"I mean, might as well just go to what you know. That's how we grew up."
AS a practice, self-care represents the bulk of all healthcare and is touted as being invaluable in not overloading or overwhelming the professional healthcare system.1,2 As Kleinman indicated,3 self-care is the first healthcare mode employed by most people in the lay health arena regardless of cultural affiliation. Mexican Americans (MAs), the largest Hispanic subgroup,4 curiously, are usually not credited for their self-care contributions, which represent an amalgamation of preferred behaviors to stay well or get well again, much like self-care in mainstream groups. If MA self-care behaviors were presented in the same light as mainstream self-care behaviors, this might highlight similarities among various populations instead of illuminating, devaluing, and denigrating differences. The purpose of this article is to present a schema that describes MA women's pathways to health.5 The schema is based on a naturalistic study of 15 MA women (5 triads; grandmother-mother-daughter) in the Texas Rio Grande Valley5 using Kleinman's3 cultural model of healthcare systems. Although the focus of the article is on the schema itself, the study's details are summarized in Table 1. Interested readers may find further methodological details in the original study report.5
According to Kleinman,3 health, health ideas, and health behaviors are embedded in cultural contexts that characterize local healthcare systems. He describes healthcare as being "a local cultural system composed of 3 overlapping parts"3(p50) that define health conditions, recognize health providers, and legitimate health experiences: the lay/ popular, folk, and professional arenas. The lay/popular arena, which includes individuals along with their family and friends, is the primary source of healthcare in most cultures. The folk arena includes unlicensed nonprofessional healthcare specialists who, as members of the community, often share similar beliefs, values, attitudes, and language with their clients. The professional arena is composed of formally organized scientific biomedical and/or "professionalized"3(p54) health prov-iders. Since all 3 arenas contribute to an individual's healthcare reality, they are each important in discerning what is culturally relevant to that person. Although the lay/popular, folk, and professional healthcare arenas interact reciprocally, most healthcare takes place in the lay/popular sector,3 where women provide or oversee much of that care.6
HEALTHCARE ARENAS
In general, the MA women's pathways included wellness and illness self-care and non-self-care practices assimilated from the lay/popular, folk, and/or professional healthcare arenas but uniquely refashioned by each woman in order to take care of her whole self, that is, achieve mind-body-spirit harmony. Although these health behaviors occurred throughout the 3 healthcare sectors, healthcare predominantly took place within the lay/popular arena and was primarily self-care. Self-care behaviors were those that the women themselves practiced; non-self-care pertained to healthcare provided by others. Wellness behaviors were those intended to maintain or promote harmony. They included health-enhancing routines, aids, prophylaxes, or preventatives enlisted to keep the women well, prevent disease or infirmity, or help them feel even better. Illness behaviors were intended to restore harmony. These included remedies, treatments, and cures geared toward eliminating a symptom, ridding a disease, or simply helping the women feel well again. It is important to note that while lay/popular self-care predominated, a woman was more likely to tap into the folk and professional healthcare sectors while she was experiencing illness as compared to maintaining wellness (Table 2).
Each woman's individual decision to seek non-self-care was multifaceted, based on such factors as her personality, past experiences, level of concern, and clinical manifestations. Furthermore, the decision-making process involved deciding not only whether to seek non-self-care but also which provider from which sector to employ. For instance, some signs, symptoms, or health conditions called for nonprofessional healthcare providers because, as several women indicated, health professionals did not acknowledge certain folk illnesses, such as susto [fright] or ojo [evil eye]. Occasionally, however, the women simultaneously employed healthcare providers from all 3 sectors, such as 1 grandmother who was overcome with mounting anxiety. In addition to her self-care endeavors, this woman was treated for susto by her husband (lay/popular), drank an herbal tea recommended by a yerbero [herbalist] (folk), and took a tranquilizer prescribed by a physician (professional). Importantly, a woman's decision to seek non-self-care did not mean that she relinquished self-control, for even when she was being cared for by others she continued to determine the appropriateness of their information, diets, medications, dosages, and other treatment protocols, modifying these as she saw fit (eg, adjusting medication dosage).
