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ComplementaryandAlternativeMedicineUseAmongHispanicsintheUnitedStates
BlancaI.Ortiz,PharmD,KellyM.Shields,PharmD,KevinA.Clauson,PharmD,PatrickG.Clay,PharmD
TheAnnalsofPharmacotherapy.200741(6):9941004.

Objective:Toreviewtheuseofcomplementaryandalternativemedicine(CAM)inHispanicsintheUSandhighlightthemodalitiesmostlikelytobe
unfamiliartohealthcarepractitioners.
DataSources:AsearchoftheliteraturepublishedinEnglishandasubsequentbibliographicsearchwereconductedusingMEDLINE,International
PharmaceuticalAbstracts,EMBASE,CumulativeIndexofNursingandAlliedHealthLiterature,andManualAlternativeandNaturalTherapyIndexSystem
(1980March2007).Primarysearchtermsincluded,butwerenotlimitedto,Hispanic,Latino,complementaryandalternativemedicine,anddietary
supplements.StudiesthatassessedorevaluatedtheuseofCAMintheHispanicpopulationwerereviewed.ArticlesthatincludedbothHispanicsandnon
Hispanicswerealsoincluded.
StudySelectionandDataExtraction:Theliteraturesearchyielded42articlesfocusedontheuseofCAMbyHispanics.Surveywasthemostcommon
methodusedinthesestudies,althoughsomehybridinterviewswerealsoconducted.
DataSynthesis:Hispanicswereidentifiedhomogenouslyinsomestudiesandmorecorrectlyasaheterogeneouspopulationinothers.Sometrialsexamined
overallCAMuse,whereasotherslookedatspecificdietarysupplementsandherbs.MostreportsfoundahigherthanexpectedrateofCAMuseinHispanics
(5090%).Anumberofproductspotentiallyunfamiliartohealthcarepractitioners,suchaslinden,sapodilla,andstaranise,werereportedascommonlyusedin
severalstudies.ManystudieswerelimitedbythesamplesizeoruseofonlyoneHispanicsubgroup.
Conclusions:HispanicsuseawiderangeofCAMtherapies,includingseveralthatmaybeunfamiliartohealthcarepractitioners.Understandingtherationale,
motivations,andhistoryofHispanics'useofCAMwillenhancetheculturalcompetenceofhealthcareprofessionalsandhelpaddressthesepatients'medical
needs.
Injust14years,complementaryandalternativemedicine(CAM)useintheUSincreasedfrom33.8%toashighas62%. [15]Initially,CAMpracticeswere
definedas"medicalinterventionsnottaughtwidelyatUSmedicalschoolsorgenerallyavailableatUShospitals." [2]TheNationalCenterforComplementary
andAlternativeMedicine(NCCAM)definitionis"agroupofdiversemedicalhealthcaresystems,practicesandproductsthatarenotpresentlyconsideredtobe
partofconventionalmedicine." [4]Withearlierstudiesfocusingonidentifyingmodalitiessuchasherbalmedicine,homeopathy,folkremedies,megavitamins,
energyhealing,andmassages,studiesnowincludepalliativeandsupportivecare.Additionally,ethnicity,education,age,andincomehavebeenidentifiedas
majorpredictorsofCAMuse. [13]
WithCAMuseratesreflectinginfluencebyethnicity,sex,andage,culturalcompetencepresentsanadditionalchallengetohealthcareprofessionals.Ofall
subpopulations,Hispanicsarethefastestgrowing. [46]Consequently,itisofparamountimportancetoimprovecomprehensionoftherationaleforanduseof
CAMwithintheHispanicpopulation. [46]
AccordingtotheUSCensusBureau,theHispanicpopulationin2002accountedfor13.3%ofthetotalpopulation.Withinthispopulation,respondersreported
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theirheritageororiginasapproximately66%Mexican,14.5%CentralandSouthAmerican,9%PuertoRican,4%Cuban,andtheremaining6.5%fromother
Hispanicorigins. [6]Itisimportanttounderstandthattheterm"Hispanics"encompassesaheterogeneousgroup.Althoughcollectivelycontainedinthis
grouping,eachgrouphasdifferingdialects,foods,andtraditions,aswellasotherfactorspredicatedinpartbycountryoforigin.Considerationiswarrantedfor
personaldifferences,socioeconomicstatus,migrationstatus,subcultures,andlifeexperiences,evenwhencountriesoforiginaresimilar.Whileitisdifficultto
makebroadcharacterizationsregardingCAMuse,language,religion,culturalvalues,andhealthbeliefsareimportantcommonalitiessharedamongthis
population.IncludedasoneimportantcommonalityisthesimilarityofuseofCAM.
