Portal de Periódicos da CAPES

Grouping people by language exacerbates health inequities—The case of Latinx/Hispanic populations in the US

2022; Wiley; Volume: 45; Issue: 2 Linguagem: Inglês

10.1002/nur.22221

1098-240X

Adrianna Nava, Leah V. Estrada, Lauren Gerchow, Joanie Scott, Roy Thompson, Allison Squires,

Cultural Competency in Health Care

The COVID-19 pandemic has highlighted the stark racial and ethnic inequities experienced by people belonging to historically marginalized groups. As direct care providers, nurses and midwives, who also represent the largest healthcare workforce in the world, should have a deeper understanding of the term "ethnicity" to provide culturally humble person-centered care (Ekman et al., 2011). Ethnicity is a complex social construct and is attributed to a conception of shared cultural heritage (Scupin, 2012). Relatedly, an ethnic group is a collection of people who share a common history, culture, and ancestry. Ethnicity has no biological or scientific meaning; however, the language used by nurses and midwives to discuss this social construct should be accurate, culturally humble, and inclusive (Flanagin et al., 2021). Categories for ethnicities differ globally and their nomenclature change over time depending on social and political forces. We recognize that given the global readership of Research in Nursing & Health, the categories for ethnicities are context-specific for the United States. In its late 1990s revision of demographic data classification standards, the U.S. Office of Management and Budget in its revised standards on the federal classification of data on race posited that the two categories of data on ethnicity are "Hispanic or Latino" and "Not Hispanic or Latino" (The United States Office of Management and Budget, 1997). Nonetheless, the underlying principles of using equitable language for ethnicity can be applied across different cultural, geographic, and political contexts. Therefore, the purpose of this editorial is to advance our understanding of the best use of contemporary and culturally humble language for ethnicity. In this editorial, we will focus on ethnicity and the issues specific to Hispanic and Latinx populations. The next editorial in this year-long series will address ethnicity as it relates to Asian and Pacific Islander populations. For this editorial, first, we will clarify the different meanings of the terms Hispanic and Latin (o, a, x). For clarity, the term Latinx will be used going forward but can be used interchangeably with Latino or Latina based on individual preference. Hispanic and Latinx are often conflated; nonetheless, nurses and midwives need to be cognizant of and sensitive to the nuances of both social constructs. Whereas Hispanic is the term used to describe someone with a heritage from Spain, Latinx is the term used to refer to people with a heritage from Latin America (Jaimes et al., 2013). The Spanish language, like most romance languages, assigns gender to nouns, and the ending of a word changes based on gender. For example, words with references to "masculine gender" end with "o," feminine with "a." Historically, the default linguistic structure sided with the masculine gendered ending of words. For example, "Latinos" refers to everyone with that ethnic heritage. "Latinx" is recent linguistic evolution as a gender-neutral term to refer to the population with a heritage from Latin America and to disrupt the gender binary encapsulated in the Spanish language (Logue, 2015; Salinas, 2020). Although this is a recent evolution, it is important to note that 76% of Hispanic adults have not heard of the term Latinx, with only 3% of Hispanic adults using it (Noe-Bustamante et al., 2020). The same grammatical rules apply to Portuguese and its dialects. Latin America is comprised of 20 countries from North (Mexico), Central (Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, and Panama), and South America (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Peru, Uruguay, and Venezuela) as well as the Caribbean (Cuba, Dominican Republic, and Puerto Rico). In the South American region, there are also the countries of Guyana, French Guiana, and Suriname. Because their colonial influences were British, French, and Dutch, respectively, they are not always considered ethnically to be a part of Latin America. Figure 1 provides a map of the region. The people of Latin America are a mosaic comprised of diverse groups of indigenous peoples who have resided in the geographic space for thousands of years, enslaved Africans brought to the continent between the 16th and 19th centuries under Spanish and Portuguese colonialism (Newson & Minchin, 2007), and waves of European, Asian, and Middle Eastern immigrants from the colonial period to the present day. To illustrate, Brazil has the second-largest Japanese population in the world outside of Japan and Argentina has the second-largest Italian population outside of Italy thanks largely to 20th-century migration patterns. They are still considered Latin Americans. When it comes to migration to the United States and other countries, who migrates and how they arrive at their destination country also varies by the person's country of origin. In recent years, the United States has seen vast migration stemming from Honduras, El Salvador, and Guatemala. These three countries have experienced tremendous political, civil, and economic unrest, which individuals from other Latin American countries may not experience. Countries like Chile and Colombia, by contrast, are more likely to have highly educated people migrate abroad voluntarily for work (Donato et al., 2010). Which gender migrates for work also varies by country of origin (Donato et al., 2010). Importantly, in the United States, 79% of the Latinx/Hispanic population are citizens (Noe-Bustamante, 2019). The languages spoken in Latin America include Spanish, Brazilian Portuguese, and 560 indigenous languages (López-Calva, 2019). Similar to English, the Spanish language has different dialects, country-specific accents, and word meanings that vary by country. Like all languages, slang words used to refer to health issues and body parts also vary by country or even region within a country. The same is true of Brazilian Portuguese. Many