United States, only flour tortillas are available. Even though the diet is low in calcium derived from milk and milk products, tortillas treated with calcium carbonate provide essential dietary calcium. Popular Mexican American foods are eggs (huevos), pork (puerco), chicken (pollo), sausage (chorizo); lard (lardo), mint (menta), chili peppers (chile), onions (cebollas), tomatoes (tomates), squash (calabaza), canned fruit (fruta de lata), mint tea (hierbabuena), chamomile tea (té de camomile or manzanilla), carbonated beverages (bebidas de gaseosa), beer (cerveza), cola-flavored soft drinks, sweetened packaged drink mixes (agua fresa) that are high in sugar (azucar), sweetened breakfast cereals (cereales de desayuno); potatoes (papas), bread (pan), corn (maíz), gelatin (gelatina), custard (flan), and other sweets (dulces). Other common dishes include chili, enchiladas, tamales, tostadas, chicken mole, arroz con pollo, refried beans, tacos, tripe soup (Menudo) and other soups (caldos). Soups (caldos) are varied in nature and may include chicken, beef, and pork with vegetables.

Mealtimes vary among different subgroups of Mexican Americans. Whereas many individuals adopt North American schedules and eating habits, many continue their native practices, especially those in rural settings and migrant-worker camps. For these groups, breakfast is usually fruit, perhaps cheese, or bread alone or in some combination. A snack may be taken in midmorning before the main meal of the day, which is eaten from 2 to 3 p.m. and, in rural areas especially, may last for 2 hours or more. Mealtime is an occasion for socialization and keeping family members informed about each other. The evening meal is usually late and is taken between 9 and 9:30 p.m. Health-care providers must consider Mexican Americans’ mealtimes when teaching clients about med- ication and dietary regimens related to diabetes mellitus and other illnesses.

DIETARY PRACTICES FOR HEALTH PROMOTION

A dominant health-care practice for Mexicans and many Mexican Americans is the hot-and-cold theory of food selection. This theory is a major aspect of health promo- tion and illness and disease prevention and treatment. According to this theory, illness or trauma may require adjustments in the hot-and-cold balance of foods to restore

body equilibrium. The hot-and-cold theory of foods is described under Health-Care Practices, later in this chapter.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

In lower socioeconomic groups, wide-scale vitamin A deficiency and iron deficiency anemia exist (Mendoza, Ventura, Saldivar, Baisden, & Martorell, 1992). Some Mexican and Mexican Americans have lactose intoler- ance, which may cause problems for schools and health- care organizations that provide milk in the diet because of its high calcium content.

Because major Mexican foods and their ingredients are available throughout the United States, native food prac- tices may not change much when Mexicans immigrate. Of course, Mexican foods are extremely popular through- out the United States and are eaten by many Americans because of the strong flavors, spiciness, and color. Table 18–1 lists the Mexican names of popular foods, their descrip- tion, and ingredients. Individual adaptations to these preparations commonly occur.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

Mexican American birth rates were 24.9 or 677,621 live births in 2004; the numbers of births have continued to rise every year since 1989 (National Vital Statistics Report, 2004). Multiple births are common, especially in the eco- nomically disadvantaged groups. Men view a large num- ber of children as proof of their virility. The optimal child- bearing age for Mexican women is between 19 and 24 years. Fertility practices of Mexican Americans are con- nected with their predominantly Catholic religious beliefs and their tendency to be modest. Some women practice the belief that prolonged infant breastfeeding is a method of birth control. Abortion in many communities is considered morally wrong and is practiced (theoreti- cally) only in extreme circumstances to keep the mother’s life intact. However, legal and illegal abortions are com- mon in some parts of Mexico and the United States. Despite the strong influence of the Catholic Church over fertility practices, being Catholic does not prevent some Mexican American women from using contraceptives, sterilization, or abortion for unwanted pregnancies.

Diaphragms, foams, and creams are not commonly used for birth control practice, mostly because they are not approved by Catholic doctrine and partly because of the belief that women are not supposed to touch their genitals. Birth control pills are unacceptable because they are an artificial means of birth control. Physicians’ offices and clinics that see large numbers of migrant workers on the Delmarva Peninsula on the U.S. east coast report that many younger female clients are using Norplant (lev- onorgestrel; a long-term contraceptive system) for birth control. Men are reluctant to use condoms because they are associated with prostitutes and because of the belief

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that they should be used only for disease control. A woman may reject the use of a condom and find it offen- sive because it means that she is “dirty.” Family planning is one area in which health-care providers can help the family to identify more realistic outcomes consistent with current economic resources and family goals.

Foreign-born Mexicans are less likely to give birth to low- birth-weight babies than U.S.-born Mexican women, even though U.S.-born mothers are usually of higher socioeco- nomic status and receive more prenatal care. Research sug- gests that better nutritional intake and lower prevalence of smoking and alcohol use are some reasons for these protec- tive outcomes (American Public Health Association, 2002).

