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On-line version ISSN 1695-6141
Enferm. glob. vol.11 n.27 Jul. 2012
The role of Culture-bound syndromes and Mexican Folk Healing in Child Health Promotions
El papel de los síndromes culturales y los remedios tradicionales mexicanos en la promoción de salud de los niños
Gallagher, M.R.*; Rehm, R.S.**
*PhD, RN. Assistant Professor University of Texas Health Science Center-School of Nursing Houston, TX. E-mail:
**PhD, RN, FAAN. Associate Professor University of California at San Francisco. USA.
This work was funded by NIH/NINR F31 NR008174. The authors also would like to thank the Women's Health Nursing Research Training Grant, NIH/NINR T32 NR0739 and the Integrating CAM: Nursing Emphasis Grant NIH/NCAM R25 AT001240 for the support in the production of this manuscript.
Purpose: To describe the context in which culture-bound syndromes that mothers of Mexican descent believed affected child wellness and describe how they restored health when these syndromes affected their children.
Design: The findings of this come from a larger study that focused on the health promotion and protection practices used by mothers of Mexican descent in urban Texas A naturalistic design, using Spradley's ethnographic interview techniques and participant observations, was selected to explore and describe the child health promotion and protection practices, including culture-bound syndromes, used by mothers of Mexican origin.
Method: Data collection consisted of 21 ethnographic interviews enhanced by focused home observations withnine Spanish speaking mothers.
Results: To these group of mothers, the culture-bound syndromes of empacho, fright and evil eye could affect children's eating and sleep patterns, thereby causing an imbalance in a child's wellbeing. Therefore the participants believed that they had be mindful of culture-bound syndromes that affected their children's health and take care of those syndromes by using folk remedies to restore balance in their children's' wellbeing.
Conclusion: The findings of this study provide an in-depth description of culture-bound syndromes and the folk remedies which mother of Mexican descent used to promote and protect the health of their preschool children. This knowledge provides a framework for healthcare professionals to use when working with mothers of Mexican descent who may be using folk healing to promote and protect the health of their children.
Key words: Folk Healing; Complementary Alternative Therapies; Health Promotion; Mexican; Maternal/Child.
Objetivo: Describir el contexto en el que los síndromes culturales de las madres de ascendencia mexicana creían que afectaban a la salud infantil y describir cómo ellas mejoraban la salud cuando estos síndromes afectaban a sus hijos.
Diseño: Los resultados de este estudio se basan en una amplia investigación que se centró en la promoción de la salud y las prácticas de protección usadas por las madres de ascendencia mexicana en la ciudad de Texas. Se seleccionó un diseño naturalista, mediante las técnicas de entrevistas etnográficas de Spradley y observaciones de los participantes, para explorar y describir la promoción de la salud infantil y las prácticas de protección, incluyendo los síndromes culturales usados por las madres de origen mexicano.
Método: La recopilación de los datos consistió en 21 entrevistas etnográficas mejoradas por el enfoque de las observaciones en hogares con 9 madres de habla hispana.
Resultados: Para este grupo de mujeres, los síndromes culturales del "empacho", "mal de ojo" y "susto" podían provocar trastornos alimenticios y del sueño, causando un desajuste en el bienestar del niño. Además, las participantes creían que ellas tenían que ser conscientes de los síndromes culturales que afectaban a la salud de sus hijos y cuidar aquellos síndromes usando remedios tradicionales para promocionar y proteger la salud de sus niños.
Conclusión: Los resultados de este estudio ofrecen una descripción en profundidad de los síndromes culturales y los remedios tradicionales que las madres de ascendencia mexicana usaban para promocionar y proteger la salud de sus niños. Este conocimiento ofrece un marco para que los profesionales de la salud lo usen cuando trabajen con madres de ascendencia mexicana que pueden estar usando este tipo de medios para cuidar a sus hijos.
Palabras clave: Remedios tradicionales; terapias alternativas complementarias; promoción de la salud; mexicano; materno/infantil.
Latinos are one of the largest ethnic minority groups in the U.S.A., with people of Mexican descent being the great majority(1). For centuries, individuals of Mexican descent have used folk healing to resolve culture bound syndromes (2). Culture-bound syndromes are illnesses and ailments confined to a particular culture or ethnic group (3). A few studies have described culture-bound syndromes and the folk healing remedies used by mothers of Mexican descent with their preschool children (4, 5). However, these studies lack an in-depth emic or contextual rationale for folk healing practices used by mothers with their children. In order for the healthcare team to foster culturally sensitive interactions with families of Mexican descent, it is important to understand the emic perspective of culture-bound syndromes that affect children and the rationale for folk healing remedies used. In addition, it is important to understand what remedies are used by Mexican mothers in order to provide safe and appropriate nursing care, and address any risk factors that may be present if the remedies are not safe or pose a contraindication to medical care.
