After reading this chapter, the nurse will be able to:
Discuss the influence of Spanish-language usage by Mexican Americans in adapting to the mainstream U.S. culture.
Explain the distance and intimacy behaviors of Mexican Americans.
Describe the organization of the Mexican American family unit.
Explain the Mexican American orientation to time.
Describe the impact of locus of control on Mexican Americans’ perceptions of the environment and their ability to control it.
Describe how the “hot–cold” beliefs of Mexican Americans influence their health and illness beliefs.
Identify the biological variations of Mexican Americans.
Overview of Mexico
Mexico, or what is officially referred to as the United Mexican States ( Estados Unidos Mexicanos ), is a country in the southern part of North America. Mexico consists of 31 states and a federal district ( ). The boundaries of Mexico extend southward from the United States to Guatemala and Belize in Central America. The western coast of Mexico borders on the Pacific Ocean, which includes the Gulf of California and the Gulf of Tehuantepec. The eastern coast of Mexico fronts on the Caribbean Sea and the Gulf of Mexico, which includes the Bay of Campeche. Mexico, which includes several outlying islands, has a total area of 758,449 square miles and is the third largest Latin American nation after Brazil and Argentina. Mexico is about one fifth the size of the United States ( ).
Over 60% of Mexicans are mestizos, that is, of mixed Spanish and Amerindian descent ( ). They trace their native heritage back to Indian groups that built great civilizations in Mexico long before the Spanish explorers arrived in the 1500s ( ). When the Spaniards came to Mexico in 1519, they found Indians who were skilled in writing, mathematics, astronomy, painting, sculpture, and architecture. Indian pottery, metalwork, and textiles were very highly developed for the period. Many Spaniards married women from the native Indian population. Spain’s discovery and eventual conquest of Mexico marked the start of the destruction of many elements of existing civilizations ( ). Missionaries were sent to convert the Indians to Christianity. Many of the riches of the land were carried back to Spain. Catholicism is the dominant religion in Mexico, with about 82.7% of the population as of 2010 ( ). In recent decades the number of Catholics has been declining, due to the growth of other Christian denominations, which constituted 9.7% of the population ( ).
After centuries of Spanish rule, the people rose and a republic was declared in 1823. After numerous conflicts and the U.S.–Mexican War (1846–1848), Mexico lost the lands north of the Rio Grande to the United States. French invasions were also repulsed. However, internal conflict continued, with years of rebellion and factional fighting. A new constitution in 1917 finally brought social reform, as the Institutional Revolutionary Party assumed control and dominated politics from 1929 to the late 1990s. During 1983 and 1984, Mexico suffered its worst financial crisis in 50 years, leading to critically high unemployment and an inability to pay its foreign debt. The collapse of oil prices in 1986 cut into Mexico’s export earnings and worsened the situation. Political and governmental conflict resulted in an unstable situation that contributed to many Mexicans seeking economic gain in the United States. Although the value of the peso fell drastically, an austerity plan and assistance from the United States saved Mexico’s currency from complete collapse in 1995. Mexico’s economic freedom score is 66.4, making its economy the fifty-ninth freest in the 2015 Index ( ). The economic freedom in Mexico has declined by 1.4 points since 2011. Deteriorations in the fiscal and regulatory environments have occurred in an environment of slow economic growth despite a reform-minded leadership bent on increasing competition and opening the economy to trade and investment. Mexico’s economic growth has been driven largely by integration with Canada and the United States in the North American Free Trade Agreement, but economic performance remains far below potential. Despite a more open economic environment, business regulations continue to undermine economic efficiency. Ensuring more dynamic growth will require broader based reforms to improve the investment climate and enhance the rule of law. Mexico is the major drug-producing and transit nation with the world’s second largest opium poppy cultivator ( ). The estimated annual wholesale earnings from illicit drug sales ranges from $13.6 billion to $39 billion ( ; ). At least 60,000 people were killed during the ongoing asymmetric war between the Mexican government and the drug cartels between 2006 and 2012; more than 18,000 additional people were reported missing ( ; ). The Merida Initiative, which provides $1.4 billion over 3 years for the United States to assist the Mexican government with training, equipment, and intelligence, has failed to make a difference ( ).
The estimated population of Mexico in 2014 was 120,286,655 ( ). By a 2014 estimate, the average annual rate of natural increase was estimated at 1.21% ( ). The birth rate in Mexico is 19.02 births per 1000 persons, whereas the infant mortality is estimated to be 12.58 deaths per 1000 live births ( ). Over the past 4 decades, the life expectancy at birth has increased from 35 to 72.7 years for males and 78.3 years for females ( ). Approximately 50% to 75% of the Mexican population suffer from malnutrition, making it one of the leading causes of death among children. On the other hand, the obesity rate was 32.1% in 2008, which ranked Mexico at the twenty-third highest obesity rate in the world; the United States was ranked eighteenth. The estimated child labor rate was 5%, or over 1.1 million child workers, in 2009. The gross domestic product (2013 estimate) is $1.33 trillion, with a per capita income of $15,600 ( ). The unemployment rate was 4.9% (2013 estimate), and the population below the poverty line was 52.3% (2012 estimate) ( ).
The southwest region of the United States was settled by Spaniards in 1598 in what is today New Mexico. Later, citizens of the United States began settling in what was then Mexican territory. Mexicans helped establish many southwestern cities and taught the settlers skills in mining, farming, and ranching. After the U.S.–Mexican War, which separated Mexico, a treaty provided land and cultural rights to those of Mexican descent. Unfortunately, these rights were never fully honored, and Mexican Americans living in these areas have tended to become an economically segregated working-class group ( ).
Mexican Americans are Americans of full or partial Mexican descent. The estimated number of Mexican Americans in 2013 was over 34 million, which was 10.8% of the total population in the United States ( ). By 2015, the estimated number of Mexican Americans was roughly 54 million, accounting for 17.0 of the total U.S. population ( ).