LAY/POPULAR HEALTHCARE ARENA
According to Kleinman,3 the lay/popular sector, the largest yet least understood arena, includes individuals along with their family and friends. Because it is influenced by the "cognitive and value orientations of the popular culture,"3(p50) this arena is "the chief source and most immediate determinant of [health] care."3(p51) In this nonprofessional, nonspecialist healthcare arena, self-care is usually the first and predominant healthcare activity employed by people in order to stay well or get well again. Nonetheless, non-self-care is also common. With these MA women, lay/popular non-self-care included healthcare provided to them by family, friends, and neighbors.
LAY/POPULAR SELF-CARE
The MA women primarily engaged in lay/popular self-care in order to maintain or regain mind-body-spirit harmony, trusting their own health behaviors over those of others. As one daughter exclaimed, "How do they know the stresses on my body? They don't know." A mother said she had the most confidence in herself because she knew her body best and knew from experience what worked best for her. "Porque yo, muchas enfermedades yo me las curo, que yo se que es bueno este y es bueno el otro y ya" [Because I cure many illnesses, I know what's good, and that's it]. Essentially, the women's wellness and illness self-care represented an interplay of physical, mental/emotional, spiritual, and cultural health behaviors.
LAY/POPULAR NON-SELF-CARE
As with the MA women's own self-care, most non-self-care took place in the lay/popular sector with family and friends helping to preserve or restore the women's harmony. God and various family members, friends, and neighbors were cited as providing lay/popular non-self-care to the women, but the most frequently cited non-self-care provider was each woman's mother. The women's non-self-care represented an intermingling of physical, mental/emotional, spiritual, and cultural health practices. It included accepting health advice, eating healthy meals prepared by others, and being prayed for, massaged, relaxed, and nurtured by others. In addition, the women took herbs, vitamins, or minerals recommended or prescribed by other people. Some women received prenatal care from family members, such as the daughter who attributed her short labors and easy deliveries to having had her pregnant abdomen massaged by her maternal grandmother (MGM) and maternal aunt as well as drinking herbal teas prepared by them. Many women took care of themselves during pregnancy but were delivered by others. For example, one woman's mother-in-law delivered 10 of the woman's 12 children. One grandmother claimed that God labored her and readied her for the partera [unlicensed midwife], who did the actual delivery. A few of the women said family members (mother, husband, children) provided postpartal care.
The MA women resorted to lay/popular illness non-self-care when they had exhausted their lay self-care reservoirs without getting well, such as the daughter who sought out her MGM's "healing" touch whenever she felt "real sick." These lay health providers nurtured, relieved, and healed the women via personal attention, prayer, therapeutic touch, massage, imagery, "mind over matter," crystals, and cultural healing traditions. When a daughter's fetus "wasn't sitting right," her MGM "would actually maneuver it. So when I had him, it was only 4 hours of labor[horizontal ellipsis]. I would go to her, and she would actually move the baby[horizontal ellipsis]. [to] get it the right way." Another daughter's aunt gave prescribed injections as needed. One mother's husband massaged her painful knee, and her aunt applied a hot flour tortilla over her niece's upper abdomen to relieve her inflamed gallbladder. Family members, especially mothers and MGMs, performed ojo or susto treatments on the women. One mother's sister provided information regarding herbal relief for various ailments. Yet another mother's daughters massaged her sore muscles. One daughter's recollection about her mother's and MGM's loving care was especially poignant. "And they'd be there, her and Grandma, all night with me. They wouldn't leave me alone, that's what I liked[horizontal ellipsis]. I think I got more comfort out of that than the eardrops." The women's lay health providers also maintained clean hygiene, forced fluids, prepared healing nutrients, administered therapeutic herbs and drugs, readied gargles and baths, sat by bedsides, and listened. In addition, these lay providers advised the women regarding treatment modalities and other non-self-care providers from the folk and professional sectors.