AsystematicliteraturesearchwasconductedusingMEDLINE,EMBASE,InternationalPharmaceuticalAbstracts,CumulativeIndexofNursingandAllied
HealthLiterature,andManualAlternativeandNaturalTherapyIndexSystem.SearchtermsincludedHispanic,Latino,Latina,alternativemedicine,
complementaryandalternativemedicine,integrativemedicine,dietarysupplements,folkmedicine,folkremedies,herb,herbalproduct,medicinalplant,
naturalproduct,andnutraceutical.ThesearchwaslimitedtoEnglishonlypublicationsfrom1980toMarch2007.Initialevaluationofcitationstodetermine
inclusionwasbasedonthetitleandabstractofthearticle.StudiesthatassessedorevaluatedtheuseofCAMintheHispanicpopulationwerereviewed.
ArticlesthatassessedcombinationsofHispanicsandnonHispanicswereincluded.Abibliographicsearchwasalsoperformedtoidentifyarticlesthatwerenot
indexedinthetargeteddatabases.
Tobetterunderstandwhyapopulationdemonstratesavastdiversitywithinitself,historicalinfluencesmustbeappreciated.Theuniquehealthandhealing
philosophysharedbytheHispanicpopulationisattributedtoafusionofcultures. [710]AncientnativeindigenesfromCentralandSouthAmericabelievedthat
naturalforcesinthesea,earth,andmoonplayedanimportantroleinanindividual'shealth.Ahealthylifecouldbeachievedonlybydemonstratingrespectfor
thepowerofthesenaturalforces.WiththearrivaloftheSpanishconquistadorsinthe16thcentury,theCatholicreligionandHippocrates'humoraltheoryof
healthwereintroducedintotheNewWorld.Accordingtothistheory,healthwasdependentontheproperdistributionofthebody's4humors:blood,phlegm,
yellowbile,andblackbile,whichareclassifiedbasedontheirphysicalpropertiesashot,cold,moist(wet),ordry. [7,8]Illnesswasattributedtoanimbalanceof
thesehumors,andtreatmentwastargetedtorestorebalance. [7]
Religionandfaithwerealsoconsideredvitaltothemaintenanceofhealthandwellbeing.Spiritualhealing(curanderismo),magic(santera),andsomeherbal
remedieswereintroducedbyAfricanslaves,particularlyinBrazilandtheCaribbean. [711]Thisblendofspiritual,humoral,andherbalhealthconceptswasthe
baseforthedevelopmentofthehot/coldtheoryofhealthanddiseaseandtheHispanicCAMpracticesoftoday.
IntheHispanictheoryofdisease,ailmentsarethoughttodevelopasaresultofanimbalancebetween2humors:hotandcold.Basedonthisprinciple,
specificdiseasesandconditionsareclassifiedashot(caliente)orcold(frio).Consequently,themedications,remedies,andfoodsthatareusedtotreatthem
areassigneddescriptorsaccordingly.Therefore,thetreatmentrecommendedforanyconditionwillusuallyhavetheoppositeclassificationorproperties.For
instance,colddiseasesaretreatedwithhotremedies,whilehotdiseasesaretreatedwithcoolorcoldremedies(). [7,8]
DiseaseClassificationBasedontheHot/ColdTheory[710]

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Hispanicculturalvaluesandtraditionsusedinhealing(categorizedtodayasCAM)havebeenpasseddownthroughgenerations.Conceptsofsickness,health
andhealing,andreligiousfaitharetransmittedandlearnedaspartoftherearingprocess.FormanyHispanics,CAMpracticesarebothapartoftheircultural
rootsandanintegralpartoftheirlives. [9,10]Assuch,manyHispanicswouldagreethatCAMdoesnotmeettheNCCAMestablisheddefinitionof"not
presentlypartofconventionalmedicine." [4]HealthcareprofessionalsattemptingtouncoverCAMuseinHispanicsmustbecautiouswhentryingtoelicitdetails
abouttheirnontraditionalhealingpractices.Itmayalsobeusefultoinitiateadialoguewiththeinfluentialfemaleinthepatient'slifetoobtainthemost
accurateandcompleteinformation.
