2008-09 Gathering of Voices

Mexican American Women:
Culturally Competent Nursing Care to Promote Physical Activity

Hillary Straatman

Abstract

Low levels of physical activity are common among Mexican American women, and they suffer from disproportionately high rates of obesity, cardiovascular disease, and non-insulin dependent diabetes. Because regular physical activity is associated with decreased rates of chronic disease, nurses can positively impact the health of this population by promoting exercise. Cultural factors play a central role in determining activity patterns in Mexican American women, and understanding these factors will enable the nurse to provide culturally competent care. By incorporating cultural beliefs and values when developing and implementing interventions, nurses can reduce the health disparities seen in this population.

Introduction

Regular physical activity is associated with a reduction in hypertension, cardiovascular disease, diabetes, colon cancer, and all-cause mortality. To maintain and promote health, the Center for Disease Control and Prevention recommends 30 minutes of moderate intensity physical activity on most days. Low physical activity levels are common among women and ethnic minority groups in the United States (U.S. Department of Health and Human Services, 2000). Mexican American women are of particular concern, as they have the highest inactivity level when compared to Black and non-Hispanic White females (Guinn & Vincent, 2008). The prevalence of obesity, non-insulin dependent diabetes, and cardiovascular disease is also higher among this population (Lopez, Bryant, & McDermott, 2008).

Research shows that cultural beliefs and values regarding family, gender roles, and religion influence activity levels of Mexican American women (Cantu & Fleuriet, 2008; Eggenberger, Grassley, & Restrepo, 2006). Participation may also be affected by cultural perceptions that exercise is a prescriptive therapy rather than a health promotion behavior (Berg, Cromwell, & Arnett, 2002). Nurses who honor these cultural views and incorporate them into interventions will be more effective in promoting physical activity among Mexican American women. By providing culturally competent care, nurses can positively influence activity patterns and improve the overall health of this population.

Methods

Peer-reviewed literature searches of the EBSCO and Medline databases were performed using the keywords Mexican American, women, Hispanic, Latina, physical activity, exercise, adolescents, nursing, and nurse. The Goggle Scholar search engine, as well as the Medscape and United States Department of Health and Human Services websites were also searched using the same keywords.

Discussion

Knowledge

For the purposes of this paper, Mexican American women are defined as American women who are of Mexican national origin. Because cultural factors influence activity patterns in this population, understanding cultural beliefs and values will be helpful when planning nursing care. Mexican American culture embraces familism, a value that places family needs above individual needs, and women tend to pattern their behavior around themes of family and gender expectations. Women are seen as the force that holds the family together, and traditional roles include cleaning, cooking and caring for children, grandchildren, and extended family (Cantu & Fleuriet, 2008; Eggenbeger et al, 2006). Being physically present is a necessity, and the structure of daily life is often driven by these family responsibilities. In fulfilling gender roles, Mexican American women put family needs first, and little time may be left over for exercise. Approval and motivation from all family members is important, and women are unlikely to participate in physical activity unless they think it will benefit the family unit (Berg et al, 2002).

Male gender roles can also influence activity patterns. Mexican American women may value mariaism, a cultural belief in which women are submissive to their husbands and patriarchal authority is favored. If a woman’s husband is disapproving or she feels that exercise will make her less available for him, she may not take part (Cantu & Fleuriet, 2008).

Physical activity patterns may also be affected by belief in Roman Catholicism, the predominant religion of Mexican American culture. Some authors suggest that many Mexican American women have an external locus-of-control regarding health status because they believe that God’s will controls everything. Individuals with an external locus-of-control are less likely to participate in health promoting activities such as exercise, because they don’t believe that health outcomes are in their control (Eggenberger et al, 2006).

Research shows that many Mexican American women view exercise as rehabilitative or restorative rather than preventative. Notions that current behaviors can positively affect future health outcomes are not consistent with Mexican American’s cultural view of health (Cromwell & Berg, 2006). Physical activity is therefore seen as a prescriptive treatment for an identified health issue, but may not be valued for health promotion. These beliefs may contribute to lower activity levels in this population, as women are less likely to take part if they have no identified health problems (Berg et al, 2002).

There are additional cultural factors that nurses must consider when working to promote physical activity among Mexican American women. The cultural values of respeto and simpatía (respect and congeniality) should be used to guide communication with clients and families. Nurses can honor respeto and simpatía by using social greetings, providing care in an unhurried manner, demonstrating a willingness to listen, and incorporating the client’s beliefs into the treatment plan (Padilla & Villalobos, 2007). By engaging in small talk about the family or community before providing care, the nurse develops a sense of persionalismo or becomes friend-like with the individual and family. Developing persionalismo builds trust and forms confianza or mutual reciprocity, which ultimately leads to improved health outcomes (Zoucha & Broome, 2008). Because physical activity may not be viewed as a priority in Mexican American culture, gaining trust and respect is important to enhance the efficacy of future interventions.