Because pregnancy among Mexican Americans is viewed as natural and desirable, many women do not seek prenatal evaluations. In addition, because prenatal care is not avail- able to every woman in Mexico, some women do not know about the need for prenatal care. With the extended family network and the woman’s role of maintaining the health status of family members, many pregnant women seek fam- ily advice before seeking medical care. Thus, familism may deter and hinder early prenatal check-ups. To encourage prenatal check-ups, health-care providers can encourage female relatives and husbands to accompany the pregnant woman for health screening and incorporate advice from family members into health teaching and preventive care services. Using videos with Spanish-speaking Mexican Americans is one culturally effective way for incorporating health education, especially for those clients who have a limited understanding of English. In addition, incorporat- ing cultural brokers known to the Mexican American fam- ily may help to empower clients and reduce conflict for Mexicans and Mexican Americans.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Beliefs related to the hot-and-cold theory of disease pre- vention and health maintenance influence conception,

pregnancy, and postpartum rituals. For instance, during pregnancy, a woman is more likely to favor hot foods, which are believed to provide warmth for the fetus and enable the baby to be born into a warm and loving envi- ronment (Eggenberger, Grassley, & Restrepo, 2006). Cold foods and environments are preferred during the men- strual cycle and in the immediate postdelivery period. Many pregnant women sleep on their backs to protect the infant from harm, keep the vaginal canal well lubricated by having frequent intercourse to facilitate an easier birth, and keep active to ensure a smaller baby and to pre- vent a decrease in the amount of amniotic fluid (Burk, Wieser, & Keegan, 1995). An important activity restric- tion is that pregnant women should not walk in the moonlight because it might cause a birth deformity. To prevent birth deformities, pregnant women may wear a safety pin, metal key, or some other metal object on their abdomen (Villarruel & Ortiz de Montellano, 1992). Other beliefs include avoiding cold air, not reaching over the head in order to prevent the baby’s cord from wrapping around its neck, and avoiding lunar eclipses because they may result in deformities.

In more traditional Mexican families, the father is not included in the delivery experience and should not see the mother or baby until after both have been cleaned and dressed. This practice is based on the fear that harm may come to the mother, baby, or both. Integrating men into the birthing of a child is a process that requires changing social habits in relation to cultural aspects of life and gender roles. For many, the presence of men during delivery is considered an uninvited intrusion into the Mexican culture. Among less-traditional and more-acculturated Mexican Americans, men participate in prenatal classes and assist in the delivery room. However, based on personal experiences, men who provide support during delivery may receive friendly gibing from their male counterparts for taking the role of the wife’s mother (personal communication, Larry Purnell, June 2007). In any event, health-care providers must respect Mexicans’ decision to not have men in the delivery room.

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T A B L E 18.1 Mexican Foods

Common Name Description Ingredients

Arroz con pollo Chicken with rice Chicken baked, boiled, or fried and served over boiled or fried rice Chili Chili Same as the United States but tends to be more spicy Chili con carne Chili with meat Chili with beef or pork Chili con salsa Chili with sauce Chili with a sauce that contains no meat Dulces Sweets Candy and desserts usually high in sugar, lard, and eggs Enchiladas Enchiladas Tortilla rolled and stuffed with meat or cheese and a spicy sauce Papas fritas Fried potatoes Potatoes usually fried in lard Flan Flan Popular dessert made of egg custard; may be filled with fruit or cheese Gelatina Gelatin Popular dessert made with sugar, eggs, and jelly Pollo con molé Chicken molé Chicken with a sauce made of hot spices, chocolate, and chili Salchica or chorizo Sausage Sausage almost always made with pork and spices Tacos Tacos Tortilla folded around meat or cheese Tamales Tamales Fried or boiled chopped meat, peppers, cornmeal, and hot spices Tortilla Tortilla A thin unleavened bread made with cornmeal and treated with lime

(calcium carbonate) Tostadas Tostadas Toast that may have a spicy sauce

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During labor, traditional Mexican women may be quite vocal and are taught to avoid breathing air in through the mouth because it can cause the uterus to rise up. Immediately after birth, they may place their legs together to prevent air from entering the womb (Olds, London, & Ladewig, 2000). Health-care providers can help the Mexican pregnant woman have a better delivery by encouraging attendance at prenatal classes.

The postpartum preference for a warm environment may restrict postpartum women from bathing or washing their hair for up to 40 days. Although postpartum women may not take showers or sit in a bathtub, this does not mean that they do not bathe. They take sitz baths, wash their hair with a washcloth, and take sponge baths. Other postpartum practices include wearing a heavy cotton abdominal binder, cord, or girdle to prevent air from entering the uterus; covering one’s ears, head, shoulders, and feet to prevent blindness, mastitis, frigidity, or steril- ity; and avoiding acidic foods to protect the baby from harm (Olds, London, & Ladewig, 2000).

When the baby is born, special attention is given to the umbilicus; the mother may place a belt around the umbilicus (ombliguero) to prevent the naval from pop- ping out when the child cries. Cutting the baby’s nails in the first 3 months is thought to cause blindness and deafness.

Health-care providers need to make special provisions to provide culturally congruent health teaching for lactat- ing women who work with or are exposed to pesticides, such as dichlorodiphenyldichlorothene (DDE), the most stable derivative from the pesticide DDT. High DDE levels among lactating women have a direct correlation with a decrease in lactation and increase in breast cancer, espe- cially in women who have had more than one pregnancy and previous lactation (Gladen & Rogan, 1995). Education level and degree of acculturation are key issues when developing health education and interventions for risk reduction.