Family,apredominantculturalfactoramongHispanics,isconsideredasupportiveandhelpfulnetwork.AmongtraditionalHispanicfamilies,womenare
primarilyresponsibleformaintainingthehealthandwellbeingofthefamily,whilemenprovidematerialsupport.Tothisend,providersmustbecognizantthat
CAMknowledge(notablytheuseofherbsandhomeremedies)isusuallyhandeddownfromafemalerelative,suchasmothertodaughter(orfroma
grandmotheroraunt). [9,10,12]
Usually,commonillnessesarefirstmanagedoutsideoftheformalhealthcaresystem,anditisatthediscretionofthecaregiver(oftenthemother)todecide
whenadiseaseisbeyondhercapacitytotreatandrequires"professional"help. [11,12]Thismaynotalwaysimmediatelytranslatetoanindividualwithan
accreditedhealthcarelicense.Familyfriendsorrelativesmayserveasthenextlevelofmedicalsourcesorcaregivers. [912]Asahealthcareprovidermakes
inquiriesintothehistoryoftreatmentforadiagnosis,severallevelsofcaremayneedtobesiftedthroughtoobtainthefulltreatmenthistory.
AsHispanicsbecomeacculturatedwithintheUS,theyparticipateinapluralistichealthcarenetwork,includingconventional(Western)medicineandCAM.
Somechangesoccurasnewinformationisintegrated.Forinstance,firstgenerationHispanicsandnewimmigrantsaremorelikelytoholdtraditionalbeliefs.
Thisgroupmayalsobemorelikelytoencounteraccessproblemsrelatedtolanguagebarriersorinsurancecoverage.Conversely,USbornHispanicsandtheir
moreeducatedcounterpartsaremorelikelytohaveassimilatedpositiveattitudestowardtraditionalmedicine.AlthoughasignificantnumberofHispanicsin
theUSusetheconventionalhealthcaresystem,asubstantialportionutilizeatleastoneCAMmodalityeitheraloneoraspartofconventionaltherapy. [1353]
CAMmodalitiesarefrequentlyusedinsupportofchronicconditionssuchasdiabetes,hypertension,andasthma.Anoverviewof42studiesexamining
HispanicuseofCAMisshownin. [1354]
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SomeofthemostcommonlyreportedherbsusedbyHispanicpatientsmaybedifferentfromthosemostcommonlyusedbynonHispanicpatients(). [1357]
SurveyshavereportedcommonuseofsomeproductsthatmaybeunfamiliartomanynonHispanicsincludingbrookmint,linden,staranise,sapodilla,and
passionflower. [40,47]
CommonHerbalRemediesUsedbyHispanicsintheUSa

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IntheHispanichot/coldtheory,diabetesmellitusisahotdisease. [7]Althoughtheuseofhomeremediesisalwaysencouraged,managementofthiscondition
reliesprimarilyonconventionalmedicalcare.Homeremediesfordiabetesareusuallyadministeredincombinationwithtraditionalmedicine.Nopal(cactus),
aloeverajuice,andbittergourdare3ofthecommonhomeremediesusedthatmaybeunfamiliartohealthcarepractitioners. [21,28,29,34]Theefficacyofthese
therapiesisyettobefullyelucidated.Somepublisheddatasuggestthatnopalandbittergourdmaybehelpfulinreductionofbloodglucoselevels.Nopalmay
exertitseffectduetohighfibercontentorhavesomeinsulinsensitizingproperties,andcomponentsofbittergourdmayhavesomeinsulinlikeproperties. [54
57]

HypertensionisalsoahotillnessaccordingtotheHispanichot/coldtheory. [7]Anger(corajes),fear(susto),nervousness,andthickbloodarethoughttobethe
mostcommoncausesofhypertensioninthisbeliefsystem.Coldremediesareusedtotreatthisconditionincludinglemonjuice,linden(tila)tea,passion
flowertea(pasionara),andsapodilla(zapoteblanco)tea. [13,15,16,24]Minimalinformationisavailableaboutthesafetyorefficacyoftheseproducts,butall
shouldbetreatedaspharmacologicallyactiveagents.