indigenous languages—sometimes known as languages of limited diffusion—have no written form. Community members grow up learning their indigenous language first and may never have formal instruction in Spanish or Portuguese. In the case of immigrants whose first language is an indigenous one, they may first learn Spanish rather than English upon arrival in the United States, further complicating communication during a healthcare encounter. With this combined rich cultural dynamic, many people from the region have mixed heritages which represent a diversity of backgrounds (e.g., racial, socioeconomic, political views, and religion [i.e., Roman Catholicism, Protestantism, Atheism, or Voodoo]); share some cultural practices (e.g., Celebrations-El Día de los Muertos, El Día del Carnival, and Día de los Reyes Magos); and the use of traditional and folk healing medicine-herbalist approach or Santeria. Food traditions vary widely. For example, flour or corn tortillas are part of the dietary habits of Mexicans and some Central Americans. The tortilla consumed by Spaniards, Argentinians, and Chileans, however, is made of eggs and potatoes and is more like an omelet. Neither type of tortilla is part of the traditional foods of most other countries in the region. Physical characteristics of Latinx/Hispanic populations, like skin color, vary widely due to their rich heritage. Making assumptions about someone's identity based on the color of their skin or other physical features runs the risk of offending them and deterring a therapeutic relationship or recruitment for research studies. For instance, the Dominican population identifies as mixed-race, with most people a combination of the Taino (the original indigenous people of the country before Spanish colonization), the legacies of African slavery, and European colonialism. The country also shares the island of Hispaniola with Haiti where the population is largely Black and speaks a combination of Haitian Creole and French. Therefore, it is essential when working with Dominican people not to assume that everyone is the same (or does not "look" Hispanic or Latino), as people have different physical characteristics (Telles, 2018). Furthermore, identifying Dominicans as African or Black is problematic due to racism within the culture (New World Encyclopedia., 2020; Noe-Bustamante, Flores, et al., 2019; Telles, 2018), with research showing that only 18% of Dominicans identify as Black because that identifier is associated with Haitians (Telles, 2018). The differing heritages of Latinx/Hispanic populations also means that the last names of people may not always appear to be traditionally Spanish or Portuguese. Our collection of authors—with heritages from Mexico, El Salvador, Guatemala, Costa Rica, and the Dominican Republic—are further evidence of that phenomenon. Overall, Hispanics or Latinos are more likely to self-identify by country of origin as opposed to a pan-ethnic label. Research from the Pew Research Center found that 24% of Latinx individuals use a pan-ethnic identifier whereas 51% use a country of origin (Taylor et al., 2012). These are just a few examples of why Hispanic and Latinx identity is complex and grouping everyone together is detrimental to health. The healthcare systems in Latin America differ by country and are deeply stratified by socioeconomic class. The accessibility of healthcare and the treatment received varies widely. For example, people of indigenous origin in the region are likely to have experienced significant discrimination when seeking healthcare and often have language barriers when seeking care (Findling et al., 2019). These experiences may further influence their health-seeking behaviors if they migrated to live elsewhere, such as the United States. The roles of nurses and midwives in Latin America also vary widely and as such, will affect people's expectations of them in terms of healthcare delivery. For example,it was not until the late 20th century that most Latin American countries changed the minimum standard for entry into the nursing profession to a post-high school degree so some may be surprised at the scope of practice of nurses and midwives in the US. Importantly, in many Latin American countries, physicians can outnumber nurses by as much as 3 to 1 in urban areas but nurses are often the primary point of care in rural areas. Formally educated midwives are rebuilding after decades of decline and indigenous peoples are more likely to have been attended to during birth by a traditional midwife (DeMaria et al., 2012; Jimenez et al., 2017; Walker et al., 2012). For Latinx/Hispanic immigrants from the region, therefore, their previous healthcare experiences in their home country may affect their health-seeking behaviors in their destination country. Historically, how providers and current systems have or have not captured data relevant to understanding health outcomes in Latinx/Hispanic populations has contributed to the current state of health disparities in the population. The health of people identifying as Latinx/Hispanic is affected by acculturation, language and cultural barriers, lack of access to preventative care, and the lack of health insurance, to name a few. As we have emphasized throughout this editorial, the grouping of Latinx/Hispanic populations in the United States as a single ethnicity obscures the true and different health outcomes among these populations from 20 unique countries in Latin American and the Caribbean (Abraído-Lanza et al., 2020). For example, studies have reported that Latinx/Hispanic people have longer life expectancies at birth of 82.1 years (females = 84.2 vs. males 79.9 years) relative to individuals who are non-Latinx/Hispanic White (hereafter referred to as White) at 80.6 years (females = 82.7 vs. males = 78.4 years; The United States Department of Health and Human Services Office of Minority Health, 2021). Is it accurate, however, to say that this is the case for all 60.5 million Latinx/Hispanic individuals living in the United States? To wit, of these individuals, those with Mexican heritage represent the largest group at 61.4% (The United States Department of Health and Human Services Office of Minority Health, 2021). Table 1 provides the most recent breakdown from