In 2014, there were more than 46 million individuals 65 and older in the United States (Colby & Ortman, 2014). However, that number is expected to reach approximately 88 million by 2050 (Colby & Ortman, 2014). It is estimated that by 2050, 17 million Hispanic older adults will reside in the United States, accounting for approximately 20% of the older adult population (Administration for Community Living, 2010).
With the growing number of Hispanic older adults, it is important that clinicians appropriately address the needs of this population. Familism, or familismo, is a traditional Hispanic value that places importance of the family unit over the self (Koerner & Shirai, 2012). This value can potentially affect health care practices within the older Hispanic population. Of note, familism is not only a value of Hispanic older adults, but also many Hispanic adults. The purpose of the current article is to present clinicians with information regarding familism, along with relevant considerations for health care provision to the Hispanic older adult population. These considerations are not meant to be a complete guide to care and should not be used to overgeneralize the heterogeneous Hispanic population.
The terms Hispanic and Latino are often used interchangeably to describe an ethnic group whose members include anyone of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin (U.S. Department of Health and Human Services [USDHHS], 2015). Hispanic individuals comprise those from multiple races and nationalities. Approximately 65% of Hispanic individuals in the United States are of Mexican origin, with Puerto Rican being the second most prominent origin at 9.4% (U.S. Census Bureau, 2013). Further, these individuals are acculturated at varying degrees dependent on multiple factors, including nativity status and environment.
Hispanic individuals in the United States experience numerous health care disparities. With exception of men ages 65 to 74, Hispanic older adults are more likely to be obese than non-Hispanic, White older adults. In fact, 46.6% of Hispanic women ages 65 to 74 are obese compared to 38.9% of White, non-Hispanic women in the same age range (Fakhouri, Ogden, Carroll, Kit, & Flegal, 2012). Obesity results in high risk for developing diabetes, cardiovascular disease, cancer, and end-stage renal disease (Go et al., 2013). Due to multiple biological, socioeconomic, and cultural factors, Hispanic individuals are approximately twice as likely to be diagnosed with—and 50% more likely to die from—diabetes than non-Hispanic, White individuals (Cersosimo & Musi, 2011; USDHHS, 2012). Further, they are more likely to rate their health fair or poor compared to non-Hispanic, White adults (Administration for Community Living, 2010). Because Hispanic individuals have a longer life expectancy than non-Hispanic, White and Black individuals in the United States, clinicians will see many Hispanic patients living into old age with chronic disease and, possibly, a multitude of needs (Arias, 2010). The term Hispanic paradox, often mentioned in the literature, refers to Hispanic individuals having longer life expectancies, but higher disability and poorer overall health than non-Hispanic, White older adults. The mechanisms behind this paradox remain unclear (Markides & Eschbach, 2011).
Hispanic individuals are less likely to use certain aspects of health care services compared to non-Hispanic, White individuals. For example, they are less likely to use preventive care, such as cancer screenings and vaccinations (Administration for Community Living, 2010; Centers for Disease Control and Prevention [CDC], 2014). They are also less likely to use long-term care (LTC). In 2008, 9.2% of Hispanic older adults reported needing assistance with self-care compared to 5.7% of their non-Hispanic counterparts (Administration for Community Living, 2010). However, Hispanic older adults are 63% less likely to be admitted to a nursing home compared to non-Hispanic, White adults when socioeconomic resources and needs are considered (Thomeer, Mudrazija, & Angel, 2014). Although approximately 40% of Hispanic older adults experience abuse or neglect within 1 year's time, few report this to their health care clinicians (DeLiema, Gassoumis, Homeier, & Wilber, 2012).