TheuseofCAMinthetreatmentofchildhoodillnessessuchasasthmaisacommonpracticeamongHispanics.Hispanicsclassifyasthmaasacolddisease
thus,remedieswithhotqualitiesareusedtorestorethishumoralimbalance.Homeremedies,suchastraditionalherbalsandmassages,accountforthemost
popularmodalities. [7]Theyareadministeredaszumosorsyrupmixtures.Themostcommonlyusedingredientsarewhaleoil,codliveroil,honey/royaljelly,
aloeverajuice,oregano,onion/garlic,lemon,andcastorandalmondoil. [1618,29,30,32,34]AcommercialsyrupknownasSieteJarabesisoftenusedbyPuerto
Ricanstotreatcough,particularlyinasthmaticpatients. [12,16]SieteJarabesisahoneysyrupthatcontainsamixtureofsweetalmondoil,castoroil,honey,
wildcherry,licorice,andcocillana.
Itisimportantforhealthprofessionalstodemonstrateanopenmindandacceptanceofpatients'interestandpractices. [58]IthasbeenreportedthatHispanics
usuallydonotinformtheirphysicians,pharmacists,orotherhealthcareprovidersabouttheirCAMpractices.Moreover,ifanegativeattitudetowardCAMuse
isperceived,theyareevenlesslikelytodisclosethisinformation.
LackofpractitionerknowledgeaboutpatientCAMpracticescanputpatientsatincreasedriskofCAMdrugorCAMdiseaseinteractions.Thislackof
knowledgemayalsoleadtounnecessarychangesintherapyordiagnostictestsifaCAMdruginteractionisleadingtoachangeintherapeuticeffectorto
adverseeffects.SincesomeCAMpracticesmaynotbebeneficialincertaindiseasestatesormayincreasetheriskoftherapeuticfailure,theuseofthese
alternativetreatmentmodalitiesshouldalwaysbeascertained.Additionally,healthcareprovidersshouldattempttoobtainageneralknowledgeregardingthe
mostcommonCAMpracticesoftheirpatients.
Dependingonapractitioner'sstyleandsetting,thefollowingrecommendationscanbefollowedwhenassessingCAMuseduringpatientinterviews.
1. AlwaysdeliveramessageoftoleranceandrespecttowardCAMuse.
2. AssumeanactiveroleindiscussingherbalremediesandotherCAMmodalitieswithpatients.
3. Learnaboutherbsusedforspecificindicationsincertainpopulationsthroughtheuseofcontinuingeducationcourses,textbooks,flashcards,oronline
databases(eg,NaturalMedicineComprehensiveDatabase,NaturalStandard).
4. Informpatientsaboutthelackofofficialstandardsofqualityamongdietarysupplements,thepossibilityofdruginteractions,andthelackofinformation
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regardingthesafetyandefficacyofsomeCAMmodalities.
5. Emphasizetheimportanceofadherencetoconventionaltherapy.RelianceonhomeremediesandcertainCAMmodalitiesmayleadtoahighrateof
nonadherencetoprescribedregimens.
6. WheneverCAMuseisnotcontraindicated,acknowledgeincorporationofsomecommonCAMremediesintoapatientregimen.Thiscouldhelpto
improveadherencetoconventionaltherapiesandgainpatients'trust.Forinstance,whenencouragingliquidintakeforcoldsandflu,consider
suggestinganaturalteadrinkorsoupwithotherformsofelectrolytereplacementaspartofthetherapeuticregimen.
ThiscollectionofstudiesassessingCAMpracticesinHispanicsresidingintheUSreinforcestheneedforfurtherexploration.Criticallyneededarestudies
ascertainingtheimpactandvalidityofCAMmodalitiesthatinfluencehealthcaredeliveryamongthispopulation.WhileimprovingCAMawarenessmighthelp
integratesomeofthesepracticesintotheconventionalhealthcaresystem,itisalsolikelytoincreasepatients'trustandenhanceadherencetoconventional
Westernmedicine.Healthcareprofessionalsmustcontinuallyeducatethemselvesregardingnotonlygeneral,butalsoculturallyspecificrelatedCAMpractices
oftheirpatientssothatthemosteffectiveculturallysensitivecareisprovided.Understandingcultureanditsimpactonhealthattitudesandbeliefsisakeyto
improvingtheassessmentofCAMuseamongethnicminorities,includingHispanics.

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ReprintAddress
Dr.Clauson,NSUDrugInformationCenter,3970RCABlvd.,Ste.7006A,PalmBeachGardens,FL33410,fax561/6270972,clauson@nova.edu
TheAnnalsofPharmacotherapy.200741(6):9941004.2007HarveyWhitneyBooksCompany

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