Culture-Bound Syndromes in the Mexican culture
In Mexican culture, the culture-bound syndromes that affected children's health are susto [fright], empacho [stomach distress], and mal de ojo [evil eye] (4, 5). Risser and Mazur found in a Houston, Texas, study that 70% of the parents of Mexican descent believed in mal de ojo [evil eye], 64% believed in empacho, and 37% believed in susto [fright] (5). Mikhail also found in a sample similar to the one in the present study that participants believed in empacho, susto, and evil eye (4). Susto or fright is a folk ailment thought to cause lack of appetite and sleep disturbance in children. Empacho is believed to be caused by a piece of raw dough stuck to the wall of the stomach or because the stomach sticks to itself. Children who suffer from empacho usually have decreased appetite, nausea, and sometimes diarrhea. Evil eye is caused by somebody looking at a child intensely, often with admiration. Usually when children get evil eye they get restless, cry without reason, and cannot sleep.
Despite our knowledge of the culture-bound syndromes and their remedies, it is not clear how mothers of Mexican descent contextually frame these illnesses and remedies. The purpose of this article is to describe the culture-bound syndromes that mothers of Mexican descent believed affected child wellness and describe how they restored health when these syndromes affected their children. In addition, we describe the context in which these practices occur. The findings of this come from a larger study that focused on the health promotion and protection practices used by mothers of Mexican descent in urban Texas (6). Findings related to culture bound syndromes that affected child wellness and maternal practices to protect health are presented.
A naturalistic design, using Spradley's ethnographic interview techniques and participant observations, was selected to explore and describe the child health promotion and protection practices, including culture-bound syndromes, used by mothers of Mexican origin. A detailed description the study and the methods is presented elsewhere (6).
Human subjects approval was obtained by the sponsoring university. Participant consent was obtained prior to data collection. Participant recruitment occurred during community activities. Mothers who self-identified as of Mexican descent, were 18 years of age or older, had at least two children, with one under the age of 5, and spoke English or Spanish were included in the study. Mothers were excluded from the study if they had a child under age 5 who had been diagnosed with a chronic illness, developmental delays, or any physical or mental disability.
The study setting was the a church-based community center that serves the largely Latino community of a large city in Texas. Some services offered by the center are a food bank and classes in physical activity, parenting, and English as a second language.
Data were collected by semi-structured ethnographic interviews, participant observations recorded as field notes, a researcher-designed demographic data sheet, and a measure of acculturation as a demographic descriptor. Data collection took place between December2004 and July of 2005.
The interview guide contained descriptive, structural, and contrast questions (7) to obtain information on health promotion and protection practices participants used with their preschool children. Interviews occurred in 3 waves, with each mother being interviewed at least 2 times. A total of 21 interviews were conducted with 9 participants. Initial descriptive questions were "What kinds of things do you do to keep your child healthy?" "What kinds of things do you do to keep your child from getting sick?" and "What kinds of things do you do to keep your child from getting physically hurt?" After domain analysis, subsequent interviews included structural questions. For example, the mothers explained that one way of protecting children from the evil eye was to place an amulet on the child. Structural questions, for example "What are the different kinds of things you do to protect your child from evil eye?", and contrast questions, for example "What is the difference between evil eye and fright?" were asked to obtain a deeper understanding of each individual culture-bound syndrome and the health promotion practice.
To establish trust with the participants, the first author spent 70.5 hours in participant observations during various activities at the study setting. These activities were parenting and salsa aerobic exercise classes, and volunteering at food bank lines and family night community gatherings. The participant observations and repeated interviews with the opportunity to discuss preliminary analysis enhanced the prolonged engagement that helped establish credibility and validity of the data (8).
At the first interview, demographic information was obtained. The demographic data included participants age, education, employment status, marital status, number of children at home, number and ages of preschool children, number of people living in the home, time living in the United States, languages spoken, and religious affiliation.
Maternal acculturation was measured by the ARSMA-II (9). The ARSMA-II assesses attitudes and behaviors concerning the Mexican and Anglo ethnicities. Cuellar et al. reported that the ARSMA-II subscales have internal consistencies ranging from .68 to .96. The subscales' test-retest reliabilities range from .72 to .96, and concurrent validity is .89. Acculturation scores were analyzed using ARSMA-II software (9) and transferred to SPSS for data management.