Familism is a multidimensional construct that refers to the attachment of individuals within families, often involving loyalty, solidarity, and reciprocity (Gelman, 2014; Rodriguez, Mira, Paez, & Myers, 2007). Those who uphold this traditional Hispanic value tend to put the family's needs over their own (Koerner & Shirai, 2012). Studies have examined the correlation between familism and acculturation, but results have varied due to inconsistent empirical referents (Perez & Cruess, 2014). Almeida, Molnar, Kawachi, and Subramanian (2009) found that familism tends to present lower among Hispanic individuals who primarily speak English at home, were born in the United States, and are of higher socioeconomic status. These findings support the idea that familism may dissipate as more time is spent exposed to U.S. values. However, some studies do not support the idea that familism and acculturation are inversely proportional. Crist, McEwen, et al. (2009) found that familism tended to present higher among more acculturated individuals. Rodriguez et al. (2007) found that prevalence of familism was high among all Hispanic individuals regardless of degree of acculturation.
Fictive kin is a term seen throughout the literature related to familism and refers to individuals who are viewed as family, although not related by blood or through marriage (Ruiz & Ransford, 2012). Although familism does not traditionally describe strong ties outside of bloodlines or marriage, it is discussed in the current article. Hispanic older adults turn to fictive kin for support when family is not in close proximity.
Use of Health Care Services
Family Roles and Responsibilities
The direct role of familism on health outcomes is unknown (Perez & Cruess, 2014). However, it is important to examine common beliefs and roles related to familism and how they can affect use of health care services and decisions. Table 1 outlines various beliefs and roles related to familism. Machismo and marianismo are two traditional roles that may be observed in Hispanic older men and women, respectively. Machismo refers to the masculine role of men that often translates into the expectation that they will provide for, and protect, their families (Davila, Reifsnider, & Pecina, 2011). In contrast, marianismo refers to the feminine role of women that tends to translate into the expectation that they will be selfless caretakers of their families (Davila et al., 2011; Ruiz & Ransford, 2012). Both roles can negatively affect health care use. Men may refrain from spending money or taking time off from work instead of visiting clinicians for preventive care or acute visits in an attempt to save money for their families (Perez & Cruess, 2014). To emphasize the strong familial effect, one study found that Hispanic older men believed their families could better influence them than health care professionals to decrease their alcohol use (del Pino et al., 2013).
Definition and Characteristics of Familism Within Hispanic Culture
Similarly, a woman's desire to be a caretaker, rather than a burden, may affect health care use. Even after controlling for income and insurance status, there is evidence that Hispanic women are more likely than their non-Hispanic, White and Black counterparts to delay breast cancer treatment (Katz et al., 2005). Furthermore, they are more likely to stop cancer treatment if they perceive they have duties to fulfill within their families. Some Hispanic women will not pursue care, fearing it may interfere with their roles within the family (Ashing-Giwa et al., 2006). Familism may also prevent the use of services, such as home care, if a spouse believes that his/her role is to care for the family (Crist & Speaks, 2011).
Familism and family roles can also potentially positively influence health care use. As many women are viewed as caretakers, female partners hold their male counterparts accountable for attending health care appointments. In addition, women are often present for their partners' appointments (Davila et al., 2011). With Hispanic older adults potentially seeing multiple clinicians, this family reliability and commitment may be beneficial.
In addition to the aforementioned family roles and responsibilities, there is a prominent expectation that children or other extended family should care for their elders (Ruiz & Ransford, 2012). Familism includes respecting the dignity of all family members, but respecting the dignity of elders is put in high regard (Crist, McEwen, et al., 2009). Adult children (especially daughters) are likely to care for their parents even when both are still living (Gallagher-Thompson, Solano, Coon, & Areán, 2003). Hispanic older adults are approximately twice as likely than the older adult population in the United States to live with a family member (Administration for Community Living, 2010).
Hispanic older adults have higher rates of disability and greater health disparities than non-Hispanic, White older adults, yet they are less likely to be admitted to LTC facilities (Feng, Fennell, Tyler, Clark, & Mor, 2011; Ruiz & Ransford, 2012; Thomeer et al., 2014). It is likely multiple reasons exist for underuse, such as few Spanish-speaking clinicians and fewer socioeconomic resources available to them than for non-Hispanic, White individuals, but familism also seems to contribute to underuse (DeNavas-Walt & Proctor, 2015). The risk of LTC admission decreases by approximately 70% when Hispanic older adults report they will have help available, if needed, in the future (Thomeer et al., 2014). In contrast, availability of future help does not affect risk of admission among non-Hispanic, White and Black individuals. Furthermore, being married, having living children, and living with a child decreases the risk of admission to LTC among Hispanic older adults (Thomeer et al., 2014).