Over the years, numerous socioeconomic and political conditions in Mexico and the demand for cheap agricultural and industrial labor in the United States have contributed to the movement of Mexicans to the United States ( ). Because of the geographical closeness of Mexico and the United States and the permeability of the border, some Mexicans move back and forth between Mexico and the United States legally and some illegally. The movement back and forth across the border allows them to remain in contact with their families and native customs while seeking economic opportunities in the United States. The U.S. Department of Homeland Security ( ) reports that the heaviest concentration of illegal immigrants coming into the United States—69% of all undocumented individuals—come from Mexico; this represents a 57% change between 2000 and 2006. Lack of citizenship may present a significant barrier to psychosocial and physical health and to gaining education, skills, stable jobs, decent living conditions, and government benefits. Mexican Americans who are undocumented frequently experience tension regarding discovery and deportation back to Mexico. Preoccupation with possible discovery and deportation for illegal aliens serves to further augment the symptoms of post-traumatic stress disorder (PTSD) ( ). The plight of the illegal alien has worsened since enactment of the Immigration Reform and Control Act of 1986 ( ). In an attempt to control illegal immigration to the United States, employers are now required to verify citizenship status within 24 hours after hiring an employee. Thus, undocumented aliens are often forced into low-paying day-labor jobs.
The Mexican immigrant populations have been concentrated mostly in the south and western portions of the United States, but more recently, the Midwest and East Coast have seen sizable increases in their populations. Thirteen states now have 100,000 or more residents who are Mexican immigrants, and California has the heaviest concentration (39%). Most Mexican Americans have rural agricultural backgrounds ( ). However, it is difficult to generalize about geographical location and the occupational background of people in this ethnic group. The diversity in Mexican Americans ranges from rural villagers in New Mexico and Colorado ( ; ) to agricultural laborers in Texas ( ) to low-income residents in Arizona and to urban lower class individuals in California ( ). Just as the people are diverse, studies often represent specific populations of Mexicans and offer differing definitions of Mexican Americans. Discussion of Mexican Americans is complicated by the diversity of this population ( ; ). Because of this, making general conclusions about Mexican Americans as a result of individual studies must be done with great caution. It bears noting, however, that of the estimated 54 million Latinos in the United States in 2013, 64% are of Mexican origin, followed by Puerto Ricans (9.5%), Central Americans (8.9%), South Americans (6.1%), Cubans (3.7%), Dominicans (3.2%), and other Hispanics and Latinos (4.6%) ( ).
The Hispanic American population is growing rapidly in the United States. In fact, in 2000 the number of Hispanics exceeded the number of African-Americans, escalating this group to the largest ethnic minority group in the United States. In 2010, 50 million Hispanic Americans were reported to live in the United States, and Hispanics now represent 16.8% of the total U.S. population ( ). As in the past, people of Hispanic origins, including Mexican Americans, Puerto Ricans, Cubans, and persons from Central or South America, could identify themselves as Hispanic ( ). However, in the 2000 census, the term Latinos was used for the first time on the census form ( ). The terms Hispanic or Latino may be used interchangeably. In fact, these terms now reflect new terminology set forth in standards issued by the Office of Management and Budget in 1997.
The Mexican American population has also been growing rapidly. According to the , the Mexican American population nearly doubled between 1970 and 1980. Between 1980 and 2000, the number of Mexican Americans residing in the United States doubled again. The Mexican American population was increased from 20,640,178 in 2000 to 31,798,258 in 2010 ( ). Today, there are some 54 million Mexican Americans residing in the United States, accounting for 17.0% of the total U.S. population ( ).
The proximity of Mexico to the United States has resulted in a noteworthy amount of drug trafficking. The practice of smoking cannabis leaves came to the United States with Mexican immigrants who came north during the 1920s ( ). Much of the cocaine that reaches the United States from Colombia comes by way of Mexico ( ). Along with the drugs has come an increase in violence for border cities, creating problems for the judicial system by overcrowding jail cells, and for the health care system, which is often unprepared for the influx of health and socially related problems ( ).
Use of the health care system in America has been problematic for many Mexican Americans because of lack of insurance ( ). As estimated in the 2013 American Community Survey conducted by the U.S. Bureau of the Census, the uninsured rate for Hispanic or Latino individuals was 28.4%, which was much higher than the national average (14.5%), White non-Hispanic (10.2%), and Black (17.1%) ( ). Explanations for lack of insurance are partly related to communication difficulties and to lack of understanding that insurance is needed. Lack of health insurance is also related to culture, because most Hispanics who have recently immigrated do not understand the competitive health care market and the need for insurance, and many still place their trust in traditional herbal remedies ( ; ). Health care agencies are not eager to treat uninsured, indigent people since undocumented aliens do not qualify for Medicare or Medicaid funds. noted that most of the Mexican Americans who were uninsured are younger, female, poor, and foreign. These persons report that they make fewer health care visits, are less likely to have a usual source of care, and more often receive care in Mexico. Another complication regarding the use of the health care system is that many Mexican Americans live in crowded, substandard city housing, which has limited access to high-quality health care facilities ( ). When comparing Mexican American, African-American, and White American low-income women, noted that while psychosocial variables were significant predictors for health care use, for Mexican American women, psychosocial vulnerability was mediated by barriers that affected utilization in a more complex way. studied rural Mexican Americans living in Texas and noted that psychosocial variables including part-time employment, lack of continuous health insurance coverage, and poor health status could be related to levels of satisfaction with health care.
Immigration of Mexicans to the United States has created difficulties in schools, such as the special needs of teaching children who do not have English-speaking skills ( ). Yet another problem can be noted in California, where funds are not provided for educating children who are illegal aliens. The educational achievement of Mexican Americans is steadily rising. For example, the prevalence of the population with a high school diploma or higher educational attainment among Hispanics or Latinos has increased from 27% in the 1970s to over 64% in 2013 ( ). Illegal and legal immigrants from Mexico present other problems for the United States since many immigrants have relatives who are citizens and who participate in the debate about deportation and obstruction to the path to citizenship ( ).
In general, it is estimated that Mexican Americans have less formal education than the national average. In fact, in 2013, approximately 64.7% of Hispanic or Latino individuals over 25 years of age have graduated from high school, and only 14% of Hispanics or Latinos have graduated from college. These figures are compared with national averages of 86.6% and 29.6%, respectively, for all racial groups in the United States ( ). Increased education has resulted in a decrease in problems related to poor housing, jobs, and discrimination. However, many customs in the United States, including needing a driver’s license and insurance to avoid problems with the police, being quiet in the evening in a conservative neighborhood, and exhibiting polite behavior toward women are part of the socialization process that must be learned in order to adapt to most communities in the United States ( ). While some Mexican Americans are positive about the socialization process, many Mexican Americans try to retain a cultural identity within the dominant population ( ).