The women's mothers were the most frequently mentioned lay non-self-care providers. Even as adults, several of the women still went to their mother for health advice or treatments. One daughter commented she would "come to Mom's and say, 'Give me something. I'm sick.'" Another said her mother would use imagery or therapeutic touch whenever the daughter felt unwell. Several women reported feeling better after their mother cured them with teas or barridas [energy sweepings]. One woman claimed that nothing else relaxed her as much as her mother's egg treatment. She added that asking for it was "just a spur of the moment thing[horizontal ellipsis]. a sudden urge [horizontal ellipsis]. 'a la mejor es lo que necesito. Maybe that's what I need."'
I would just relax and listen to her as she prayed and moved the [intact] egg around[horizontal ellipsis]. I do feel better. I guess just the fact that I've been laying there relaxed, and she has been praying for me. Something makes me feel better.
One woman said that whenever she had a headache her mother would get rid of it by performing the egg treatment, or she would use a branch of ruda [rue] to cure her daughter when she was feeling "low" or "down," and she "would feel good" right away. That woman's daughter shared the same thing about herself, saying that whenever she was feeling tense, preoccupied, or unwell, "I come to Mom" for teas or barridas, because they helped her relax and feel better.
Lay/popular non-self-care was, thus, instrumental in helping to maintain or regain the women's harmony. Importantly, however, it should be noted that since most requests for lay/popular non-self-care were initiated by the women, these requests could easily be construed as extensions of their own self-care. Furthermore, the predominant non-self-care providers were often close family members, resonating with the concept of familismo [familism], whereby MAs often consider family members as integral parts of themselves and rarely draw distinct boundaries between each other. As such, to these MA women, self-care may have included caring for their family members and vice versa.
FOLK HEALTHCARE ARENA
The folk healthcare sector, as described by Kleinman,3 includes unlicensed, nonprofessional specialists, who are involved in health maintenance, promotion, and/or restoration as well as disease prevention, detection, and/or treatment. As might be expected, the women's folk health providers were more involved in restoring the women's harmony than in preserving it.
With this schema, the folk healthcare arena was the least utilized, probably because, as with most people, these women had a rich repertoire of readily available and trustworthy lay/popular health behaviors. When the folk sector was employed, the women's folk providers included the curandera/o [healer], sobadora [massager], partera, and yerbera/o, who were sometimes consulted regarding cures for ojo, susto, empacho [surfeit], or other folk conditions.
FOLK WELLNESS CARE
Very little wellness care was attributed to folk healthcare providers. However, a few folk wellness behaviors were named by the women, such as accepting health advice from folk specialists, eating healthy meals prepared by them, and being prayed for, massaged, relaxed, and nurtured by them. In addition, the women ingested wellness herbs or foods that folk providers recommended or prescribed. Some women received prenatal care from parteras. Others took care of themselves during pregnancy but were delivered by parteras.
FOLK ILLNESS CARE
The folk sector was mostly utilized for harmony restoration. For example, sometimes when they were unwell the women saw folk healers, such as the curandera/o who cured ojo and susto. Oftentimes these folk providers had been summoned by the women's parents who were concerned because their children were not eating, sleeping, or behaving normally. Occasionally, these folk healers prescribed special foods, herbs, or rituals to restore wellness. Other women consulted with yerberas/os regarding appropriate herbal remedies for certain health conditions. One grandmother repeatedly praised a sobadora's massages as being the cure for her unrelenting mastoid pain, especially since her physician had been unsuccessful in that endeavor. Thus, although folk health providers played a role in the women's healthcare, it was a relatively small one as compared to lay/popular healthcare providers since the latter represented numerous reliable resources from which to draw.