Death Rituals DEATH RITUALS AND EXPECTATIONS

Mexicans often have a stoic acceptance of the way things are and view death as a natural part of life and the will of God (Eggenberger et al., 2006). Death practices are primarily an adaptation of their religion. Family members may arrive in large numbers at the hospital or home in times of illness or an approaching death. In more-traditional families, family members may take turns sitting vigil over the sick or dying person. Autopsy is acceptable as long as the body is treated with respect. Burial is the common practice; cremation is an individ- ual choice.

RESPONSES TO DEATH AND GRIEF

When a person dies, the word travels rapidly, and family and friends travel from long distances to get to the funeral. They may gather for a velorio, a festive watch over the body of the deceased person before burial. Some

Mexican Americans bury the body within 24 hours, which is required by law in Mexico.

More-traditional grieving families may engage in protection of the dying and bereaved such as small chil- dren who have difficulty dealing with the death (Andrews & Boyle, 2003). Mexican Americans encour- age expressions of feeling during the grieving process. In these cases, health-care providers can assist the per- son by providing support and privacy during the bereavement.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

The predominant religion of most Mexicans and Mexican Americans is Catholicism. The major religions in Mexico are Roman Catholic, 89 percent; Protestant, 6 percent; and other, 5 percent of the population. Since the mid-1980s, other religious groups such as Mormons, Jehovah’s Witnesses, Seventh Day Adventists, Presbyteri- ans, and Baptists have been gaining in popularity in Mexico (CIA, 2007). Although many Mexicans and Mexican Americans may not appear to be practicing their faith on a daily basis, they may still consider themselves devout Catholics, and their religion has a major influ- ence on health-care practices and beliefs. For many, Catholic religious practices are influenced by indigenous Indian practices.

Newer immigrant Mexican Americans may continue their traditional practice of having two marriage cere- monies, especially in lower socioeconomic groups. A civil ceremony is performed whenever two people decide to make a union. When the family gets enough money for a religious ceremony, they schedule an elaborate celebra- tion within the church. Common practice, especially in rural Mexican villages and some rural villages in the southwestern United States, is to post a handwritten sign on the local church announcing the marriage, with an invitation for all to attend.

Frequency of prayer is highly individualized for most Mexican Americans. Even though some do not attend church on a regular basis, they may have an altar in their homes and say prayers several times each day, a practice more common among rural isolationists.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

The family is foremost to most Mexicans, and individuals get strength from family ties and relationships. Individuals may speak in terms of a person’s soul or spirit (alma or espiritu) when they refer to one’s inner qualities. These inner qualities represent the person’s dignity and must be protected at all costs in times of both wellness and illness. In addition, Mexicans derive great pride and strength from their nationality, which embraces a long and rich history of traditions.

Leisure is considered essential for a full life, and work is a necessity to make money for enjoying life. Mexican

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Americans pride themselves on good manners, etiquette, and grooming as signs of respect. Because the overall outlook for many Mexicans is one of fatalism, pride may be taken in stoic acceptance of life’s adversities.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Most Mexicans enjoy talking about their soul or spirit, especially in times of illness, whereas many health-care providers may feel uncomfortable talking about spiritual- ity. This tendency may communicate to Mexicans that the health-care provider has suspect intentions, is insen- sitive, and is not really interested in them as individuals. It may be common for a person needing care in the home or hospital to have a statue of a patron saint or a candle with a picture of the saint. Rosaries may be present, and at times, the family may pray as a group. Depending on the confidence maintained with the family and client, a health-care professional may be asked to join in the prayer. If time permits, it is very appropriate to pray with the family even if only for a few minutes. This action pro- motes confidence in the relationship and can have a pos- itive impact on the health and well-being of the client and family (Zoucha, 2007).

Health-Care Practices V I G N E T T E 1 8 . 3

Juan Diaz is a 26-year-old Mexican man who was recently diagnosed with a herniated lumbar disc after a work-related injury. An emergency room physician has recommended back surgery and physical therapy. Juan is unmarried and is a recent immigrant from Oaxaca, Mexico. Juan is an undocu- mented worker and has been working for a construction com- pany doing roofing and bricklaying. Juan’s family resides in Mexico. His parents, maternal grandparents, five sisters, and two brothers live in a small two-bedroom stone home in Oaxaca. Juan is the oldest of the children and has come to the United States to work and send money back to the family. Juan’s dad is being treated for tuberculosis and needs money to pay for health care. Juan is also trying to earn enough money to bring his dad to the United States for tuberculosis treatment. Juan speaks mainly Spanish with limited ability in English.

Juan is a devout Catholic who attends Mass weekly and prays the rosary to La Virgen de Guadalupe daily. Juan often blesses himself with holy water he brought from San Juan de Los Lagos. Juan believes that God will heal him and that his health is in the hands of God.

Juan is sharing the rent on a three-bedroom apartment with five other migrant workers from Mexico. The apartment is located 10 miles from his job where new homes are being built outside the city. Juan usually takes two buses to work. One of the migrant workers has an uncle who helped secure the jobs for them. Juan and his coworkers cook and eat dinner together most evenings and enjoy drinking cervezas (beer) on the weekends.