“Cultural uniqueness” is not academic nomenclature for Mexican Americans. The phrase is used to describe physical, emotional, and behavioral distinctions unique to many Mexican Americans ( ). Unlike European immigrants, who often hasten to absorb the culture found in the United States, many Mexican Americans have not. In Megatrends, John states that “none of the new groups individually can begin to match the numbers and the potential influence of Spanish-speaking Americans.” Concepts such as machismo (manliness), confianza (confidence), respeto (respect), vergüenza (shame), and orgullo (pride) predominate in the culture, and traditional gender and family roles continue to be part of the heritage that separates Mexican Americans from other cultural groups. Unfortunately, and perhaps because of the desire to retain cultural identity, many Mexican Americans have experienced discrimination in education, jobs, and housing. Skin color, language differences, and Spanish surnames have all contributed to discrimination ( ).
In 2013, 47.7% of Mexican American families were married couple families, 8.9% were single male household families, and 20.2% were female-headed households ( ). In addition, in 2010, Mexican American households had 3.52 people, compared with 2.38 people for the rest of the general population among non-Hispanic Whites. This increase in persons per household partly accounts for the rapid growth of both the Mexican Americans in particular and the Hispanic populations in the general population. Mexican Americans are a younger population; 32.8% of Mexican Americans are 18 years or younger compared with 21.4% of non-Hispanic Whites ( ). The median age for Hispanic and Latino individuals was 28 years, while the national average was 37.5 ( ).
In 2013, of the total number of Mexican American males (16 years and over) in the workforce, 15.9% held jobs in management, professional, or related occupations; 22.2% held jobs in service occupations; 14.7% held jobs in sales or office occupations; 3.1% held jobs in farming, fishing, or forestry occupations; 22.3% held jobs in construction, extraction, maintenance, and repair occupations; and 21.7% held jobs in production, transportation, or material moving occupations. Of the total number of Mexican American females (16 years and over) in the workforce, 24.6% held jobs in management, professional, or related occupations; 32.2% held jobs in service occupations; 12.5% held jobs in sales or office occupations; 1.4% held jobs in farming, fishing, or forestry occupations; and 9.5% held jobs in production, transportation, or material moving occupations ( ).
Despite the shift from jobs related to agriculture for the general population of Mexican Americans residing in the United States, in 2013 the median family income for Mexican Americans in general was only $42,897, as compared with $62,367 for all other races. The median per capita income for Mexican Americans was only $16,117 as compared with $45,320 for all other races ( ). Among all Mexican Americans at all ages, 24.7% live below the federally defined poverty level ( .
While Mexican Americans are merging into the general labor force, other than seasonal work, reported that except for southern Florida, 80% to 90% of all the migrant and seasonal labor force were foreign born and almost all were of Mexican origin ( ). Kissam reported the following developments in the migrant Mexican labor force: (1) diffusion into other geographical areas of the United States, (2) greater ethnic and linguistic diversity than earlier workers, (3) increasing numbers of unaccompanied males supporting families who remain at home, (4) changing characteristics of reunited families settling in the United States after the father had migrated for 5 to 10 years (children of these families transfer to U.S. schools after years of school in Mexico, rather than having K–12 schooling in the United States, and these families experience a high level of stress in assimilating as a united family and as immigrants), (5) increasing numbers of very young and very old migrant workers, and (6) growing numbers of female-headed households. The changing demographics of Mexican migrant farm workers present many challenges to U.S. agencies in adequately meeting their needs.
Spanish, the primary language for many Mexican Americans, is the fourth most commonly used language in the world, the second most commonly spoken language in the United States, and one of the six languages used by the United Nations ( ). Of the people in the United States who speak a second language, over 50% speak Spanish. Of U.S. Latinos, almost 90% speak Spanish ( ).
The Spanish language is spoken in many dialects; Mexican Americans who have an Indian heritage may speak one of more than 50 Spanish dialects. Fortunately, the majority of words spoken have the same meaning ( ). Differences in dialect may be found in certain communities. Dialects may also be identified by their proximity to the Mexican border. In the nineteenth century, the dominant language in the barrios and rural settlements was that of Mexico, although some Tejanos also attained facility in English and thus became bilingual. Various linguistic codes characterize oral communications in present-day enclaves. However, because of continued emigration from Mexico, racial separation, and exposure to American mass culture, some Texas Mexicans speak formal Spanish only, just as there are those who communicate strictly in formal English. More common are those Spanish speakers using English loan words as they borrow from the lexicon of mainstream society. Another form of expression, referred to as codeswitching, involves the systematic mixing of the English and Spanish languages. Another mode of communication is caló, a hip code composed of innovative terminology and codeswitching used primarily by boys in their own groups ( ). This southwestern regional form of dialogue, now used across subculture groups of Mexican American teens, is also used to a lesser extent by older Mexican Americans ( ).
Adult Mexican Americans can be characterized as tactile in their relationships. Embracing or holding hands while walking is common among close friends of the same gender. Although female Mexican Americans may initiate more tactile behavior in communicating, there is a contradiction where modesty is concerned. Mexican American women have been taught to highly value female modesty and not to expose their bodies to men or even other women. Nakedness is avoided and will cause embarrassment, even among close family members. Consequently, being touched by health care providers is often a source of embarrassment ( ; ). Women will generally prefer to receive care from a female health care provider, and adolescent girls may desire to have their mother or female relative present for pelvic examinations and other intimate aspects of a physical examination. Although religious beliefs may explain lack of birth control, discomfort with certain areas of the body may also explain why some Mexican American women avoid the use of a diaphragm. Men also have strong feelings about modesty and may feel threatened if expected to have a complete physical examination ( ). While this modesty may explain the reluctance of some Mexican American men to use condoms, this reluctance may also reflect the imbalance of power between men and women. Increasingly, women in committed relationships are being included in contraceptive decision making ( ). Consideration of the Mexican American client’s need for modesty suggests approaches for nurses doing physical assessments ( ). During the examination, care should be taken to uncover only the body part being examined and to allow only persons essential to the examination in the examination room.
Hispanic men who are asked to participate in prostate screening experience embarrassment, which poses a barrier to disease prevention behaviors ( ). Breast self-examinations are often perceived to be embarrassing but are done by Mexican American women who are more acculturated ( ). Education using breast models, videotapes, and community-based group discussion improves breast health knowledge and promotes screening behavior in Mexican American women ( ).
When being interviewed, Mexican Americans may engage in small talk before approaching the business of the interview. It is important for the nurse to remember that small talk will often facilitate accomplishing nursing objectives for the interview and is therefore not a waste of time.