Data Management and Analysis
Interviews were conducted in Spanish and audio recorded and transcribed verbatim. Transcript accuracy was checked by the first author and two Latino nurses who were familiar with the topic and fluent in Spanish. Text data were managed with Atlas ti, version 4.2 software. Demographic data was transferred to SPSS for management. To preserve cultural meaning in the data, the ethnographic analysis and initial documentation of the findings were done in Spanish. The findings were not translated to English until the final report.
Transcripts were analyzed after informational redundancy was reached with each wave of interviews. Analysis occurred at four levels: (a) domain analysis (a search for larger units of cultural knowledge and semantic relationships), (b) taxonomic analysis (in-depth study of the internal structures of each domain), (c) componential analysis (a search for attributes that signal differences among symbols in a domain), and (d) thematic analysis (a search for relationships among domains and their relationship to the whole) (7). Cultural themes were obtained from the various analyses. These cultural themes were then discussed with all the participants in the final interview.
The sample consisted of nine mothers of Mexican descent. Informational redundancy was reached with all participants. The age of the participants ranged from 24 to 40, with a mean of 32.6 (SD=4.8). Six of the participants were married. Two participants were separated and one was living in union libre [common law marriage]. Two of the nine participants lived with two or more adults in their home, besides their spouse. Only two participants sent their children to a daycare sponsored by the community center. The number of years the participants resided in the U.S. ranged from 1 to 24, with a mean of 10.7 (SD=8.9). Three of the nine participants were bilingual; however, they preferred to communicate in Spanish. Based on results from the ARSMA, this group of mothers were oriented to the Mexican culture and had not fully acculturated to mainstream U.S. culture. Only one participant was not employed. The other participants were self-employed or worked part-time as housekeepers in homes and businesses around the community. All of the preschool children of participants were enrolled in Medicaid, indicating that the participants' family income was no more than 133% of the federal poverty level (10). Eight of the 9 participants were practicing Catholics. One participant stated she did not have a religious affiliation.
Culture Bound Syndromes and their effect on overall child wellness
The participants in this study believed in the culture-bound syndromes of empacho, fright, and evil eye. The participants in this study framed the culture-bound syndromes in two different contexts: those that affect a child's eating patterns and appetite, and those that affect a child's sleep patterns. The culture bound syndromes that affected children's eating pattern and appetite were empacho and fright. The culture bound syndromes that affected children's sleep were fright and evil eye.
Empacho and its effect on eating
One participant described how empacho affected children's eating:
Because their stomach is not working like it should...his food he ate stays there [in the stomach]. . . and it does not allow. . . for him to have normal digestion. Then, when the stomach is heavy, he has no appetite. I try to give him [food] I am offering, and he does not want anything because he feels he is not hungry. So then you have to get it out [bydoing a rubbing] so his stomach starts working.
The mothers usually knew that the empacho was gone when the child started to eat again.
The mothers explained that they possibly could prevent empacho in children by making sure they did not eat food that was not cooked well. One mother stated, "You can prevent it maybe if you do not give them raw flour tortilla dough. "Empacho was also believed to be caused bythe children eating something that did not settle well in their stomachs. All of the participants believed that flour products that were not thoroughly cooked would stick to children's stomachs and impede digestion. This lack of digestion would cause children to cease eating.
Empacho was usually treated by massage of children's stomachs and back. The mothers called the massage performed to cure empacho a sobada [rub]. One participant stated that empacho was cured by the use of "a little bit of oil you massage their stomach and you pull on the skin of their back." Another participant explained how she cured empacho in her household:
With baking soda and . . . your own saliva . . . you place it around the bellybutton and you start to rub, and rub and rub. And then you go to the back and you start to rub, and when you are rubbing you pick up the skin in the back and it has to pop three times, and with that the empacho goes away.
Fright and its effect on children's eating and sleep
Several of the mothers said that fright could cause preschool children to stop eating and have problems sleeping. One participant said: "Fright causes them to stop eating and they get skinny and lose weight and do not want eat." The participants explained that fright occurred because children had received a strong impression or had experienced something that had scared them. A mother explained what caused fright in her children:
When they are little and they hear a loud sound, like the sound of a car, a muffler, or like when one screams, that is scary for a child. They shiver. . . When they are sleeping it happens a lot that they are sleeping, and you get them up and they shiver and they get scared . . . or when you wake them up roughly.