In addition to lower rates of LTC admission, Hispanic older adults, especially those who highly value familism, may also be hesitant to allow home care services (Crist, Suk-Sun, Pasvogel, & Velázquez, 2009). Crist and Speaks (2011) found that Mexican American caregivers and older adults preferred to be cared for in the home by family members; caregivers and the older adult were comforted to know that family members would provide genuine care rather than receiving care solely from paid caregivers. In fact, children of older adults have refrained from giving their parents information about available home care services, as they believe family should be the caregivers (Crist, 2002; Purdy & Arguello, 1992). Some Hispanic older adults and their families cannot differentiate between the levels of care provided by a health care clinician versus a family member, which may be a contributing factor to the reluctance to accept home care (Crist & Speaks, 2011).
That said, rates of LTC admission among Hispanic older adults are rising (Feng et al., 2011; Smith, Feng, Fennell, Zinn, & Mor, 2008). Although familism is still a prominent value among Hispanic older adults, shifting norms related to family caregiving may have played a role in these rising rates (Thomeer et al., 2014). Ruiz (2007) found that many Hispanic older adults reported receiving health care support from families, but approximately 80% had infrequent contact with family members. Decreased contact and/or increased distance between family members affects the ability of family members to care for their older relatives. For example, more Latina individuals have joined the work-force and migration of family members has increased (Angel, Angel, Aranda, & Miles, 2004; Thomeer et al., 2014). However, of the LTC services used by Hispanic older adults, the most common was adult day services (20.2% of all adult day service users). This sector was the most ethnically diverse service used compared with those from home health agencies, hospice, nursing homes, and residential care communities (Harris-Kojetin, Sengupta, Park-Lee, & Valverde, 2013).
Some Hispanic older adults are concerned by the “Americanization” of, and infrequent contact with, their families; however, older women may be encouraging their children to spend more time caring for their nuclear families in an attempt to not be perceived as a burden (Gelman, 2014; Ruiz & Ransford, 2012). Thus, Hispanic older adults are turning to friends who act as family, or fictive kin, for caregiving needs (Ruiz & Ransford, 2012). Hispanic older adults, especially women, are at risk for self-treating with home remedies rather than seeking medical treatment (Ruiz & Ransford, 2012). This situation is concerning, as many of these individuals are unable to recognize emergency or serious issues and may delay care (Ruiz & Ransford, 2012).
Caregivers and Hispanic older adults may be increasingly more open to use of home health services. According to the CDC (2013), 8.4% of home health use in 2011 and 2012 was by Hispanic consumers even though Hispanic older adults comprised only 6.9% of the population at this time. Caregivers are more likely to report older adults' use of home care with higher levels of impairment and knowledge of available services (Crist, Suk-Sun, et al., 2009).
Stigma and Mental Health
Hispanic older adults may also underuse health care services to protect their families' and their own reputations. Clinicians and caregivers have reported that this population tends to address mental health needs with family members (if at all) out of fear of being labeled (Barrio et al., 2008). If an Hispanic older adult feels abandoned by his/her children, he/she seems to be at increased risk for developing a mental illness (Barrio et al., 2008). Therefore, access to mental health services is vital. Primary care clinicians may assist augmenting positive attitudes toward mental health by creating initial positive experiences and fostering trust (Cabassa, Lester, & Zayas, 2007).
Familism may lead to the reluctance of reporting elder abuse to protect family members (DeLiema et al., 2012). As mentioned previously, approximately40%ofHispanicolder adults experience neglect or abuse within 1 year's time. Approximately 25% of reported abuse was psychological, with 21% of Hispanic older adults experiencing multiple types of abuse. Financial, physical, and sexual abuse, along with neglect, were also reported. Only approximately 1.5% of these individuals reported abuse to adult protective services (DeLiema et al., 2012). This may be due to the fact that Hispanic older adults are more likely to live with family members. Elder abuse victims, in general, are less likely to initiate a safety plan if the abuser is a child or grandchild (Burnes, Rizzo, Gorroochurn, Pollack, & Lachs, 2014).