Traditionally, in communicating with others, Mexican Americans have used diplomacy and tactfulness. There is also pride in verbal expression, which is likely to be elaborate and indirect. Direct confrontation and arguments are considered rude and disrespectful. Self-disclosure is reserved for those whom the individual knows well. The Mexican American may appear agreeable on the surface regarding an issue because of the value of courtesy. However, the nurse may later be surprised and disappointed because agreements are not being carried out.
Eye behavior is important to Mexican Americans, especially when children are involved. Mal ojo (evil eye) is a folk illness described as a condition that affects infants and children and occurs because an individual who is believed to possess a special power voluntarily or involuntarily injures a child by looking at and admiring but not touching the child ( ). With this condition the child cries, develops a fever, vomits, and loses his or her appetite. If one is admiring a child, this disorder may be prevented by also touching the child’s head or arm. The spell is broken when the individual who has given the “evil eye” touches the child. Therefore, the nurse should touch the child when giving care because in the minds of Mexican Americans, this action can both prevent and treat the illness.
English as a Second Language
Most Mexican Americans can also speak some English and for those of Mexican descent born in the United States, 98% are fluent in English. The inability to speak English fluently has led to increased failure rates for school-aged Mexican Americans ( ). Lack of language fluency has a negative impact on psychological well-being and diminishes quality of life ( ). The longer Mexican immigrants stay in the United States, the less likely they are to retain the mother language, which probably is most directly attributable to the fact that English is the language used in schools and at work. Increasing attention is being given to the need for bilingual education for Mexican American students, and as a result, more Mexican Americans are becoming bilingual. , in a unique study of acculturation of the same cohort of Mexican Americans followed across four generations, noted that by the fourth generation, almost all are English and Spanish speaking. Paradoxically the learning of English by Mexican immigrants who also attain greater economic well-being is associated with increased risk of cardiovascular disease ( ).
Some Mexican Americans still use English selectively. In an extensive study on language loyalty among various ethnic groups residing in the United States, it was found that Spanish remains the most persistent of all foreign languages. Although other ethnic groups may have lost the connection to their mother tongue over time, Mexican Americans have been more likely to retain their mother language in succeeding generations in the United States. Even today, some fluency in Spanish characterizes most Mexican Americans at all income levels. Another reason for the persistence of Spanish among Mexican Americans is that in the United States, the mass media for information and entertainment are permeated with Spanish. Spanish accounts for approximately 66% of the total foreign-language broadcasting in the United States. In 2009 there were over 1323 Spanish-language radio stations with Internet broadcasts ( ). This is significant for the provision of improved health care for those with limited English fluency.
It is not uncommon for people who speak different languages to use each language in different contexts or for different purposes. Perhaps the most frequent situation is that of Mexican Americans who use English in their work and Spanish at home or with their friends. In northern New Mexico it is common to find words retained from sixteenth- and seventeenth-century Spanish colonial times ( ) and some villages where the only English spoken is for official occasions, such as conferring with a government agency. Because of the remoteness of these communities, these Mexican Americans may retain Spanish as their principal language. Communication by Mexican Americans is also complicated because many Mexican Americans learn a language that blends English and Spanish. Mexican American adults use this blended form of language more often than children do. Consequently, a nurse who may know both English and Spanish may still have difficulty understanding this blended language.
Implications for Nursing Care
Because some Mexican Americans rely on Spanish to communicate with other people, it may be very frightening for them to participate in the American health care system, and it is frustrating for the nurses giving them care. Nurses caring for clients who do not speak English need to develop and use strategies that show respect for and comfort with cultural differences of these clients ( ). In a metasynthesis of qualitative studies, having a translator present was not sufficient for nurses to connect with their Mexican American clients ( ). Friendly facial expressions, facing the client, and talking directly to the client even when using the services of an interpreter were found to be important ( ). The use of certified translators is designed to enhance the communication experience between clinician and clients. However, the translator and client sometimes engage in a separate conversation in an attempt to culturally advocate client concerns with the system or provider ( ). Care should be taken to ensure that this experience does not undermine the client–provider relationship. Technology, through digital translators, has been designed to help the health care provider maintain direct interaction with Spanish-speaking clients. Digital translators enable translation, back translation, and the creation of a communication log. conducted a study of primary care physicians speaking with diabetics and reported that patients with low literacy in the primary language of the physician received less interactive communication about their disease process. Thus, while efforts should be increased to recruit Mexican Americans into the health professions and to encourage students and professionals to study Spanish in order to communicate with clients, attention to the social features of how people speak when languages differ is needed. The way people use language to motivate health behavior or persuade one another is affected by cultural differences ( ). When professional staff cannot speak Spanish, interpretation services must be obtained in order to provide culturally competent care. Based on the recommendations of the Office of Minority Health National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards), family and friends should not be used as interpreters. Using children as translators should be avoided since children lack understanding of medical conditions, and as with other untrained interpreters, conflict of interest is likely to arise. Bilingual hospital staff members have as high as 50% inaccuracy when interpreting ( ). Although the CLAS Standards recommend asking individuals to rate their primary language and capacity in English and to use qualified institutional interpreters, hospitals continue to find it challenging to comply.
It is important for the nurse to remember that language is a cultural factor that influences health care practices ( ). Mexican American clients view nurses who attempt to speak some Spanish as caring and respectful. It is uncommon for Mexican Americans to be aggressive or assertive when interacting with health care providers. Direct conflict or disagreement with a health care provider generally does not occur; rather, the Mexican American client will be silent or not adhere to the prescribed treatment plan. The nurse who works with bilingual Mexican Americans must remember that when under stress, these persons often may revert to their first language, Spanish. The nurse should explain that the nurse can be more helpful if the client communicates in the language that both the nurse and the client understand. When this is impossible because of high levels of stress on the part of the client, the nurse should find a translator. Understanding the profound effect of bilingualism on the client also requires appreciation of the dimension of language independence—the capacity to acquire, maintain, and use two separate language codes, each with its own lexical, syntactic, phonetic, semantic, and ideational components. Many Mexican Americans who are proficient in both Spanish and English operate parallel language codes, each with its own associations between message words and events in their ideational system ( ). A good example of language compartmentalization can be found in the saying of Emperor Charles V: “To God I speak in Spanish, to women in Italian, to men in French, and to my horse in German” ( ). In certain situations a client may speak to his or her family in Spanish, to the nurse in English, and, when extremely stressed, to both family and nurse in a combination of both English and Spanish ( ).