the latest U.S. census. Indeed, notable health differences have been reported between the U.S. born and immigrant Latinx/Hispanic individuals, often citing the Hispanic Health Paradox, which highlights the better overall health of this population (Balcazar et al., 2015; Camacho-Rivera et al., 2015; Olsen et al., 2019; Shor et al., 2017; Weden et al., 2017). Recent research, however, has begun to disentangle the data associated with the paradox and is finding complex relationships between generational status and nativity. An excellent example is a recent study on breastfeeding patterns in Latinx populations. By the numbers, Latinx breastfeeding rates appear to be higher than those of almost all other populations. Yet when the country of origin is factored into the analysis, the results are quite different as shown in a recent study by Gerchow et al. (2021). Their analysis of New York City public health data on breastfeeding accounted for country of origin and showed stark differences in breastfeeding duration among Latinx populations, with South America-born individuals breastfeeding for the longest duration and Dominicans the shortest. A "one size fits all" approach to breastfeeding promotion, therefore, would not work. It is an excellent example of how grouping people into a single ethnicity translates into inappropriate interventions and implementation of health services. It may also contribute to discriminatory practices by healthcare providers when one group with a specific heritage does not align with the "grouped" norm. To meet the needs of the diverse Latinx/Hispanic population, nurses and midwives can practice a person-centered care approach and prepare the next generation of nurses with the same skills (Eastman, 2022; Greenfield et al., 2014; Santana et al., 2018). Person-centered care highlights the importance of patients' unique physical and emotional space to be "seen" and "heard" mechanisms (Greenfield et al., 2014). When using a person-centered care approach, nurses recognize the entire person (personality, life history, and social structure) because these factors allow nurses to understand the person's needs (Greenfield et al., 2014; Santana et al., 2018). Moreover, nurses and midwives must move towards a person-centered care approach and away from a patient-centered approach. To differentiate between patient-centered care and person-centered care: The patient-centered care approach focuses on disease and symptoms, and the person-centered care approach focuses on both a holistic and a person's worldview approach (Eastman, 2022: Greenfield et al., 2014; Santana et al., 2018). Part of practicing a person-centered care approach is recognizing that the lived experiences of individuals with Latinx/Hispanic heritage are not homogeneous and allowing the person to self-identify is necessary-regardless of language spoken or given name. Rather than assume Hispanic/Latinx persons are a monolithic group, nurses should be more aware of within-group differences and ask about individual country of heritage, how an individual self-identifies, and their reason for migration to better understand the possible cultural, lifestyle, sociopolitical, or behavioral patterns that may be related to their origins. Failure to allow for self-identification when communicating with Latinx/Hispanic sends the message that the nurse or midwife is being dismissive of the person's identity and does not convey respect. It is also important to note that asking, "Where are you from?" can shut down a conversation. Asking that question can be interpreted as either trying to uncover a person's immigration status or implying that they do not belong because they were not born in the country. Alternatively, try asking "What's your heritage?" That phrase will open a conversation that can be relationship building, instead of relationship deterring, and shift practice toward a person-centered care approach. Proper identification among Latinx/Hispanic populations remains an important challenge for clinical nurses and nurse scientists working with this diverse population, but successful practices will help advance health equity. We recommend the following strategies for data collection in research and documentation in clinical practice. First, when collecting demographic information, including a question that asks country of heritage (or nativity) and allows for additional self-identifying data such as indigenous group. Self-identification by the person is the gold standard for race and ethnic demographics collected for any kind of health data (Ver Ploeg et al., 2004). Nurses and midwives must never assume the country of heritage for a Latinx/Hispanic person when entering data. Second, not making assumptions about the country of heritage also applies to the person's preferred language. Even if the person can speak a few sentences of simple English, it does not mean that is what they prefer to speak it when feeling unwell. Accurate documentation of language preference is also a person-centered care practice. Third, research and interventions should be based on country of heritage, migration patterns (for example, rural to urban, rural to rural, urban to urban), and other cultural needs. Qualitative studies can serve as a tool to better identify the diversity of the Latinx population and uncover within-group differences and similarities, but the methods should include non-English speakers to fully capture the scope of experiences. Cross-language qualitative research methods are critical for ensuring rigor in this case. Relevant, reliable, and valid translations of survey instruments—of which there are fewer in Spanish than most researchers realize—are also critical. Whether the reader is a nurse or midwife in clinical practice, a student, or a researcher, we each can take action to address health inequities among Latinx/Hispanic populations. The simple act of respecting a person's heritage through self-identification is a significant first step. Even just that will improve our ability to study within-group differences that may help explain health outcome disparities in the population. The authors declare no conflicts of interest. All authors contributed to writing the editorial. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.