Juan has saved money from working over the past 11 months but is worried about health-care coverage. He usually goes to a local clinic for his health-care needs. His friends suggested that he should visit a bruja because he might have had a spell cast upon him. He and his friends believe that the bruja can rid him of the spell and heal him. Juan’s friends are able to help take care of him on weekends only because of their weekday 12-hour work schedules. Juan has an uncle from Mexico who is trying to get money together for a trip up

PEOPLE OF MEXICAN HERITAGE • 319

V I G N E T T E 1 8 . 2

Mrs. Lopez is a 65-year-old Mexican American recently diag- nosed with breast cancer who will undergo a radical mastec- tomy and chemotherapy. Mrs. Lopez is recently widowed and is grieving for her husband of 50 years. Mrs. Lopez has 7 chil- dren (3 daughters aged 49, 44, and 41; 4 sons aged 47, 45, 43, and 39), 8 grandchildren, and 20 great grandchildren. The youngest son lives at home with his mother along with his wife and four children. The other children live within 10 blocks. Mrs. Lopez spends a lot of time helping to care for the grandchildren while her children work. The five youngest members of the family were born in the United States, and the rest of the family was born in Vera Cruz, Mexico. Mrs. Perez has never worked outside of the home and receives survivor benefits from her husband’s pension. The only job she has ever done is baby-sitting for neighbors, nieces, and nephews. Mrs. Lopez has one living brother who lives 5 miles away and a sister who died of breast cancer 7 years ago.

The Lopez family members are Catholics. Mrs. Lopez is a very devout Catholic and attends Mass daily at the church two blocks away. The children attend Mass with the family on occasional Sundays. Mrs. Lopez prays the rosary and novenas so that God will take care of her and her family. Mrs. Lopez is a good cook and prepares dinner every evening for her son and his family. The daughter-in-law helps cook the meals even after a full day of work. Mrs. Lopez and her family live in a three-bedroom wood frame house. The home is located in a Mexican American neighborhood 2 miles from the Mexican border in San Juan, Texas.

Mrs. Lopez does not have any work experience and is grateful her husband left a small but substantial life insur- ance policy. Mrs. Lopez receives help with shopping and rides to the doctor from her youngest daughter and many comadres. One of her comadres is a curandera who has been offering Mrs. Lopez herbs and teas to help healing. Mrs. Lopez enjoys making tamales in her kitchen along with her family and comadres. All of the Lopez children and comadres have committed to help Mrs. Lopez during and after her surgery.

1. When the home health nurse comes to assess Mrs. Lopez’s incision and teaches about Jackson Pratt drain care, who should be included in the teaching and why?

2. Explain the importance of familism to the Lopez family. 3. Mrs. Lopez has been offered herbal tea by the curan-

dera while the home nurse is making a visit. Should the nurse intervene to stop this practice? Please provide rationale for your answer.

4. The nurse is making a visit when the family is praying the rosary together for the health of Mrs. Lopez. The nurse is invited to join. What should the nurse do in this situation?

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to help Juan as he recovers. Juan will require home physical therapy and nursing care after his surgery.

1. The home care case manager, a registered nurse, is sending a physical therapist to the home. What should the nurse consider?

2. What does the nurse need to know about where Juan and his family are from in Mexico?

3. Identify potential communication needs of Juan, his friends, and his visiting family.

4. Juan is concerned about letting his boss down because of his illness. Why is Juan concerned about this with his boss?

HEALTH-SEEKING BELIEFS AND BEHAVIORS

The family is the most credible source of health informa- tion and the most significant impediment to positive health-seeking behavior. Mexican Americans’ fatalistic worldview and external locus of control are closely tied to health-seeking behaviors. Because expressions of negative feelings are considered impolite, Mexicans may be reluc- tant to complain about health problems or to place blame on the individual for poor health. If a person becomes seriously ill, that is just the way things are; all events are acts of God (Eggenberger et al., 2006). This belief system may impair the dominant view of communications and hinder health teaching, health promotion, and disease prevention practices. Therefore, it is imperative for health-care professionals to plan health promoting activ- ities and teaching that are consistent with this belief but encourage health. For instance, if a person believes that the illness is due to a punishment from God, it may be possible to ask to be forgiven by God, thereby restoring health. This may be an opportune time to call a priest or minister for official recognition of forgiveness.

RESPONSIBILITY FOR HEALTH CARE

To many Mexicans, good health may mean the ability to keep working and have a general feeing of well-being (Zoucha, 1998). Illness may occur when the person can no longer work or take care of the family. Therefore, many Mexicans may not seek health care until they are incapacitated and unable to go about the activities of daily living. Unfortunately, many people of Mexican her- itage may not know and understand the occupational dangers inherent in their daily work. Migrant workers are often unaware of the dangers of pesticides and the poten- tially dangerous agricultural machinery. Health-care pro- fessionals must serve as advocates for these people regard- ing occupational safety. Often, the companies do not tell the workers of the dangers of the work, or the workers may not understand owing to the inability of the com- pany officials to speak the language of the workers.

The use of over-the-counter medicine may pose a sig- nificant health problem related to self-care for many Mexican Americans. In part, this is a carryover from Mexico’s practice of allowing over-the-counter purchases of antibiotics, intramuscular injections, intravenous flu- ids, birth control pills, and other medications that require

a prescription in the United States. Often, Mexican immi- grants bring these medications across the border and share them with friends. In addition, friends and relatives in Mexico send drugs through the mail. To protect clients from contradictory or potentiating effects of prescribed treatments, health-care providers need to ask clients about prescription and nonprescription medications they may be taking.