It is also important for the nurse to keep in mind that Mexican Americans tend to describe emotional problems by using dramatic body language. In addition, research has shown that when Mexican Americans are interviewed in English, or across their language barrier, they are usually judged by experienced clinicians as showing more severe symptoms than when they are interviewed in their mother tongue ( ; ). The nurse should keep in mind that nonverbal communication differs among cultures; thus, it is important to work closely with the client and family in order to evaluate symptoms from a variety of perspectives.
The nurse must guard against the use of idioms and abstractions when dealing with clients who do not completely understand the language. The nurse should also avoid responding to the client in a joking manner. Jokes are easily misinterpreted, frequently based on nuances of communication or language, and for the most part are lost in translation. When working with a Mexican American client who lacks understanding of the language, statements using slang or colloquialisms should be avoided because they may be interpreted literally.
One of the most important roles of the nurse in caring for the Mexican American client is that of teacher. Teaching should begin with an assessment of the client’s ability to communicate and understand, which will guide the nurse in deciding which other family members should be included in the teaching process. The home situation must be carefully evaluated to adapt care to the reality of the living situation. Instruction should include all aspects of the client’s condition and treatment and should be communicated in simple, concrete terms with ample opportunity allowed to raise questions and validate understanding. There should be continuous evaluation of learning by questioning and return demonstrations, and problem solving should be encouraged. Throughout this process, the nurse must continue to build a trusting relationship with the client so that follow-up care will be maintained, helping to ensure that the client will seek medical care before future situations get out of control.
categorized people and the modalities of relationships as individualistic, collateral, or lineal. Some Mexican Americans are categorized as both collateral and lineal, implying that there may be a patron–peon system, such as a boss–worker relationship, or a family-versus-individual relationship.
In caring for Mexican Americans, simpatia and personalismo play a significant role. Simpatia is characterized by smooth or harmonious interpersonal relationships, described by courtesy, respect, and the absence of critical or confrontational behavior. Among Mexican Americans, a high degree of intimacy may lead to expectations of involving the nurse in the family system, with expectations of participation in familial activities and social functions ( ). Mexican Americans as a group demonstrate a great need for group togetherness. Some Mexican Americans think of Anglos as distant because they require more personal space during conversation than Mexican Americans ( ). found that when Mexican American second graders related to others, there was closer interpersonal distance and more touching among girls. Touching was of longer duration when spatial distances were closer. Boys tended to be less tactile when relating to others. It is believed that this pattern of socialization begins with the parent–child relationship and continues into adulthood. During the early years, the parents are permissive, warm, and caring with all their children. However, in later years, the girls remain much closer to home and are protected and guarded in their contacts. In contrast, the boys are allowed to be with other boys in informal social groups, where they develop their “machismo” ( ). (In delivering care to male clients, nurses must be aware of the concept of “machismo,” a set of attitudes and identities associated with the Mexican concept of masculinity and manliness [ ].) described issues encountered by Mexican American families trying to adapt to the placement of an older adult in long-term care settings and the concern for staff to create a living space for their parents that respected their cultural heritage and routines.
Implications for Nursing Care
The concepts of family obligation and spirituality are pervasive among Mexican American clients. Personalismo and respeto are expected from health providers; Mexican American patients expect a handshake in greeting and not offering this is considered rude ( ).
The nurse who plans care delivery for Mexican American clients must keep in mind that Mexican Americans may resist care provided by those perceived as being different or from a different ethnic background ( ). Some Mexican Americans may also have cultural biases that prohibit care being administered by persons of the opposite sex. For example, a male student nurse was assigned to a Mexican American client in labor. This assignment precipitated problems because the client, husband, and family were all very uncomfortable because “only her husband should see her like that.” It was necessary to change the assignment in order to provide care. However, although same-sex health care providers are preferred, a health care provider of the opposite sex is usually acceptable by Mexican Americans as long as the care provider is sensitive to the modesty needs of the client ( ).
Within the Mexican culture, the family is the most valued institution and the main focus of social identification. Most Mexican Americans have nuclear families who live separately, although some extended family or other relatives often live in the same household ( ). According to , new immigrants (especially those who are undocumented) tend to live in a multiple-family arrangement, which offers the advantages of social and economic support. As the length of residency increases and the family becomes more financially independent, the nuclear family tends to find a singular arrangement for its household.
Traditional females display subdued qualities, while males have been the authority figure in the family, assuming responsibility for being head of the household and the decision maker ( ). In a typical Mexican American family, male members usually display a strong sense of machismo that is irreconcilable with self-esteem or authority loss ( ). The culture dictates that men need to be strong, reliable, virile, intelligent, and wise. They are expected to exhibit valor, dignity, self-confidence, and a high degree of individuality outside the family and be knowledgeable regarding sexual matters ( ). Men want to project the image of honesty, compassion, and integrity. The man of the family needs to be regarded as being proud, brave, courageous, devoted, loyal, honorable, and worthy of being the head of the household ( ).
The male is considered the decision maker ( ). The mother of the family has the primary role of keeping the family cohesive. Although the mother may influence family decisions, she does not have a dominant role in the family. Increasing numbers of Mexican American women are finding work outside the home. Women who live in a rural setting often help with the family farming activities. Divorce is uncommon, but stable out-of-wedlock relationships are common in the lower socioeconomic levels. reported on a group of employed, low-income Mexican women who worked in urban hospitals who experienced role overload and stress. There appeared to be difficulty reconciling the traditional cultural expectations of a woman’s role in the changing society, which added the role of working outside the home.
Families are usually large, consisting of the parents and four or more children. Parent–child connectedness and respect for parental authority are valued over the husband–wife bond emphasized by the Western nuclear family. It is generally believed that Mexican Americans are familistic. Familismo or family interdependence is valued in the Mexican American culture. Familismo involves sharing by extended family members the responsibilities to nurture and discipline children, provide financial aid, provide companionship for lonely or isolated members, and engage in problem solving. There is low reliance on institutions and outsiders. Mexican families value behavior in children that denotes respect, responsibility, compliance, and being “well brought up” ( ; ; ). For some Mexican Americans, familism has been perceived as curtailing mobility by sustaining emotional attachment to people, places, and things. In the Mexican American culture, familism has been identified as the prime cause not only of low mobility but also of resistance to changes of all kinds. For Mexican Americans, familism, along with the specially assigned male role, is a source of collective pride. Nevertheless, Mexican Americans are believed to be deterred from collective and individual progress because of familism.