Fright caused a child to be scared and therefore affected a child's sleep. When her children had fright, a participant described her children's behavior "Then they can't sleep. They are crying and crying, restless. That is when you say, they have fright and you have to do a barrida [body sweep] on them."
The cure for fright is a body sweep. The sweep usually was done by passing over the child'sbody a branch of the pirul tree [pepper tree] and saying a prayer. The pirul tree is the kind of plant that will remove accumulated bad energy from the fright (Personal communication, Sr. Madrigal-Herbero, February, 2005).
Evil eye and sleep
Evil eye was another folk ailment that participants believed could affect preschool children'ssleep. The participants explained that some people have very strong energy that comes through their eyes. One participant stated, "My husband says that there are a lot of people [who have] an energy or something like that in their eyes." When these individuals admire children, the individuals can pass that strong energy on to the children. The children's bodies cannot handle the excess energy, and they become restless, cannot sleep, and sometimes get fever. Another participant explained what occurred when an individual with "strong eye" looked at a young child: The person with the strong eye "just sees [the children] and warms up their blood. . . [the children] are just restless, they can't sleep. It's because [the person with the strong eye] has stolen their sleep and their little bodies get hot."
Participants believed that strong energy could be dissipated by benign touch. When individuals knew that they had the ability of giving evil eye, they touched the children to dissipate the accumulated energy in children. At other times when people said that preschool children were pretty or cute, and mothers' suspected that they had that strong energy, they would ask people to touch the children to ensure that they did not get evil eye. A mother described what would happen when she took her four 4-year-old out in public:
I would pay attention to people, but like I tell you, you do not notice the reaction [from evil eye] until they are going to go to sleep. When it is their bedtime is when you realize that their sleep is going away. . . . But what I would do was to take her out and I would ask, "She is so pretty, please touch her. Yes, touch. Look at her little cheeks. Yes, but touch them."
The participants stated that another way to prevent or avert evil eye in preschool children was to place an ojo de venado [deer's eye] on children when going out in public. The deer's eye is a round seed, about the size of a quarter. The color is dark brown with a black thick line that is around three fourths of the edge of the seed. The deer's eyes are sold as part of a little beaded bracelet with an image of a saint in the middle of the seed. The deer's eye also can be worn as part of a pin. One participant stated that, after her 2-year-old child had a bad episodeof evil eye, her husband now "makes sure she has her little bracelet on."
If preschool children got evil eye, the only way to cure it was by doing a body sweep with an egg. The participants explained that an egg had to be rubbed over the child's body while a prayer was said. The egg was thought to absorb the energy overload and steer it away from the child. A participant explained, "I say and believe that the egg absorbs energy. That is what happens, it absorbs the energy that was transmitted. . . I only pass the egg over and she's fixed."
The way the mothers knew that the evil eye had been removed was that the child fell asleep soon after the body sweep, "Automatically she fell asleep. In other words, not even 2 minutes passed, I swear, and she fell asleep."
After curing children from evil eye, other mothers would try to protect children's sleep by placing a pair of open scissors under the mattress or placing a Bible, a rosary, or a religious image in the bed next to the child. One participant explained that the scissors were used as protection:
Whenever you want something to not be done to you, you cut it. You cut whatever isbeing done to you. [The open scissors] represent the symbol of the cross. That way if something was being done to her, I guess it would cut it, the scissors and the cross would cut it.
To these participants, the culture-bound syndromes of empacho, fright and evil eye could affect children's eating and sleep patterns, thereby causing an imbalance in a child's wellbeing(6). Therefore the participants believed that they had be mindful of culture-bound syndromes that affected their children's health and take care of those syndromes by using folk remedies to restore balance in their children's' wellbeing.
This qualitative study provides an in-depth description of culture-bound syndromes and the folk remedies which mother of Mexican descent used to promote and protect the health of their preschool children. The findings of this study are congruent with the findings from earlier work(4, 5). However, the findings in this study take the description provided by Mikhail and Risser & Mazur further by offering the contextual framework that mothers of Mexican descent use when dealing with culture-bound syndromes and folk remedies. The participants in this current study viewed that sleep and balanced food intake were important for health; therefore, the mothers took advantage of their unique cultural knowledge to cure the culture-bound syndromes they believed would prevent a child from sleeping well or eating a balanced meal. Furthermore, the mothers conceived of their efforts to prevent the onset of these culture-bound syndromes as protective of children's health by preventing the complications and disruptions that they cancause.