Discussion

Application

Nurses can apply cultural knowledge when working to promote physical activity in Mexican American women. A comprehensive assessment will be necessary before developing further interventions, because individual factors including age, acculturation, and personal views will affect each woman’s perspective. Asking questions about perceived benefits and barriers, past and current exercise patterns, and ideas about acceptable and enjoyable forms of exercise will provide valuable information (Cantu & Fleuriet, 2008). Using this information to create client specific interventions will lead to better outcomes.

Much of the research shows family and gender role commitments to be a primary cause of sedentary lifestyles in Mexican American women. Knowing this information, nurses may come up with interventions that are framed within the context of family. Nurses can help the woman identify activities that do not interfere with care giving, and suggest activities that involve family members and can be done at home (Berg et al, 2002). Compliance may also be increased by encouraging women to view exercise as a means to becoming healthier and hence better able to care for family (Cantu & Fleuriet, 2008). 

Including family members when teaching about the about the benefits of physical activity will improve outcomes. This may be especially true of the husband, being that the male is often dominant and in charge of health care decision-making (Eggenberger et al, 2006). If family members understand that the health of the woman will positively affect the overall health of the family, they are more likely to value physical activity. Knowledge about the benefits of exercise will lead them to be more supportive of the woman’s efforts, and increase the chance that they will participate along with her (Berg et al, 2002).

Developing nursing interventions that honor a woman’s religious views may also result in better outcomes. If a woman believes that God has control over her health status, the nurse can work collaboratively with the community church to promote physical activity (Eggenberger et al, 2006). Churches may be used as effective sites for publicizing and holding physical activity programs, and recruiting participants. Women are more likely to extend their time at church to participate then to making separate time for exercise, and the implied support of the church is a motivator for participation (Berg et al, 2002). Incorporating physical activity into church events will encourage family involvement, which also provides incentive to take part (Cromwell & Berg, 2006).

Nurses who consider that health promotion is not consistent with the traditional Mexican American cultural view of health are able to better design interventions. Women may be less receptive to interventions that are framed as self-care, and more receptive to those put in the context of treatment (Berg et al, 2002). Identifying and providing education about specific health issues can increase compliance with a physical activity program; for example, the woman with hypertension will be more likely to exercise if the nurse explains that exercise can lower blood pressure. Because culture is dynamic and acculturation levels will vary among women, nurses should assess each individual’s view of health and encourage exercise for health promotion when appropriate.

It is also important that nurses recognize and suggest culturally appropriate activities when promoting exercise. One study determined that gardening and walking are preferred leisure activities of Mexican American women (Wood, 2004). These activities require little cost, and can be done at or close to home with other family members. Dance, tai chi, and yoga are also culturally acceptable, and are beneficial for their ability to increase strength, balance, flexibility, mobility, and aerobic capacity (Cromwell & Berg, 2006). Nurses can help the woman identify types of exercise she prefers, and work with her to develop a plan to incorporate it into her daily routine. 

Outside the clinic or hospital setting, nurses may promote physical activity in the community by working collaboratively with lay health advisors, also known as promotoras. Because they have an intimate understanding of their community’s sociocultural background, experiences, challenges, and strengths, promotoras are in a unique position to provide peer education. One study, which included mostly women of Mexican heritage, used lay health advisors to deliver messages about the importance of physical activity among other topics. Significant increases in participants’ physical activity levels were seen after three classes, suggesting that promotoras have a positive health-promoting influence among Mexican American women (Kim, Koniak-Griffin, Flaskerud & Guarnero, 2004). Nurses can play an integral role in this type of community based approach by organizing the outreach programs and recruiting and training the lay health advisors. By working closely with one another, nurses and promotoras can effectively generate educational materials that are linguistically and culturally relevant to Mexican American women.

Low rates of physical activity are also seen among adolescent Mexican American females, and studies show that this group has disproportionally higher rates of inactivity and obesity than its non-Hispanic white counterpart (Grieser, Neumark-Sztainer, Saksvig, Lee, Felton, & Kubik, 2008). Because lifelong activity patterns are influenced by habits developed in earlier years (Cromwell & Berg, 2006), it is important to promote the value of exercise in this adolescent population. It has been noted that cultural factors contribute to low physical activity rates in these girls, and adolescents in one study reported lack family support as a reason for decreased participation (Grieser et al, 2008). Based on this information, many of the previously mentioned nursing interventions could positively influence activity levels among adolescents. If women and families participate in regular exercise, they may be more likely to support and encourage the same behavior in their adolescent. Additionally, healthy activity patterns in women may be passed down to their adolescent daughters as learned behaviors.