The major dominating theme of the traditional Mexican American family is the need for collective achievement of the family as a group. The collective needs of family supersede the needs of individual members. Also, any dishonor or shame that may occur for an individual member is considered a reflection on the entire family. The Mexican American family takes pride in family endeavors and generally does not seek help from outsiders to solve problems or meet needs. Mexican American families highly value having many relatives live nearby. The local extended family is tightly integrated, has frequent face-to-face encounters, and provides members with mutual aid ( ). Mexican Americans have a mean network size of 5.78, which may include in-laws, grandparents, and a substantial number of other relatives, with some 69% of those studied reporting that most of their support was provided by immediate family members ( ; ). The importance and obligation of Mexican Americans in meeting the needs of others indicate that there may be a higher priority placed on promoting and supporting the development of abilities to care for others than on abilities to care for self. Two other patterns, the “accepted obligation to perform roles within the family” and the “willingness to bear the burden so as not to cause pain for others” further indicate that caring for others is both expected and rewarded ( ; ).
There is a high incidence of teenage pregnancy among Mexican Americans. The overall teen pregnancy rate in the United States has fallen 57% since 1991; however, in 2013, the birth rate for women between 15 and 19 years old for Hispanics (41.7 per 1000, total 92,960 births) was still the highest among all races and origins followed by non-Hispanic Blacks (39 per 1000, total 67,537 births) ( ). In 2012, the birth rate for Mexican American teenagers (15–17 years old) was 24.8 per 1000 population, compared with 21.9 per 1000 for African-American teenagers and 8.4 per 1000 for White teenagers ( ). Likewise, the teenage pregnancy rate in 2012 for Mexican Americans 18 to 19 years of age was 74.2, compared with 74.1 for African-Americans and 37.9 for Whites ( ).
The entire family may contribute to the financial welfare of the family. Parental control in Mexican American families is strong. Older children contribute by caring for younger family members or animals or by helping with the production of food or other family enterprises. Children in migrant families often earn money by working along with other family members.
Children also assume other responsibilities in the family. For example, found that older children of immigrant families served multiple roles in assisting their parents to learn certain skills or activities that ranged from filing taxes to understanding difficult-to-read manuals and intervening or advocating on behalf of their parents or their household on complicated transactions. The elderly are respected and live with married children if they are not self-sufficient. The elderly also pass down cultural and folk medicine beliefs. Elder care among Mexican Americans is greatly influenced by the belief that the family is the most important and main source of assistance; thus, Mexican American elders turn to their children and other family members for assistance before seeking out any services in the community.
found that Mexican American families of a lower socioeconomic class tended to show more ethnic identification than those of a higher socioeconomic class. This phenomenon served to provide support for Mexican Americans of lower socioeconomic classes and a more positive adaptation to the mainstream U.S. culture. investigated gender and academic success among Mexican Americans. The findings indicated that Mexican American females in New York City choose high schools that ensure academic success in spite of the expectation that they return home after school to care for their younger siblings and help with housework. Males, on the other hand, took little time in selecting a high school and after school had no responsibility, giving them unstructured time that often led to gang activity and eventually dropping out of high school. Smith noted that whereas this enabled Mexican women to be upwardly mobile, the opposite effect was noted in men.
An important institution in the Mexican heritage is the Catholic practice of compadrazgo, or co-parenthood (godparenthood), which was introduced to Mexico by the Spaniards. Godparents ( compadrazgos ) accept co-responsibilities for a child along with the parents. This kinship begins with the baptism of the child and continues throughout the child’s life ( ); it is used for religious purposes and becomes an important resource for coping with the stresses of life ( ). Frequently, a godparent is chosen from a higher socioeconomic level, which enables the child to have social resources that are more extensive than what the family could provide.
Another important tradition for many Mexican American families is the way in which holidays are celebrated with Mexican traditions. Others continue to celebrate Mexican holidays. During the celebration of the Mexican Christmas, called Las Posadas, the children are fond of breaking a piñata, a papier-mâché container filled with candy and gifts. Other important holidays are Cinco de Mayo (May 5) and Guadalupe Day (December 12), which is Mexico’s most important religious holiday. Affluent Mexican Americans often spend significant amounts of money on special food and drink, decorations, and fireworks for a holiday festival. Holidays provide an opportunity for Mexican Americans to share with others.
Beliefs and Practices in Death and Dying
Death is a prevalent theme in Mexican culture, which may be influenced by the Aztec and Catholic beliefs that death is not the end but rather an entry into a new way of life ( ). In a landmark study that examined the thoughts and behaviors about death, dying, and grief among Mexican American immigrants, found that religious symbols and rituals are important and that large, supportive Mexican American family networks provide comfort and practical aid while grieving. This is consistent with other findings that support the importance of familismo when coping with the death of a loved one. Many Mexican Americans believe that whatever the cause of death, it is the will of God, often referred to as fatalism ( ). For example, found that 72% of Mexican Americans believed that accidental death was attributable to divine will, as compared with 56% of Anglo Americans. Additionally, they found that 27% of Mexican Americans thought of their own death daily, compared with 13% of Anglo Americans. Whereas none of the Anglo Americans believed that individuals should be allowed to die when they feel unproductive or unhappy, 3% of Mexican Americans reported they believed this should be allowed. Seventy-six percent of the Mexican Americans in this study reported that they are likely to touch the body of a deceased family member compared with 51% of Anglo Americans. In addition, 59% reported they would be likely to kiss the body of the deceased, compared with 33% of Anglo Americans. In addition, 59% of Mexican Americans believe that a person should visit the grave of his or her spouse at least six times during the first year, compared with 35% of Anglo Americans. reported that Mexican Americans do not use hospice care because they are a close-knit community who prefer to take care of their own. On the other hand, examined differences in attitudes toward place of death among Whites, Mexican Americans, and Blacks that could not be explained by age, sex, income, education, and cause of death. After an inpatient hospital stay, 56% of Mexican Americans died, compared with 50% of Blacks and 43% of Whites. Twenty-two percent of Mexican Americans died in a nursing home compared with 18% of Blacks and 20% of Whites. Only 9% of Mexican Americans died in a private residence, compared with 18% of Blacks and 22% of Whites. Using an ethnographic approach interviewed Mexican American families about their bereavement experiences after the death of a child and found several themes reflecting the ways in which family members maintained an ongoing relationship with the deceased through dreams, storytelling, sense of presence (“I place a setting on the table for him on special occasions”), faith-based connections, proximity connections (“If I die I want to be buried here with him”), ongoing rituals (“I still prepare his favorite meal on his birthday”), and pictorial remembrances.
