Even in the most comfortable environments, seeking health care can be daunting. Imagine wanting to get help, only to find that no one understands you, your beliefs, your customs, or your point of view. This unfortunate situation happens every day, all over our nation, creating hurdles that prevent people from obtaining the care that they need and deserve. Understanding basic ideas of culture and communication can help overcome these hurdles. To better understand these ideas and how they affect health care, I recently traveled to Guanajuato, Mexico, with a group of health care providers and students.

Started 5 years ago as an educational experience through West Chester University, West Chester, Pa, the program has blossomed into a rich exchange between the university and the University of Guanajuato. Our group was led by Debra Bill, PhD, MPH, a public health instructor; Andrew Dinniman, EdD, a history instructor and county commissioner; and Sister Consuela Sparks, a Latin American studies instructor at Immaculata University, Immaculata, Pa. We examined cultural differences between Americans and Mexicans and worked to understand how these differences can be understood to make health care accessible.

Throughout our research, four main characteristics of culture were clear: time, space, context, and language. There are other factors at work, but it all comes back to these four main ideas. The American ideas of these four characteristics do not always mesh with the Mexican interpretation. As a result, there is potential for conflicts that can easily be averted by understanding and respecting others’ views.

Is the Timing Right?

Most Americans are not flexible in regard to their schedules. Many Mexicans view Americans as “slaves to their clocks.” There is little time for small talk, friendship, and understanding in the American schedule. Conversely, Mexicans tend to view their time more freely, with more flexibility. They allow time for a laugh, for a meal, for a story with a friend.1 We experienced this many times during our days in Mexico. Whether it was the bus driver stopping to talk to his children and his wife outside of his house (with 30 of us roasting in the back of his bus!) or the tour guide who insisted we visit her home and see her handmade crafts, our Mexican friends made time to do what they enjoyed. They did not live according to a schedule. They would get to their destination whenever they could, whether in a few minutes or “mañana.”

It is important for health care providers in the United States to understand this concept of time. Those who work in predominately Mexican environments must understand that time is not viewed in the typical American fashion. While an American might cut someone short to keep to a certain schedule, Mexicans might feel slighted if they have not been given the time they feel they deserve. Americans view their time as an asset that can be “spent, saved, wasted, or lost.”1 This is not to say that Mexicans disregard time; they simply do not view it as rigidly as Americans do. This is an important distinction for health care providers to make. Failing to understand the different ideas of time may leave Mexican patients with an unfavorable view of the provider. They may feel shunned and disrespected and see the provider as a cold, uncaring figure. In a time when continuing care is often necessary, losing a patient from the beginning due to a misunderstanding of time could have serious effects on the patient’s health down the road.

The Space Between

The use of space and the idea of spatial relationships are important characteristics of Mexican culture. Many cultures, such as ours, are highly territorial. Space can imply power, and this space is defended to keep power.1 Americans tend to be comfortable at arm’s length, and when this personal area is lost, Americans can feel attacked or violated. Mexicans, on the other hand, are comfortable in closer proximity than are their North American counterparts. They will greet others with a kiss or an embrace, as opposed to the typical American handshake greeting.2 Everywhere we visited on our trip, we were greeted with hugs and kisses on the cheek. Aside from our group’s leaders, no one had ever visited these areas in Mexico before. Still, the people we met treated us as their neighbors, showing us more respect and courtesy than we could have hoped for.

This comfort in close quarters allows Mexicans to be more comfortable working in group settings than are Americans. Other cultures see Americans working long hours alone in cubicles, isolated from their coworkers, their families, the outside world. This life is something many Mexicans cannot comprehend. This isolation does not fit into the culture.3 On our tour through one of the clinics in a small town outside of Moroleon, we were greeted by many of the townspeople. They told us we were the first “Americanos” to visit this town. As a group, they showed us their clinic (which consisted of two rooms: a waiting room and an examination room). After the tour, they cooked us a beautiful lunch. They worked together to be sure everyone ate and enjoyed the meal. It was easy to see how well they worked together as a group, as a community. (One interesting note: We noticed very few men aged 13-40 in this community. When we asked why this was, we were told that the men had gone to the United States to work on farms in order to support the townspeople. The money they earned was sent back to provide for their families.)