FOLK AND TRADITIONAL PRACTICES

Mexican Americans engage in folk medicine practices and use a variety of prayers, herbal teas, and poultices to treat illnesses. Many of these practices are regionally specific and vary between and among families. The Mexican Ministerio de Salud Publica y Asistencia Social (Ministry of Public Health and Social Assistance) publishes an exten- sive manual on herbal medicines that are readily available in Mexico. Lower socioeconomic groups and well-edu- cated upper and middle socioeconomic Mexicans to some degree practice traditional and folk medicine. Many of these practices are harmless, but some may contradict or potentiate therapeutic interventions. Thus, as with the use of other prescription and nonprescription drugs dis- cussed earlier, it is essential for health-care providers to be aware of these practices and to take them into consid- eration when providing treatments (Rivera, Anaya, & Meza, 2003). The provider must ask the Mexican American client specifically whether she or he is using folk medicine.

To provide culturally competent care, health-care prac- titioners must be aware of the hot-and-cold theory of dis- ease when prescribing treatment modalities and when providing health teaching. According to this theory, many diseases are caused by a disruption in the hot-and- cold balance of the body. Thus, eating foods of the oppo- site variety may either cure or prevent specific hot-and- cold illnesses and conditions. Physical or mental illness may be attributed to an imbalance between the person and the environment. Influences include emotional, spir- itual, and social state, as well as physical factors such as humoral imbalance expressed as either too much hot or cold. As health-care providers, it is important to under- stand that if people of Mexican heritage believe in the hot-and-cold theory, it means that they do not believe or use professional Western practices (Spector, 2004). Unless a level of trust and confidence is maintained, Mexicans who follow these beliefs may not express them to health professionals (Zoucha & Husted, 2000).

Hot and cold are viewed as specific properties of vari- ous substances and conditions, and sometimes opinions differ about what is hot and what is cold in the Mexican community. In general, cold diseases or conditions are characterized by vasoconstriction and a lower metabolic rate. Cold diseases or conditions include menstrual cramps, frio de la matriz, rhinitis (coryza), pneumonia, empacho, cancer, malaria, earaches, arthritis, pneumonia and other pulmonary conditions, headaches, and muscu- loskeletal conditions and colic. Common hot foods used to treat cold diseases and conditions include cheeses, liquor, beef, pork, spicy foods, eggs, grains other than bar- ley, vitamins, tobacco, and onions (Kemp, 2001).

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Hot diseases and conditions may be characterized by vasodilation and a higher metabolic rate. Pregnancy, hypertension, diabetes, acid indigestion, susto, mal de ojo (bad eye or evil eye), bilis (imbalance of bile, which runs into the blood stream), infection, diarrhea, sore throats, stomach ulcers, liver conditions, kidney problems, and fever may be examples of hot conditions. Common cold foods used to treat hot diseases and conditions include fresh fruits and vegetables, dairy products (even though fresh fruits and dairy products may cause diarrhea), barley water, fish, chicken, goat meat, and dried fruits (Neff, 1998).

Folk practitioners are consulted for several notable conditions. Mal de ojo is a folk illness that occurs when one person (usually older) looks at another (usually a child) in an admiring fashion. Another example of mal de ojo is if a person admires something about a baby or child, such as beautiful eyes or hair. Such eye contact can be either voluntary or involuntary. Symptoms are numerous, ranging from fever, anorexia, and vomiting to irritability. The spell can be broken if the person doing the admiring touches the person admired while it is hap- pening. Children are more susceptible to this condition than women, and women are more susceptible than men. To prevent mal de ojo, the child wears a bracelet with a seed (ojo de venado) or a bag of seeds pinned to the clothes (Kemp, 2001).

Another childhood condition often treated by folk practitioners is caida de la mollera (fallen fontanel). The condition has numerous causes, which may include removing the nursing infant too harshly from the nipple or handling an infant too roughly. Symptoms range from irritability to failure to thrive. To cure the condition, the child is held upside down by the legs.

Susto (magical fright or soul loss) is associated with epilepsy, tuberculosis, and other infectious diseases and is caused by the loss of spirit from the body. The illness is also believed to be caused by a fright or by the soul being frightened out of the person. This culture-bound disorder may be psychological, physical, or physiological in nature. Symptoms may include anxiety, depression, loss of appetite, excessive sleep, bad dreams, feelings of sad- ness, and lack of motivation. Treatment sometimes includes elaborate ceremonies at a crossroads with herbs and holy water to return the spirit to the body (R. Zamarripa, personal communication, April 2006).

Empacho (blocked intestines) may result from an incor- rect balance of hot and cold foods, causing a lump of food to stick in the gastrointestinal tract. To make the diagno- sis, the healer may place a fresh egg on the abdomen. If the egg appears to stick to a particular area, this confirms the diagnosis. Older women usually treat the condition in children by massaging their stomach and back to dislodge the food bolus and to promote its continued passage through the body.

Health-care practitioners are cautioned against diag- nosing psychiatric illnesses too readily in the Mexican population. The syndromes mal ojo and susto are culture bound and are potential sources of diagnostic bias. The potential culture-bound mental illness must be under- stood in the context of the culture and the unique symp- toms that accompany each illness.

BARRIERS TO HEALTH CARE

Thirty-two percent of Mexican Americans, compared with 14 percent of the U.S. population in general, do not have health insurance (U.S. Bureau of the Census, 2001). A number of factors may account for this high percent- age of uninsured individuals. First, many Mexican Americans constitute the working poor and are unable to purchase insurance. Second, many are migratory and do not qualify for Medicaid. Third, many have an undocu- mented status and are afraid to apply for health insur- ance. Fourth, even though insurance is available in their native homeland, it is very expensive and not part of the culture.