Because of strong family ties among Mexican Americans, the idea of truth telling and decision making during the end of life may have to be viewed differently from the traditional Western lens of individual autonomy and broadened to integrate the needs of the family. Religion and faith, and the role of the clergy, are important components of life in Mexican American families, and these components become intensified in the death and dying experience. Spiritual beliefs, the role of prayer, and the role of family in caregiving were predominant aspects in the end-of-life experience investigated in a sample of Mexican Americans ( ). The study validated the need to focus on the role of religious institutions in Mexican American culture, where spirituality and religion are strong influences in the life experience. Pain and suffering are common aspects in the experience of death and dying. If the nurse and other health care providers do not understand Hispanic values about causes of pain, illness, and suffering, these experiences may go unrecognized or untreated ( ). Differences in the expression of pain and suffering may exist even in the same culture. Hispanic males tend to be stoic and uncomplaining ( ), whereas among the women, moaning and crying are accepted means of expression of discomfort and pain.
Implications for Nursing Care
Of primary importance for the nurse caring for Mexican American clients is the concept that family values and roles are paramount in the client’s treatment and recovery. Although the male head of the family should be consulted in health care decision making for other family members, clinicians need to focus more on engaging extended family and community supports. The inclusion of the entire family, both immediate and extended members, in the assessment, planning, and implementation of nursing care is critical if treatment is to be effective. Rather than viewing a large family who wishes to be with the client as an annoyance and frustration to staff, the nurse should discuss with the family how visits can be planned so that care can still be delivered and the client can obtain needed rest.
The family needs to be partners in the provision of care to clients. By integrating them into the provision of care, the family can provide assistance in feeding, bathing, or walking the client. Allowing the family to participate in the client’s care builds trust and respect and encourages compliance and support for discharge planning and teaching. On the issue of medical information, Mexican American clients and families may not agree on who has the right to have this information. For example, in one study by researchers at the University of California, only two thirds (65%) of the Mexican Americans in the study believed that the patient should be told if there was a diagnosis of metastatic cancer. The other respondents believed that the giving of information and the decision-making responsibility and information should rest with the family ( ). Thus, Mexican American clients and families may not agree on who has the right to have medical information.
When the nurse is experiencing difficulty in getting a client to follow a particular medical regimen, the nurse may suggest that the client solicit the opinions of other family members regarding proposed actions. This will demonstrate that the nurse understands the importance of the family in regard to health matters. Nurses can encourage Mexican American clients to use health-promoting behaviors, with the rationale that the family cares about their health and will support them in meeting their goals ( ). Furthermore, the nurse’s actions should help to build a relationship of trust between the nurse and the client. note that to facilitate provision of culturally sensitive care to Mexican Americans at a birthing center on the Mexican border, prospective certified nurse-midwives are evaluated for their understanding of and desire to work with this particular population. New staff are required to read culture-specific information and are encouraged to attend Spanish classes to develop a familiarity with the language. Knowledge of the client’s culture has been found to be a positive dimension in the client–provider process and important in providing culturally appropriate care.
Mexican Americans are usually characterized as having a present orientation of time and as being unable or reluctant to incorporate the future into their plans. An example of this orientation is that some Mexican Americans may spend several years’ savings on an important religious festival. Also, the Mexican custom of the siesta in some ways represents the belief that rest (or the present) has a priority over continued work that could produce monies to safeguard the future. Individuals with this present orientation of time may appear to lack practical concern about the future or the need for deferring gratification to a future time. Many investigators believe that this orientation restrains Mexican Americans from upward social mobility. In addition, some regard the present orientation of time as a barrier to assimilation and integration into the mainstream of American culture. However, of particular significance in terms of time orientation is the fact that Mexican Americans place more value on the quality of interpersonal relationships than on the length of time in which they take place ( ).
found few differences in the time perceptions of Mexican American and White American college students, despite the fact that the Mexican American students in the study were still maintaining cultural ties with the Mexican American culture. However, these findings cannot be generalized to Mexican Americans who are more immersed in their culture and less educated.
Implications for Nursing Care
Flexibility and creativity may be needed in order to work with differences in time orientation. It is important for the nurse to remember that personal ethnocentric attitudes toward time may negatively affect the planning of care for clients with a different time orientation. In the Western culture, health care settings tend to be future oriented, with weekly appointments, long-term treatment goals, and strict adherence to schedules. Scheduling can pose a barrier because patients and their families may not be able to leave work during the day to attend regular appointments. Because health care scheduling tends to be fixed and rigid, and traditional Hispanic culture time orientation tends to be more present oriented, Mexican American patients may encounter difficulties when trying to work within the schedules of the medical setting. A Mexican American client may be late for an appointment not because of reluctance or lack of respect but because the client may be more concerned with a current activity than with the activity of planning ahead to be on time. This concept, known as elasticity, implies that future-oriented activities can be recovered but present-oriented activities cannot.
Because Mexican Americans are likely to be present-time oriented, the nurse may experience difficulties in planning and implementing health care measures such as long-term planning. In addition, the nurse may experience difficulties in explaining why and when medications should be taken. When working with a client who has a condition such as hypertension, it is important for the nurse to emphasize the effects of this condition, as well as short-term problems that can occur if the medication is not taken on time. Emphasis on short-term problems is more likely to be beneficial because it is more likely to get results. Because Mexican Americans are present-time oriented, their perceptions and understanding of acute and chronic illness may be affected.
Locus of Control
Many Mexican Americans have an external locus of control, believing that external forces operate in many social and individual circumstances. Some Mexican Americans perceive life as being under the constant influence of the divine will. There is also a fatalistic belief that one is at the mercy of the environment and has little control over what happens. Associated with this view is the belief that personal efforts are unlikely to influence the outcome of a situation; thus, some Mexican Americans do not believe that they are personally responsible for present or future successes or failures. This belief may precipitate feelings of hopelessness regarding the future and positive change. The effect of this fatalistic belief was noted in study of Hispanic women who had difficulty maintaining cancer-prevention activities.
Effect on Personal Control.