Health Care Decision Making
Familism may also influence Hispanic older adults' decisions to change health behaviors (del Pino et al., 2013). For instance, an older woman with diabetes may want to prepare meals that her husband or family prefers instead of cooking a meal appropriate for her diagnosis. Even if a woman has the option of preparing her own meal, she may believe that she needs to consume the same meal as her family out of respect (Adams, 2003). However, familism also has the potential to positively affect health care behaviors, such as encouraging self-care and providing reminders to take medications and attend appointments (Perez & Cruess, 2012; Ruiz & Ransford, 2012).
When it comes to health care decisions for Hispanic older adults, clinicians are likely to observe family decision making rather than the autonomous decision making often encouraged in the United States (Kelley, Wenger, & Sarkisian, 2010). Arguably, some of the most significant decisions in an older adult's life revolve around end-of-life care. A majority of Hispanic older adults prefer making decisions about their end-of-life care with their families rather than doing so independently (Kelley et al., 2010). If family is involved with decision making at the end of life, it is helpful that they know the wishes of the older adult. However, Kelley et al. (2010) found that although approximately 84% of Hispanic older adults preferred comfort care in the event of becoming ill, only 24% completed an advance directive and approximately one half had not discussed their wishes with their family. Approximately 63% of those who preferred comfort care initiated at least some form of advanced planning. Older adults who were more acculturated, had a higher income, and were more autonomous were more likely to have an advance directive (Kelley et al., 2010).
Although decisions are often made as a family, clinicians may find that the oldest male tends to act as the spokesperson (Adames, Chavez-Dueñas, Fuentes, Salas, & Perez-Chavez, 2014). In addition to speaking on behalf of the family or older adult, the oldest male may also be responsible for receiving poor news regarding his loved one. Some Hispanic older adults do not want to participate in certain discussions. Hispanic American individuals, along with Asian American and Eastern European American individuals, are more likely than other minority groups to prefer nondisclosure pertaining to poor health care outcomes (Larkin & Searight, 2014). In addition, clinicians have found that some Hispanic families do not want the patient to know about his/her own terminal diagnosis (Braun, Ford, Beyth, & McCullough, 2010). However, clinicians should refrain from assuming that all Hispanic older adults prefer to not be involved in important decisions or provided with complete health care information. Therefore, with the help of a translator, clinicians should discuss the purpose of informed consent with patients and offer information regarding diagnosis and treatment (Searight & Gafford, 2005). This way, informed consent is offered, but allows patients to decide what they would like disclosed.
Implications for Health Care Clinicians
Familism can greatly affect clinicians' decisions in the provision of care (Table 2). Clinicians must respect the views of Hispanic older patients while ensuring they receive quality care (Perez & Cruess, 2012). This may be difficult for some clinicians who are used to creating plans of care based on values of individualism, full disclosure of risks and benefits, and autonomy.
Clinical Implications for Addressing Familism
Although acculturation may play a role in the value of familism, its impact is not entirely clear. Therefore, clinicians must first assess the family dynamics of their Hispanic older patients (Radina, Gibbons, & Lim, 2009). Clinicians should be aware of the role that family members play in their patients' lives and who exactly is considered family (Adames et al., 2014). Patients may speak about a family member and not necessarily be referring to a blood relative, but instead fictive kin (Ruiz & Ransford, 2012). Fictive kin should be respected the same as blood relatives if they are who patients designate as their kin. In addition, there is a possibility that multiple individuals will be involved with an Hispanic older patient's care (Adames et al., 2014). Therefore, clinicians should involve these individuals in health care discussions, but only after obtaining and documenting permission from the patient.
