Impact of Diversity on Healthcare in Hispanic Populations
Before attempting to contemplate strategies that may aid in the diagnosis and treatment of ADHD in Hispanic children, it is necessary to reflect on the diversity of subgroups that comprise the Hispanic population in the United States. Increasing our knowledge regarding the diversity of this group is especially important, considering that the Hispanic population is now the largest minority group in the United States. Therefore, to best meet the needs of this large and growing population, it is important for clinicians to recognize factors that contribute to the diversity of the Hispanic population and that may impact medical care.
Although many Hispanics share the same language, religion and fundamental beliefs in hard work and the importance of family, they follow different migration patterns and come from countries with diverse histories and cultural beliefs. According to the U.S. Bureau of Census, the Hispanic population in the continental United States is comprised mostly of people from Mexico (59%), followed by those from Puerto Rico (12%) and Cuba (5%) (Figure 1). Other groups (24%) originate from Central or South America, are of European Spaniard descent or are of unknown Spanish origin. These groups are distinctly distributed throughout the United States, with Mexican-American families living primarily in the west, Puerto Rican families in the northeast region and Cuban-American families in the southeast. Differences in levels of acculturation, immigration history, socioeconomic status, access to the healthcare system, education, literacy and assimilation must be considered because these factors may have an impact on the diagnosis and treatment of disease. viagra online pharmacy
Figure 1. Percentages of Hispanic groups residing in the United States according to race or country of origin
Socioeconomic backgrounds of Hispanic patients vary among each subgroup. For example, in the early-to-mid-1990s, 34% of Cubans had a family income of >$35,000, compared with only 20% of Mexicans and 22% of Puerto Ricans. Furthermore, the percentage of Cubans (12%) who reported living below the poverty level was similar to that of the total (all races/ethnicities) population (11.9%) but less than half that reported by Mexicans (27%) or Puerto Ricans (28%). The Cuban population had a higher percentage of employed individuals (63.4%), compared with the Puerto Rican (49.2%) or Mexican (57.3%) populations. Data describing the educational status among Hispanics aged >25 years revealed that the majority of Mexicans (55.3%) did not graduate from high school, with somewhat lower rates reported in Puerto Ricans (42.1%) and Cubans (31.2%). The highest percentage of Hispanics who graduated from college were Cubans (21.3%); only 8.6% of Mexicans and 12.8% of Puerto Ricans reported receiving a college degree. Several studies have reported that socioeconomic variables, such as income, occupation and education, influence ADHD treatment outcomes. For example, more educated mothers may be better able to understand and cooperate with multimodal treatment plans that include behavioral treatment compared with less educated mothers. In addition, multiple stressors are inherent in low-income, single-parent households, and these stressors may decrease treatment adherence. Low-income status also may result in the inability to afford appropriate medical care.
English proficiency may differ among Hispanic subgroups. This is an important consideration because language barriers may interfere with the ability of caregivers to report ADHD symptoms to the primary care physician. In 1990, approximately 78% of Hispanics who lived in the United States reported speaking Spanish in the home. Of those who spoke Spanish at home, the majority of Dominicans (63.7%) and Central Americans (65.5%) reported that they did not speak English “very well,” compared with only 41.4% of Puerto Ricans, 54.5% of Cubans and 50.9% of Mexicans. Not surprisingly, because English is taught from kindergarten to high school to all island-Puerto-Rican children, this group was the most likely of all Latin American subgroups to speak English “very well” (58.6%).
Many studies suggest that limited proficiency of the English language is associated with a substantial reduction in both access to care and the quality of services rendered. For example, in patients for whom English is a second language, limited literacy skills may have an adverse impact on the ability to understand and follow prescribed healthcare regimens. In one study, researchers who questioned 203 parents of Latino children who visited inner-city clinics reported that parents cited language problems as the most common barrier to healthcare for their children. The majority of parents in that study rated their ability to speak English as “not very well” (46%) or “not at all” (26%). Other challenges involve lowering the reading level of patient education materials because it is too high for most patients, especially those whose native language is not English.
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Aside from differences in socioeconomic background and language skills, many Hispanic subgroups display varying degrees of acculturation. When treating Hispanic patients, assessing the degree of acculturation is important because it often provides clues to patients’ health-related beliefs and practices and may predict if these practices stem from the culture of origin or from the American culture. It is important to note that the degree of acculturation may be related to parental perceptions of ADHD symptoms. Research has shown that less acculturated mothers are less likely to recognize symptoms of ADHD than more acculturated mothers. Furthermore, less acculturated mothers may not perceive ADHD symptoms as being problematic and may not feel the need to discuss behavioral issues with a healthcare provider.
It has been reported that Mexican Americans may resist assimilation simply because the proximity of their homeland to the United States facilitates frequent visits, which provide a constant infusion of culture. A numerically significant subgroup of Mexicans who originate from the poorest areas of Mexico survive in the United States as illegal aliens living an “underground” lifestyle and in constant fear of apprehension and deportation. This fear may result in a lower use of healthcare services, especially when the need for treatment is not considered as urgent. Often, duration of residence in the United States provides a rough index of the degree of acculturation. The majority of foreign-born Cubans (~68%) have lived in the United States for >15 years, compared with approximately 56% of foreign-born Mexicans.
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The beliefs and customs of less acculturated Hispanic groups may differ dramatically from the traditional practices and beliefs of acculturated U.S. residents. For example, some patients from Colombia, the Dominican Republic and Guatemala report that they prefer a natural or holistic approach to treatment over the use of conventional prescription drugs. Furthermore, although more acculturated Mexican Americans no longer use folk medicine (curanderismo), less acculturated Mexican Americans still prefer self-treatment or folk healing over Western medicine. Some Mexican patients may use the services of a curandera (practitioner of folk medicine) to abrogate the mal puesto (hex), which is thought to cause symptoms of disease. It has been reported that traditional Mexican beliefs, such as these, are encountered frequently enough to merit the attention of the medical community.
The preferred use of a natural approach to healing by certain Hispanic subgroups may be partly the result of concerns about the addictive or toxic effects of long-term treatment with medications, which have been reported in both Mexicans and Puerto Ricans. One study that questioned mothers from Cuba, Puerto Rico and the Dominican Republic reported that a substantial number of parents thought stimulant medications had serious side effects, such as the risk of addiction or dulling of cognitive processes. These misconceptions led mothers to decrease the dose of the prescribed ADHD medication or to administer the medication inconsistently or not at all. viagra plus
A number of Puerto Ricans believe in espiritismo, which is a belief system consisting of an invisible world populated by spirits that surrounds the visible world and is described in the work of Allan Kardec. Espiritismo is also a form of psychotherapy that is consistent with the Puerto Rican concept of mental health; thus, clinicians who work with Puerto Rican families who practice espiritismo may be asked to collaborate with espiritistas, a medium who communicates with the spiritual world.