The manner in which a culture-bound syndrome is treated varies from one ethnic group to another. This difference was noted in the way evil eye and empacho were treated. Evil eye is a culture-bound syndrome known to exist in several cultures and ethnic groups in the world, but the way it is treated varies. Tripp-Reimer reported that Greek immigrants removed evil eye by drinking a mixture of oil and water, making the sign of the cross over the glass, and then washing the face with the water (11). The folk healing practices for evil eye described by Tripp-Reimer are different from those of individuals of Mexican descent. How culture-bound syndromes are treated also varies intra-ethnically. In a sample similar to the one in this study, Mikhail found that participants treated empacho by giving children lead-contaminated compounds like azacón or greta. Azacon and greta are powders that are mixed in water (4). However, the participants in this current study treated empacho by massaging the stomach and the back of the child. The difference in the treatment of evil eye and empacho is probably caused by ethnic differences and regional or geographical variations, but may reflect a common need to explain disturbances in children's routines and health statuses that seem to coincide with other variations in daily routines.
The literature of studies exploring the use of folk medicine by people of Mexican descent (12, 13,2) and the findings in the current study point to the fact that mothers of Mexican descent use a family member or close friends who cures culture-bound syndromes instead of going to a curandero [Mexican folk healer]. In this current study, empacho, fright, and evil eye were dealt with by the child's mother. Some literature has suggested that parents of Mexican descent goto Mexican folk healers when they think that their children are sick due to a culture-bound syndrome, causing a delay in medical care (14). The findings in this present study indicate otherwise. The assumption that people of Mexican descent seek Mexican folk healers when there is an illness instead of seeking medical care is not supported by the results in this present study. Mothers of Mexican descent in this study used the resources available to them to restore balance in their children's health. The participants took their children to the doctor when they felt that medical care would restore balance. The participants used folk healing to treat culture-bound syndromes because they knew a doctor trained in biomedical science didnot know how to heal empacho, fright, or evil eye. If children were not cured from these culture-bound syndromes, mothers believed that an imbalance in the body, mind, or soul would put their health at risk.
Practitioners must understand that there are culture-bound syndromes and that Western medicine does not have an explanation for their causes or the knowledge of how to treat them. To dismiss culture-bound syndromes and their treatments as quackery or as superstition is to continue placing Western medicine at a higher level than other forms of healing. Awareness of culture-bound syndromes and how they may be perceived as creating disharmony or imbalance in the body, mind, or soul would facilitate tailoring culturally specific interventions inethnic minority communities.
Implications for Nursing Education
Ensuring that nurses effectively address the health care needs of individual of diverse populations requires cultural competence. Findings in this study point to the importance of the continued inclusion of cultural sensitivity and openness in nursing education programs. Educators must continue to implement a curriculum that addresses students' awareness and understanding of patients' cultural backgrounds to ensure that future nurses effectively address the health care needs of individuals of Mexican descent and other diverse cultures. Meleis argued that knowing about a particular group's perceptions concerning health issues is essential for the understanding required to develop intervention plans that improve the health of individuals of varied cultural backgrounds (15). The findings in this current study support the continued need to educate nursing students on the importance of providing culturally sensitive nursing care.
Nursing schools must incorporate teaching strategies that facilitate learning complementary alternative medicine used by diverse populations. For example, the use of service learning projects in cultural enclaves or in communities where ethnic minorities live would be a valuable teaching tool. Nursing student could assess various culture-bound syndromes and the herbs and folk healing practices used. The students would use the literature to evaluate the uses and safety of the herbs and folk healing practices. Then, the students could provide a workshop tothe community. The workshop would provide community members with precautions and recommendations related to particular herbs or folk healing practices, and information to reinforce symptoms that require allopathic care instead of or in addition to folk-based care. The intent of the workshop would not be to change the community's members' beliefs, but to make them aware of the various uses and precautions when using particular herbs or folk healing practices. Through service learning projects, such as the example presented, students would understand the underlying logic behind a culture-bound syndrome. This understanding provides awareness of a particular culture's worldviews of health. This awareness smooths the nurse-patient encounter for more effective nursing care.
Implications for Nursing Research
The findings in this current study illustrate that understanding how people of Mexican descent and other diverse groups conceptualize the culture-bound syndromes that affect the wellness of their children can enhance health promotion and wellness. Nursing is at the forefront to conduct studies to understand health-related worldviews. This understanding facilitates the creation of health programs that are culturally sensitive. Future research should focus on exploring and describing how other ethnic groups define health promotion and health protection.
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