PROFESSIONAL HEALTHCARE ARENA
Kleinman describes the professional healthcare sector as being composed of formally organized modern scientific biomedical and/ or "professionalized indigenous"3(p54) health providers. These MA women's professional healthcare providers included nurses, a physical therapist, a counselor, dentists, a home health aide, and physicians from Mexico and the United States. Although professional healthcare providers were more often involved in helping to restore the women's harmony by being consulted for conditions such as asthma, bronchitis, otitis, tonsillitis, and intestinal bleeding, they also dealt with the women's harmony preservation.
PROFESSIONAL WELLNESS CARE
Although limited in scope, the women's professional wellness care included accepting health advice, receiving vitamin shots, and getting glucometer checks from healthcare professionals. In addition, the women ate nutritious foods and took oral vitamins, minerals, or maintenance medications recommended or prescribed by professionals. Some women received prenatal care from nurses or physicians; others took care of themselves during pregnancy but were delivered by nurses or physicians.
PROFESSIONAL ILLNESS CARE
In general, however, most of the women tended to resort to the professional healthcare sector when there were extenuating circumstances, such as (1) if they were in a lot of distress, (2) if a family member was worried, or (3) if the physician would not renew a prescription, "but we didn't run to the doctor very often." For example, as a child with bronchitis, one daughter recalled telling her father "I need a shot" when she was experiencing extreme dyspnea. As teens, one mother had a tooth extracted without anesthesia in a dentist's office, while another had her tonsils removed under local anesthesia in a physician's office. Some of the women went to the emergency department with breathing difficulties, gallbladder attacks, or trauma sustained falling off a horse, playing tennis, or being in a car wreck. Several had been hospitalized on 1 or more occasions. When one mother's own self-cures were insufficient, which was rare, she visited her favorite physician in Mexico. When her daughter had Bell's palsy, she saw her regular physician in Mexico as well as a US physician and a physical therapist. Her treatment protocols included vitamin injections, steroid tablets, faradic stimulation, heat and cold applications, and massage. A daughter consulted a counselor about her unresolved anger regarding her little sister's death and her parents' self-absorbed grief. One grandmother switched physicians because of his rude staff, signifying that she valued personalismo [personal interaction] more than scientific protocols.
Nonetheless, the professional healthcare arena was infrequently utilized for various reasons, with only a few women limiting professional visits because of money. Some women saw no need to go when they felt fine, so they resisted forced return visits. "Pues no me duele nada, pa' que vengo?" [Why should I go when nothing hurts?]. Others did not believe that the professional sector offered any insights, relief, or guarantees. For example, one mother, who took her son to a pediatrician because of bloody stools, said the physician told her there was blood in the stools. "I said, 'doctor, you don't need to tell me that. That is why I came in!!'[horizontal ellipsis]. so I left him, and I went to somebody else." A daughter used the professional sector because she had "good insurance" even though, in most instances, she "knew he would not do anything[horizontal ellipsis]. And he ended up telling me what" she already knew. A few went in because "that's what you're supposed to do" or for "reassurance" that something was not as bad as they feared. For example, a daughter went to the emergency department because she was afraid her intense ankle pain meant she had sustained a fracture. Yet:
as soon as the doctor said, "You know, you've just got a bad sprain, it's no big deal," I was so happy, and I was over it. I was goofing off, the pain was gone. I mean I was happy that it was not fractured.
A mother's severe pain caused her to "imagine I have cancer. I imagine I have everything," so she saw a physician to quell her fears. One grandmother was concerned about the harm inflicted by physicians, because she had lost her vision after cataract surgery. Two other grandmothers whose intense pain had been disregarded by their physicians fortunately found relief elsewhere, that is, outside of the professional arena. Some women were simply confident in their own self-care.
Furthermore, some of the women were essentially able to use the professional arena while circumventing US healthcare professionals by buying prescription medications in Mexico [without a prescription]. Most of the women who bought these medications did so because they were less expensive than in the United States, especially since a physician's office visit was not required. Some women did so because they had more faith in Mexican medications, believing them to be stronger and more effective. Other women were particular about which medications they bought in Mexico.