Family Roles and Responsibilities
Because health care behavior recommendations are often given to older patients, clinicians should be cognizant about best practices in approaching Hispanic patients. Patients should be encouraged to change health behaviors by discussing the positive effects on family members as well as the self (Davila et al., 2011; del Pino et al., 2013). For example, an Hispanic older male may be advised to adhere to antihypertensive therapy to prevent future complications and be able to continue providing for his wife, children, or grandchildren. In addition, a female who strives to maintain the traditional marianismo role may be advised about ways to care for herself so that she can effectively care for others. Encouraging the presence of significant others at appointments (especially women, who traditionally tend to men's health care needs) may help ensure patients are following instructions at home and appointments are kept.
In addition to spousal involvement, clinicians should ensure patients and caregivers understand health care instructions. Because caregivers often make decisions about which services will be used, they should be aware of available services and resources that could potentially benefit the patient (Crist, Suk-Sun, et al., 2009). Hispanic family members have reported feeling pressured to provide care; referrals and information about available resources may help relieve such pressure (Gelman, 2014; Herrera, Lee, Palos, & Torres-Vigil, 2008). Caregivers are more likely to use resources if provided with information about their availability (Herrera et al., 2008). If home care is warranted, patients and their caregivers should be educated on why this is needed. Clinicians should explain that home care is not used to replace family care, but instead used to augment, support, and oversee the family's care (Crist, Suk-Sun, et al., 2009). It is important that the family understands the home health professional's role in conducting medical assessments and providing invaluable education. Because Hispanic older adults are less likely to use LTC services and instead wish to stay in their homes, clinicians should consider explaining that the provision of home care may delay or prevent admission to long-term institutions (Crist, McEwen, et al., 2009; Crist & Speaks, 2011).
It should not be assumed that Hispanic older patients' needs are being met by their families. Children may live far from their parents and only attend certain appointments, being unavailable for day-to-day needs (Ruiz & Ransford, 2012). At the same time, older adults may not use health care services, resulting in unmet needs. Even if family members are, in fact, providing care, health care clinicians should audit whether resources exist, especially if family members quit their jobs to become full-time caregivers (Gelman, 2014).
Stigma and Mental Health
Because many Hispanic older adults are in close contact with children or grandchildren and are reluctant to report abuse, clinicians should assess for elder abuse at each visit. Although it is important for clinicians to ask Hispanic older adults questions about their perception of safety and presence of elder abuse, they should be aware that these patients may be silent about these issues. Therefore, clinicians must be vigilant about assessing for physical signs of abuse or neglect, such as poor hygiene, pressure ulcers, or bruises in different stages of healing (Fulmer, 2008). Clinically unexplained findings should be discussed and reported to local authorities.
Fostering trust with Hispanic older adults is important. They should understand that the role of the clinician is to help, rather than harm, them (del Pino et al., 2013; Perez & Cruess, 2014). When a health care professional is viewed similarly to fictive kin, patients are motivated to make behavior changes (del Pino et al., 2013). In addition, these patients may feel more comfortable discussing topics that they may not have otherwise discussed.
Health Care Decision Making
Although it is important to discuss health care plans with involved family members, clinicians should allow patients to speak with them in private, if desired (Perez & Cruess, 2014). There may be information being withheld due to the presence of family members, such as situations that involve neglect or unaddressed mental health issues. Although sometimes uncomfortable to discuss, clinicians should initiate conversations regarding end-of-life care and encourage completion of an advance directive (Kelley et al., 2010).
If the patient is not fluent in English, clinicians should ensure information is translated. Clinicians may choose to use a professional or ad hoc translator, who does not have specific training in translation services and may include family members or bilingual staff members (Karliner, Jacobs, Chen, & Mutha, 2007). Although professional interpreters positively affect clinical care more than ad hoc interpreters, there is a time and place for each (Brisset, Leanza, & Laforest, 2013; Karliner et al., 2007). Professional interpreters are costly and may not be available in certain locations. Further, patients may prefer certain ad hoc translators due to familiarity (Brisset et al., 2013). However, Hispanic older adults may be less likely to participate in open conversation if they do not trust a family member or community member with their health information. Clinicians should decide on an appropriate translation choice on a case-by-case basis.