Whereas wealthier Mexican Americans have little diffi- culty accessing health care in the United States, lower socioeconomic groups may experience significant barri- ers, including inadequate financial resources, lack of insurance and transportation, limited knowledge regard- ing available services, language difficulties, and the cul- ture of health-care organizations. Like many other immi- grant groups who lack a primary provider, Mexican Americans may use emergency rooms for minor illnesses. Health-care providers have the opportunity to improve the care of Mexican Americans by explaining the health- care system, incorporating a primary-care provider when- ever possible, using an interpreter of the same gender, securing a cultural broker, and assisting clients in locating culturally specific mental health programs (Zoucha & Husted, 2000).

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Good health to many Mexican Americans is to be free of pain, able to work, and spend time with the family. In addition, good health is a gift from God and from living a good life (Zoucha, 1998).

Mexicans and Mexican Americans tend to perceive pain as a necessary part of life, and enduring the pain is often viewed as a sign of strength. Men commonly toler- ate pain until it becomes extreme (Luckmann, 1999). Often, pain is viewed as the will of God and is tolerated as long as the person can work and care for the family. These attitudes toward pain delay seeking treatment; many hope that the pain will simply go away. Research has shown that many Mexican Americans experience more pain than other ethnic groups, but that they report the occurrence of pain less frequently and endure pain longer (Sobralske & Katz, 2005). Six themes have emerged that describe culturally specific attributes of Mexican Americans experiencing pain:

Mexicans accept and anticipate pain as a necessary part of life.

They are obligated to endure pain in the perfor- mance of duties.

The ability to endure pain and to suffer stoically is valued.

The type and amount of pain a person experiences is divinely predetermined.

Pain and suffering are a consequence of immoral behavior.

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Methods to alleviate pain are directed toward main- taining balance within the person and the sur- rounding environment (Villarruel & Ortiz de Montellano, 1992).

By using these themes, health-care providers can evaluate Mexicans experiencing pain within their cultural frame- work and provide culturally specific interventions.

Because long-term-care facilities in Mexico are rare and tend to be crowded, understaffed, and expensive, many Mexican Americans may not consider long-term care as a viable option for a family member. In addition, because of the importance of extended family, Mexican Americans may prefer to care for their family members with mental illness, physical handicaps, and extended physical ill- nesses at home. In Mexican American culture, someone with a mental illness is not looked on with scorn or blamed for their condition because mental illness, like physical illness, is viewed as God’s will. It is common to accept those with mental illness and care for them in the context of the family until the illness is so bad that they cannot be managed in the home (Zoucha & Husted, 2000).

Mexicans can readily enter the sick role without per- sonal feelings of inadequacy or blame. A person can enter the sick role with any acceptable excuse and be relieved of life’s responsibilities. Other family members willingly take over the sick person’s obligations during his or her time of illness.

BLOOD TRANSFUSIONS AND ORGAN DONATION

Extraordinary means to preserve life are frowned on in the Mexican and Mexican American cultures, and ordi- nary means are commonly used to preserve life. Extraordinary means are defined and determined by the individual, taking into account such factors as finances, education, and availability of services.

Blood transfusions are acceptable if the individual and the family agree that the transfusion is necessary. Organ donation, although not deemed morally wrong, is not a common practice and is usually restricted to cadaver donations, because donating an organ while the person is still alive means that the body is not whole. Acceptance of organ transplant as a treatment option is seen primarily among more-educated people. One reason that organ transplant is unacceptable to some groups is the belief that mal aire (bad air) enters the body if it is left open too long during surgery and increases the potential for the development of cancer.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

Educated physicians and nurses are often seen as out- siders, especially among newer immigrants. However, health-care professionals are viewed as knowledgeable and respected because of their education (Zoucha & Husted, 2002). To overcome this initial awkwardness, health-care providers should attempt to get to know the client on a

more personal level and gain confidence before initiating treatment regimens. Engaging in small talk unrelated to the health-care encounter before obtaining a health his- tory or providing health education is advised. Health-care providers must respect this cultural practice to achieve an optimal outcome from the encounter.

Folk practitioners, who are usually well known by the family, are usually consulted before and during biomed- ical treatment. Numerous illnesses and conditions are caused by witchcraft. Specific rituals are carried out to eliminate the evils from the body. Lower socioeconomic and newer immigrants are more likely to use folk practi- tioners, but well-educated upper- and middle-class peo- ple also visit folk practitioners and brujas (witches) on a regular basis (Torres, 2001). Although often no contra- dictions or contraindications to folk remedies exist, health-care providers must always consider clients’ use of these practitioners to prevent conflicting treatment regimens.

Even though the Catholic Church preaches against some types of folk practitioners, they are common and meet yearly for several days in Catemaco, Veracruz. Folk practitioners include the curandero, who may receive their talents from God or serve an apprenticeship with an estab- lished practitioner. The curandero has great respect from the community, accepts no monetary payment (but may accept gifts), is usually a member of the extended family, and treats many traditional illnesses. A curandero does not usually treat illnesses caused by witchcraft.