School nurses can also promote physical activity in Mexican American adolescents by working collaboratively with educators. Research shows that Mexican American girls perceive less social support for physical activity from teachers and boys at school than non-Hispanic white girls. Support in this environment is crucial since adolescents spend much of their time at school, and school is where opportunities for exercise such as physical education and sports are available (Grieser et al, 2008). Nurses can educate staff on the importance of both encouraging Mexican American girls to participate in physical education and organized sports, and modeling appropriate and enjoyable activities. Working together with physical education teachers to develop peer-led activity groups during gym class will be beneficial, as these groups are shown to increase moderate and vigorous activity levels among this population (Frenn & Malin, 2003).

Interventions used to increase physical activity among Mexican American women can also be applied when working with women of Asian and African American cultures. These cultures are similar in that they all value the centrality of family, and women are usually the primary care givers (Hahn, 2003). Framing interventions within the context of family and including family members in teaching may therefore enhance activity patterns among Asian and African American women. Research shows that these women respond well to congregational health programs, so working collaboratively with community churches will also be effective to promote physical activity in these groups (Hahn, 2003).

Conclusion

Mexican Americans suffer from disproportionately high rates of chronic health issues such as obesity, non-insulin dependent diabetes, and cardiovascular disease (Lopez et al, 2008). Regular physical activity reduces the risk of chronic disease, moderates related complications, and improves the overall health of the individual. Very low physical activity levels are seen among Mexican American women, and they are the least likely to participate when compared to Black and non-Hispanic White women (Guinn & Vincent, 2008). Understanding and applying cultural knowledge will allow the nurse to better promote physical activity when working with this population. By honoring cultural values and beliefs and viewing them as strengths upon which to build interventions, nurses will provide culturally competent care that reduces the health disparities seen in Mexican American women.

References

Berg, J. A., Cromwell, S. L., & Arnett, M. (2002). Physical activity: Perspectives of Mexican American and Anglo American midlife women. Health Care for Women International, 23(8), 894-904.

Cantu, A. G., & Fleuriet, K. J. (2008). The sociocultural context of physical activity in older Mexican American women. Hispanic Health Care International, 6(1), 27-40.

Cromwell, S. L., & Berg, J. A. (2006). Lifelong physical activity patterns of sedentary Mexican American women. Geriatric Nursing, 27(4), 209-213.

Eggenberger, S. K., Grassley, J., & Restrepo, E. (2006). Culturally competent nursing care for families: Listening to the voices of Mexican-American women. Online Journal of Issues in Nursing, 11(3).

Frenn, M., Malin, S., Bansal, N., Delgado, M., Greer, M., Havice, M., et al. (2003). Addressing health disparities in middle school students’ nutrition and exercise. Journal of Community Health Nursing, 20(1), 1-14.

Grieser, M., Neumark-Sztainer, D., Saksvig, B. I., Lee, J., Felton, G. M., & Kubik, M. Y. (2008). Black, Hispanic, and White girls’ perceptions of environmental and social support and enjoyment of physical activity. Journal of School Health, 78(6), 314-320.

Guinn, B., & Vincent, V. (2008). Leisure time physical activity barriers among border Mexican American women. American Journal of Health Studies, 23(1), 9-16.

Hahn, K. (2003). Older ethnic women in faith communities: Culturally appropriate program planning. Journal of Gerontological Nursing, 29(7), 5-12.

Kim, S., Koniak-Griffin, D., Flaskerud, J. H., & Guarnero, P. A. (2004). The impact of lay health advisors on cardiovascular health promotion using a community based participatory approach. Journal of Cardiovascular Nursing, 19(3), 192-199.

Lopez, I. A., Bryant, C. A., & McDermott, R. J. (2008). Influences on physical activity participation among Latinas: An ecological perspective. American Journal of Health Behavior, 32(6), 627-639.

Padilla, Y. C., & Villalobos, G. (2007). Cultural responses to health among Mexican American women and their families. Family Community Health, 30(1S), S24-S33.

U.S. Department of Health and Human Services. (2000). Healthy People 2010: Physical activity and fitness. Retrieved February 13, 2009, from  http://www.healthypeople.gov/Document/HTML/ Volume2/22Physical.htm#_Toc490380801

Wood, F. G. (2004). Leisure time activity of Mexican Americans with diabetes. Journal of Advanced Nursing, 45(2), 190-196.

Zoucha, R., & Broome, B. (2008). The significance of culture in nursing: Examples from the Mexican American culture and knowing the unknown. Urologic Nursing, 28(2), 140-142.

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