Interestingly, the women were selective about what information they shared with their US professional healthcare providers. For instance, they did not usually tell their professional healthcare providers about being comanaged, and these providers rarely inquired what else the women were doing. Even when they did, the women had learned to withhold certain information because of their past experiences with being ridiculed, embarrassed, or misunderstood by US healthcare professionals. One mother, who believed that herbs had side effects, stated that she always informed her professional healthcare providers about her various herbal remedies but not about her ojo treatment. Thus, although these MA women utilized the professional healthcare sector for a variety of health needs, and although it was employed more often than the folk sector, the lay/popular healthcare arena remained the most frequented of all.
LINKAGE TO EXTANT LITERATURE
The MA women believed they could maximize their own health, no matter the circumstance, via their own attitude, beliefs, and behaviors. This attitude was much in line with Northrup's statement, "God moves mountains-bring a shovel."7(p516)
This schema of MA women's health pathways5 shared several commonalities with the classic anthropological literature on healthcare arenas, especially the lay/popular healthcare sector.3,8-11 For people with strong cultural beliefs, nonprofessional healthcare "may be as effective as some forms of modern health care."12(p252) The lay/popular arena is where people initiate healthcare by deciding if, when, or with whom to consult; whether to abide by someone else's advice or recommendations; and whether care is effective and/or satisfactory. Furthermore, the MA women did not frequent either the folk or professional healthcare sector, not because of limited access or money but because they perceived little need to do so. Indeed, as primary caregiver, the majority of the MA women had a rich reservoir of trusted behaviors within the lay sector, primarily self-care but also non-self-care, that served to preserve or restore their personal harmony.
According to Chrisman, the lay system is an integration of the scientific system into "the context of everyday life."8(p360) Thus, "popular health care is the norm and professional health care is the exception," with lay treatment "a much more common function of social networks than lay referral."9(p570) To illustrate, Chrisman and Kleinman enumerate an extensive inventory of lay treatment methods, such as herbs, food, exercise, massage, baths, rest, prayer, nurturance, nonprescription medications, and prescription medications that "have been obtained[horizontal ellipsis]for past illnesses or[horizontal ellipsis]from neighborhood pharmacists or family physicians[horizontal ellipsis]or[horizontal ellipsis]from family and friends."9(p571) The MA women's lay treatment methods mirrored those listed by Chrisman and Kleinman9 and represented a meaningful interplay of lay/popular, folk, and professional healthcare beliefs and practices that were successively utilized to preserve and/or restore a personal sense of harmony. The MA women's methods included the use of herbal preparations, food, eggs, prayer, massage, touch, [physical] manipulations, amulets, religious objects, prescription and nonprescription medications, and barridas for treating common folk conditions as well as numerous other ailments.
With such a vast repertoire of lay healthcare that borrows liberally from "mainstream and ethnic"9(p571) practices, it is easy to understand why the folk and professional healthcare sectors are not utilized as frequently. Even when people do decide to interact with these other sectors, it is, as Friedson13 indicated, usually only after lay/popular resources have been exhausted, although not necessarily abandoned. Gonzalez-Swafford and Gutierrez14 similarly acknowledge that MA folk curers are usually consulted only after the family's (ie, lay) care has not achieved the desired results.