Data from transcultural studies have found that people with a belief in external control can be expected to have more distress as an outcome of this view ( ). On the other hand, noted that distress was not observed in the Mexican culture as an outcome of a belief in an external locus of control. They also suggested that although distress can result from strong family ties, it is offset by the family’s strong support and responsibility to the individual. A consequence of strong family ties is that the individual may have a greater feeling of personal control, which in turn deters anxiety. When Mexican Americans experience pain, they value stoicism and self-control. suggest that crying and moaning in these clients may serve the purpose of relieving pain rather than communicating that the pain is intolerable and intervention is desired.
Research has shown that health practices among Mexican Americans are influenced by psychosocial variables hypothesized in various models of health beliefs and behavior. reported that when the Health-Promoting Lifestyle Profile (HPLP) was administered, Mexican American women had the highest total scores of all minority groups but lower scores than all predominantly White groups. HPLP self-actualization and interpersonal support scores were the highest subscale scores. Although Mexican American women in this study tended to practice more health-promoting lifestyle behaviors than other minority groups, it was also noted that a high number of the women worked in professional health care–related fields. However, their scores were lower than those reported for predominantly White groups, an indication that Mexican American women may lag substantially behind their White counterparts in the practice of “heart-healthy” lifestyles, even when the influence of socioeconomic status was removed. The exercise subscale was the lowest score for all groups, including minorities. Age, education, self-efficacy, health locus of control (internal and powerful others), and current health status made statistically significant contributions to the HPLP subscale scores. The Theory of Reasoned Action was tested by in Mexican farm workers; this study revealed that certain constructs in the model predicted participation in health screenings for tuberculosis (TB), for which this group is at risk because of recent immigration history and exposure. noted that whereas 37% of all women over 60 use hormone replacement therapy, 24% of Mexican American women do so. On the other hand, conducted a study of prevalence and predictors of periodontitis. In a study of African-Americans, Mexican Americans, and non-Hispanic Whites, Mexican Americans had periodontal health profiles closer to those of non-Hispanic Whites than did African-Americans. These findings have significant implications for health professionals in terms of education related to health-promotion activities for Mexican Americans.
studied a sample of 74 Latino Americans and 115 European Americans with type 2 diabetes to determine if a sense of control was related to health. A model of control beliefs, disease-management behaviors, and health indicators was tested with two measures of control beliefs—one diabetes-specific (diabetes self-efficacy) and one global (mastery)—which were used to examine effects on management behaviors (diet and exercise) and on health (hemoglobin A 1c and general health). Results indicated that the relationship between control and management behaviors varied by measure of control and by group. For Latino participants, global mastery was related to management behaviors, whereas self-efficacy was related to such behaviors among European Americans. This study provides support for a diversified approach to control, behavior, and health, particularly in dealing with minority populations. A study on parental locus of control (PLOC) among parents of clinic-referred Mexican American preschoolers demonstrated that referred Mexican American parents exhibited a more external PLOC than non-referred Mexican American parents across a number of domains. Thus, similar to non-Hispanic Whites, preschoolers’ behavioral problems are associated with an external PLOC among Mexican Americans ( ).
Health Care Beliefs
Health care beliefs are determined by several factors inherent in an individual’s history, environments, cultural norms and patterns, mores, and folkways. In turn, health behaviors are influenced by these health beliefs and determine how clients respond to interventions designed to improve health behaviors. reviewed literature on physical activity in Hispanic women and found that factors such as individual, social, and cultural influences can serve as promoting as well as hindering factors to physical activity among this group. For instance, self-efficacy and social support tend to be positively related to increased physical activity among Mexican American women; however, the likelihood of engaging in physical activity may be modulated by traditional values that consider this inappropriate for older women. This review supported the notion that ethnic groups cannot be considered heterogenous based upon a common language and that socioeconomic factors influence health behaviors significantly ( ).
The cultural belief in external locus of control influences the manner in which some Mexican Americans view health. Some Mexican Americans believe that health may be the result of good luck or a reward from God for good behavior. For some Mexican Americans, health represents a state of equilibrium in the universe wherein the forces of “hot,” “cold,” “wet,” and “dry” must be balanced. This concept is believed to have originated with the early Hippocratic theory of health and the four humors. According to the Hippocratic theory, the body humors—blood, phlegm, black bile, and yellow bile—vary in both temperature and moisture ( ). Persons who subscribe to this theory believe that health exists only when these four humors are in balance. Thus, health can be maintained by diet and other practices that keep the four humors in balance. Illness, on the other hand, is believed to be misfortune or bad luck, a punishment from God for evil thoughts or actions, or a result of the imbalance of hot and cold or wet and dry. found that a large number of elderly Hispanics attributed their health problems to old age and therefore did not seek any type of intervention.
Theory of Hot and Cold and Perception of Illness.
One category of disease is hot and cold imbalance, in which illness is believed to be caused by prolonged exposure to hot or cold. To cure the illness, the opposite quality of the causative agent is applied to assimilate the hot or cold. Included in this category are illnesses that, rather than being caused by temperature itself, are associated with hot or cold aspects of substances found in medicines, elements, air, food, and bodily organs. Treatment is focused on such things as suggestions, practical advice, prayers, or indigenous herbs, with the goal of reestablishing balance ( ).
Although cold is believed to harm the body from without, excesses of heat developed from within the body itself and extending outward are believed to be related to such diseases as cancer, rheumatism, TB, and paralysis ( ) ( Box 9-1 ). The focus of heat in the body is the stomach, whereas the head, arms, and legs are believed to be cool. Hot illnesses, such as skin ailments and fever, may be visible to the outside world. Many of the disorders caused by hot and cold imbalances are digestive in nature, which is related to the fact that an imbalance of hot and cold foods is believed to be damaging and suggests that to ensure good health, both hot and cold foods must be taken into the body. The quality of the food eaten determines whether diarrhea is a hot or cold condition. If the stool is green or yellow, the diarrhea is hot and the remedy is cold tea; if the stool is white, the diarrhea is cold and the remedy is hot tea.
|Hot Conditions||Cold Conditions|
|Kidney problems||Joint pain|
|Hot Foods||Cold Foods|
|Temperate-zone fruit||Dairy products|
|Eggs||Meats such as goats, fish, chicken|
|Hard liquor||Bottled milk|
|Meats such as beef, waterfowl, mutton|
|Hot Medicines and Herbs||Cold Medicines and Herbs|
|Penicillin||Orange flower water|
|Garlic||Milk of magnesia|
|Cinnamon||Bicarbonate of soda|