The yerbero (also spelled jerbero) is a folk healer with specialized training in growing herbs, teas, and roots and who prescribes these remedies for prevention and cure of illnesses. A yerbero may suggest that the person go to a botanica (herb shop) for specific herbs. In addition, these folk practitioners frequently prescribe the use of laxatives.

A sobador subscribes to treatment methods similar to those of a Western chiropractor. The sobador treats ill- nesses, primarily affecting the joints and musculoskeletal system, with massage and manipulation.

Even though Mexicans like closeness and touch within the context of family, most tend to be modest in other settings. Women are not supposed to expose their bodies to men or even to other women. Female clients may expe- rience embarrassment when it is necessary to touch their genitals or may refuse to have pelvic examinations as a routine part of a health assessment. Men may have strong feelings about modesty as well, especially in front of women, and may be reluctant to disrobe completely for an examination. Mexican Americans often desire that members of the same gender provide intimate care (C. Zamarripa, personal communication, March 2002). Health-care providers must keep in mind clients’ need for modesty when disrobing or being examined. Thus, only the body part being examined should be exposed, and direct care should be provided in private. Whenever pos- sible, a same-gender caregiver should be assigned to Mexican Americans.

STATUS OF HEALTH-CARE PROVIDERS

Mexican American clients have great respect for health- care providers because of their training and experience.

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They expect health-care providers to project a profes- sional image and be well groomed and dressed in attire that reflects their professional status (Zoucha, 2002). Whereas they have great respect for health-care providers, some Mexican Americans may distrust them out of fear that they will disclose their undocumented status. Health-care practitioners who incorporate folk practition- ers, the concept of personalismo, and respect into their approaches to care of Mexican American clients will gain their clients’ confidence and be able to obtain more thor- ough assessments.

Health-care providers can demonstrate respect for Mexican American clients by greeting the client with a handshake, touching the client, or holding the client’s hand, all of which help to build trust in the therapeutic relationship. Providing information and involving the family in decisions regarding health; listening to the indi- vidual’s concerns; and treating the individual with person- alismo, which stresses warmth and personal relationships, also fosters trust.

REFERENCES American Public Health Association. (2002). Maternal health risks of immi-

grant women from Latin America. Retrieved March 2, 2007, from http:// www.apha.org

Andrews, M., & Boyle, J. (2003). Transcultural concepts in nursing care (4th ed.). Philadelphia: Lippincott.

Burk, M. E., Wieser, P. C., & Keegan, L. (1995). Cultural beliefs and health behaviors of pregnant Mexican-American women: Implications for primary care. Advances in Nursing Science, 17(4), 37–52.

Centers for Disease Control and Prevention (CDC). (2006). Regional malaria information. Retrieved February 20, 2007, from http://www. cdc.gov/travel/regionalmalaria/camerica.htm

Centers for Disease Control and Prevention (CDC). (2007). Health of Mexican American population. Retrieved September 25, 2007, from http://www.cdc.gov/nchs/fastats/mexican_health.htm

CIA. (2007). Retrieved September 25, 2007, from http://www.cia.gov Collins, R. L., & McNair, L. D. (2002). Minority women and alcohol use.

Alcohol Research and Health, 26(4), 251–256. Congress. (2005). Mexico: Revolution and 20th century. Retrieved September

25, 2007, from http://www.casahistoria.net Eden, S., & Aguilar, R. (1989). The Hispanic chemically dependent client:

Considerations for diagnosis and treatment. In G. Lawson & A. Lawson (Eds.), Alcoholism and substance abuse in special populations (pp. 291–295). Rockville, MD: Aspen.

Eggenberger, S. K., Grassley, J., & Restrepo, E. (2006). Culturally competent nursing care: Listening to the voices of Mexican-American women. Online Journal of Issues in Nursing, 11(3), 7.

Gates, G., Lau, H., & Sears, B. (2006). Race and ethnicity of same-sex couples in California: The Williams Project on Sexual Orientation Law and Public Policy UCLA School of Law. Los Angeles: UCLA.

Gladen, B., & Rogan, W. (1995). DDE and shortened duration of lactation in a northern Mexican town. American Journal of Public Health, 85(4), 504–508.

Grothaus, K. L. (1996). Family dynamics and family therapy with Mexican Americans. Journal of Psychosocial Nursing and Mental Health Services, 34(2), 31–37.

Kemp, C. (2001). Hispanic health beliefs and practices: Mexican and Mexican-Americans (clinical notes) [Electronic version]. Retrieved May 23, 2003, from http://www3.baylor.edu/~Charles_Kemp/ hispanic_health.htm

Kim-Godwin, Y. S., Alexander, J. W., Felton, G., Mackey, M. C., & Kasakoff, A. (2006). Prerequisites to providing culturally competent care to Mexican migrant farmworkers: A Delphi study. Journal of Cultural Diversity, 13(1), 27–33.

Kurian, A. K., & Cardarelli, K. M. (2007). Racial and ethnic differences in cardiovascular disease risk factors: A systematic review. Ethnic Diseases, 17(1), 143–152.

Library of Congress. (2005). Mexican immigration. Retrieved March 2, 2007, from http://memory.loc.gov/learn/features/immig/mexican. html

Locke, D. (1999). Increasing multicultural understanding: A comprehensive model (2nd ed.). Newbury Park, CA: Sage.

Luckmann, J. (1999). Transcultural communication in nursing. Albany, NY: Delmar.