This schema of MA women's health pathways5 differed from the early literature on MA healthcare, which was often described as home, indigenous, cultural, traditional, ethnic, or folk care.15-21 As such, MA lay healthcare was given a cryptic or quaint slant as opposed to the ordinary everyday tone used to describe the self-care behaviors of mainstream groups, behaviors that undoubtedly include home remedies as well. In addition, the early literature insinuates that MAs resort to folk healthcare instead of professional healthcare,22 when a complementary, simultaneous use of the lay/popular, folk, and professional healthcare arenas is a much more likely scenario.17,18,21,23,24
This lamentable misrepresentation is perhaps the result of labeling by professional healthcare providers and researchers who tend to view any MA healthcare that occurs outside the professional healthcare arena as folk, a set of practices that is often scoffed at by healthcare professionals. However, as described by Kleinman,3 the folk arena, which represents nonprofessional specialists, is only 1 of 3 overlapping healthcare sectors and is less important than the lay/popular sector. Consequently, while some of the health beliefs and behaviors labeled in the literature as folk, are, in fact, folk, most of these beliefs and behaviors, when analyzed, actually reflect lay/popular influences, that is, pertaining to self, family, and friends as opposed to nonprofessional specialists. Such a finding is consistent with reports on self-care,1,2 yet the term self-care is infrequently used when referring to MA health behaviors,25-27 almost as if the concept were not applicable to them.
This schema on MA women's pathways to health5 also differed from many of the suppositions presented in the literature on MA women, which described them as passive, weak, submissive, and fatalistic with external loci of control.22,28,29 Such stereotypical labels suggest that MAs do not feel personally responsible for their actions and, hence, may feel hopeless. In contrast, the MA women in this study were expert guardians of their own and their family's health. They knew what they needed and when they needed it. They also knew what worked best for them and where to go, if anywhere, to get it. In other words, they evaluated their health status, determined the need for healthcare, and enlisted a variety of healthcare resources within the lay/popular, folk, and professional healthcare arenas. The women also decided which, if any, providers were to be involved in their family's and their own healthcare and evaluated these providers as well. In addition, the women accepted the consequences of their actions without blaming others.
Such attitudes and actions are in keeping with Villarruel's claim26 that the primacy of caring for others is the essence of the MA family (ie, familismo). That value manifests itself in being motivated to meet the healthcare needs of self and family. Villarruel and Denyes27 speculate that, for MAs, care for others may be as developed as self-care-or may be even more valued as a cultural expression. Consequently, Villarruel and Denyes27 recommend that these 2 tightly interwoven behaviors be considered as one collective concept. In addition, these attitudes and practices, such as confidently making decisions about healthcare and carrying them out, signify power and personal control, both reinforced by the MA's strong family support. As such, these MA women successfully negotiated their own and their family's pathways to health.
SUMMARY
This schema5 of MA women's pathways to health paralleled Kleinman's3 and illuminated the women's full reservoir of cultural health behaviors enlisted to maintain or regain personal harmony. In so doing, this schema5 also corroborated Chrisman and Kleinman's9 work on the lay/popular network, with an added emphasis on wellness care.
The MA women predominantly engaged in self-care in the lay/popular healthcare arena. Self-care behaviors were those that the women themselves practiced; non-self-care pertained to healthcare provided by others. While numerous other people contributed to the modeling, teaching, and acquisition of these myriad health behaviors, the most central person was the woman herself. She believed herself to be an expert on her body, her healthcare needs, and the most appropriate health behavior for any given scenario. Even when a woman solicited non-self-care she usually did so based on her own expert evaluation of her own needs, so that, in essence, most of her non-self-care was an extension of her own self-care. By so doing, she treaded her own pathway to health.
RECOMMENDATIONS
All people have a culture and, hence, cultural health needs. In essence, then, all healthcare beliefs, values, needs, and behaviors are culturally based, and everyone can benefit from culturally competent nursing care. Nurses are the logical mediators, teachers, and client advocates to ensure that people's cultural health rights are understood and respected.30 Nurses can promote positive health behaviors outside the professional healthcare arena as well as deliver culturally competent care within it. To optimize holistic client care, it is recommended that nurses recognize and applaud their clients' abilities to tap into their own personal resilience, inner strength, faith, and positive attitude in order to maximize their wellness. Being aware of Kleinman's3 cultural healthcare arenas and this complementary schema5 of MA women's health pathways will facilitate the attainment of mutually established, personally meaningful, and culturally relevant health goals. As such, nurses can help pave the enormously diverse cultural pathways to health.
REFERENCES