A family gathers for an open-air meal in Guanajuato, Mexico.

This closeness and togetherness are manifested most clearly in how Mexicans value family. The family has a big impact on the everyday lives of Mexicans. Their idea of close family includes distant aunts, uncles, and cousins. This large family has an impact on the decisions and actions made at every turn in life. It is important for health care providers to understand and account for this relationship.1,3 Many of the clinics had pictures illustrating the idea of family, such as posters that encouraged women to breast feed their children, and also depicted men sitting with their wives. The entire family is to be involved every step of the way.

Having an understanding of the Mexican view of space is key for health care providers. There are many pitfalls that can doom treatment before it starts if the provider does not account for the Mexican view of space. Providers must share personal space and not feel uncomfortable in proximity to patients. Staying at a distance will not help build trust and may undermine the goals. Most important, the inclusion of the family (the large Mexican family) is vital to successful treatment. Closing doors to family and not allowing access to those who are close to the patient (no matter how many there are) also build distrust and prevent effective dialogue and treatment.

Understanding Context and Language

Most cultures can be described as either “high context” or “low context.” Context relates to how much and what type of background information are needed for effective communication. In high-context cultures there is little need for extra information. Many background facts are known by the parties trying to communicate. Providing background information can be seen as a waste of time to high-context people. Low-context cultures have a greater need for background information. Facts are needed “in explicit code.”1 It cannot be assume
d, in low-context cultures, that pertinent information is already known. Mexican culture is known as a high-context culture, whereas the United States is typically seen as having a low-context culture.2

Typically, building context is a slow process and cannot be done overnight. It must be nurtured through years of hard work, trust, and loyalty. This is a difficult concept for many Americans to understand. They expect all information to be given directly to them. If they need something, they fully expect to get it without trouble. This view is not shared by the Mexican culture. The building of context is directly related to their views of time and space. Stopping to talk to friends on the street and being flexible with schedules allow the Mexican to build context.2 Having a large family and allowing it to have input in important decisions help to build context. By being rigid and keeping a relatively small circle of friends and family, the American is not able to build context as readily as the Mexican.

Making matters worse for the American dealing with Mexicans is the dual nature of language. Americans are accustomed to receiving an answer and understanding exactly what it means. This is not always the case with Mexicans. Many Mexicans believe it is rude to turn down a request. They may answer “yes” with a smile even though it may be impossible to fulfill. Americans are familiar with a more straightforward answer, one that can be counted on.3 Understanding this difference in language is crucial for health care providers. It is important to determine whether the patients are really following home instructions (therapy, medications, lifestyle changes, etc) or if their “yes” is simply a failure to say no.

Tying It All Together

Search our online archives for other articles about cultural barriers to health care.

Getting through to patients and building a trusting relationship can be a difficult process, even under the best of circumstances. Dealing with a patient from a different cultural background, requires understanding and trust, which will be achieved only if the beliefs of both the patient and practitioner are understood and respected. American health care practitioners need to be mindful of the cultural differences between themselves and their Mexican patients. With the growing number of Mexicans joining our nation, this becomes increasingly important. Understanding time, space, language, and context will give providers a strong foundation based on mutual understanding on which to build a relationship and gain a deeper insight to the patient and their situation. The patient will, in turn, receive more comprehensive care based on and tailored to their beliefs. With any luck, these patients will continue to lead healthy, productive lives and be examples of just how much can be accomplished with an open mind and an appreciation for other cultures.

Jim Christie, MPH, RRT, is a respiratory therapist at Lancaster General Hospital, Lancaster, Pa. For further information, contact [email protected]

References

  1. Hall E, Hall MR. Understanding Cultural Differences. Yarmouth, Me: Intercultural Press Inc; 1990.
  2. Condon J. Good Neighbors: Communicating with the Mexicans. Yarmouth, Me: Intercultural Press Inc; 1997.
  3. Crouch N. Mexicans & Americans: Cracking the Cultural Code. Yarmouth, Me: Nicholas Brealey Publishing; 2004.