Mendoza, F. S., Ventura S., Saldivar L., Baisden K., & Martorell R. (1992). In A. Furino (Ed.), Health policy and the Hispanic (pp. 97–115). Boulder, CO: Westview Press.

Meyer, M., & Beezley, W. (2000). The Oxford history of Mexico. Oxford: Oxford University Press.

National Sample Survey of Registered Nurses. (2004). Retrieved March 2, 2007, from http://bhpr.hrsa.gov/healthworkforce/reports/rnpopula- tion/preliminaryfindings.htm

National Vital Statistics Report. (2004). Retrieved September 25, 2007, from http://www.cdc.gov/nchs/data

Neff, N. (1998). Folk medicine in Hispanics in the Southwestern United States. Retrieved March 2, 2007, from http://www.riceinfo.edu/projects/ Hispanichealth/Courses/mod7/mid7.html

Olds, S., London, M., & Ladewig, P. (2000). Maternal newborn nursing: A family-centered approach (5th ed.) Redwood City, CA: Addison Wesley.

Pandey, D. K., Labarthe, D. R., Goff, D. C., Chan, W., & Nichaman, M. Z. (2001). Community-wide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: The Corpus Christi Heart Project. American Journal of Medicine, 110(2), 81–87.

Passel, J. (2004). Mexican immigration to the US: The latest estimates [Electronic version]. Migration Information Source. Retrieved February 13, 2007, from http://www.migrationinformation.org/usfocus/dis- play.cfm?ID=208

Redding, A. (1999). Mexico: Update on treatment of homosexuals. Resource Center of the Immigration and Naturalization Service, U.S. Department of Justice. Retrieved March 9, 2002, from http://world- policy.org/Americas/sexorient/mexgay-99.html

Rivera, J. O., Anaya, J. P., & Meza, A. (2003). Herbal product use in Mexican-Americans. American Journal of Health-System Pharmacy, 60(12), 1281–1282.

Schmal, J., & Madrer, J. (2007). Ethnic diversity in Mexico [Electronic ver- sion]. Mexico Connect. Retrieved January 17, 2007, from http://www. mexconnect.com/mex_/feature/ethnic/ethnicindex.html#imm

Sobralske, M. (2006). Machismo sustains health and illness beliefs of Mexican American men. Journal of American Academy of Nurse Practitioners, 18(8), 348–350.

Sobralske, M., & Katz, J. (2005). Culturally competent care of patients with acute chest pain. Journal of American Academy of Nurse Practitioners, 17(9), 342–349.

Spanish Language. (2007). Fact, figures and statistics about Spanish. Retrieved February 15, 2007, from http://spanish.about.com/library/ weekly/aa070300a.htm

Spector, R. (2004). Cultural diversity in health and illness (6th ed.). Upper Saddle River, NJ: Pearson.

Torres, E. (2001). The folk healer: The Mexican American tradition of curan- derismo. Albuquerque, NM: Nieves Press.

U.S. Bureau of the Census. (2001). Census 2000 briefs and special reports. Retrieved February 10, 2007, from http://www.census.gov/population/ www/cen2000/briefs.html

Van Hook, J., Bean, F., & Passel, J. (2005). Unauthorized migrants living in the United States: A mid-decade portrait [Electronic version]. Migration Information Source. Retrieved February 12, 2007, from http:// www.migrationinformation.org/Feature/display.cfm?ID=329

Vázquez, R. (2000). Is the phrase “La raza” racist? [Electronic version]. Las Culturas. Retrieved January 17, 2007, from http://www.lasculturas. com/aa/aa031200a.htm

Vázquez, R. (2001). ¿Hispanic or Latino [Electronic version]. Las culturas. Retrieved February 7, 2007, from http://www.lasculturas.com/aa/ aa070501a.htm

Villarruel, A. M., & Ortiz de Montellano, B. (1992). Culture and pain: A Mesoamerican perspective. Advances in Nursing Science, 15(1), 21–32.

Wells, J. N., Cagle, C. S., & Bradley, P. J. (2006). Building on Mexican- American cultural values. Nursing, 36(7), 20–21.

Zoucha, R. (2007). Understanding confianza (confidence) in the nursing relationship with Mexican Americans. Pittsburgh: Duquesne University School of Nursing.

Zoucha, R., & Husted, G. L. (2000). The ethical dimensions of delivering culturally congruent nursing and health care. Issues in Mental Health Nursing, 21(3), 325–340.

Zoucha, R., & Husted, G. L. (2002). The ethical dimensions of delivering culturally congruent nursing and health care. Review Series in Psychiatry, 3, 10–11.

PEOPLE OF MEXICAN HERITAGE • 323

FABK017-C18[309-324].qxd 12/12/2007 10:45am Page 323 Aptara Inc.

Zoucha, R., & Zamarripa, C. (1997). The significance of culture in the care of the client with an ostomy. Journal of Wound, Ostomy, and Continence Nursing, 24(5), 270–276.

Zoucha, R. D. (1998). The experience of Mexican Americans receiving pro- fessional nursing care: An ethnonursing study. Journal of Transcultural Nursing, 9(2), 34–44.

Zoucha, R. D., Reeves, J. (1999). A view of professional caring as personal for Mexican Americans. International Journal for Human Caring, 3(3), 14–20.

For case studies, review questions, and additional information, go to http://davisplus.fadavis.com

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