A study on the effects of income and education on preference between allopathic and traditional treatment-types and how medical pluralism impacts the allopathic doctor-patient relationships in Oaxaca, Mexico.
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1. ---------------------------------------------------------------------------------------------------------------------
A study on the effects of income and education on preference between allopathic and
traditional treatment-types and how medical pluralism impacts the allopathic doctor-
patient relationships in Oaxaca, Mexico.
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Principal Investigator: Richard Alan Russell
Advisors: Carmen-Garcia Downing, Theodore Downing
Sponsor: University of Arizona, The Honors College
Date Fieldwork: May 20th, 2010 thru July 20th, 2010
Date Presented: February 9th
, 2011
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2. ABSTRACT
This study focuses on the doctor-patient relationship between allopathic doctors and their patients in
the public health sector of Oaxaca, Mexico in context of culturally prominent medical pluralism. Both
allopathic and traditional treatment types that are widely available throughout the city constitute this
medical pluralism. The original purpose of this study was to determine if income and education
influence treatment type preference, but the study expanded to inquire into the doctor-patient
relationship. The techniques used to collect data include a 36-question questionnaire with a comments
section and a structured interview. Ninety-two questionnaire participants supplied usable data and six
healthcare professionals were interviewed.
The data supports the prominence of pluralism in Oaxacan healthcare and reveals no significant
correlation between either income or years of education in relation to preferred treatment type. A
patient’s pluralistic belief and usage of traditional and allopathic medical remedies can be somewhat
problematic for allopathic doctors attempting to most effectively treat a patient’s acute illness due to:
one, the doctors’ lack of information on proper co-prescription—combining allopathic and traditional
medicines—which is further complicated by non-existent scientific literature investigating traditional
remedies and two, the dualism between maintaining a patients faith and hope, while honestly, tactfully
and respectfully sharing the benefits of modern allopathic studies and science. These shortcomings are
exacerbated by time constraints that cause rushed visits, especially in the public healthcare sector, and
together, these hurdles can hinder the allopathic doctor-patient relationship. Based on these
observations, when considering allopathic treatment, re-evaluation of the importance of the doctor-
patient relationship as an educational opportunity for the doctor and patient to share scientific and
traditional-healing information likely will benefit both parties in both short and long -run.
INTRODUCTION
The research population is localized within the city Oaxaca De Juárez and nearby satellite communities.
It’s important to know traditional healing alternatives are widely used throughout Oaxaca and the more
localized research population.1
Likewise, allopathic medical services are also widely utilized. Most
frequently urban citizens receive this allopathic treatment through federally managed and mandated
hospitals. Instituto Mexicano del Seguros Sociales (IMSS) is one of the federal hospitals, and it serves,
free of charge, all citizens of Mexico employed by a business. Instituto de Seguridad y Servicios Sociales
de los Trabajadores del Estado (ISSSTE) is a similar institute, no costs, but for government employees.1,2
Previous research notes common positive and negative perceptions, held by the patients, and
associated with each type of treatment, whether allopathic or traditional8
, and this project’s main goal is
to determine if the variable factors of education and income affect or relate to preference between
treatment types. Specifically, preference of these individuals is measured with implementation of
questionnaires requiring participants to compare effectiveness, utility and price/benefit of both types of
medicine on a scale (1-100). The questionnaire develops mostly quantitative grounds to consider
allopathic and traditional treatment-type preference from the perspective of individuals categorized
based upon education and income, and these grounds are further developed, and complemented, with
3. structured interviews aimed to capture the perspectives (of allopathic doctors) on the current state of
pluralism, specifically concerning their notions of the doctor-patient relationship.
BACKGROUND
The people of Oaxaca remain severely economically challenged compared to the wealthiest of nations
and are calculated to live in one of the poorest states of Mexico.4,18
Although, the poverty is not
absolute and uniform because juxtaposed to the common, affluent individuals do reside in the urban
centers and outskirts. Pueblos are rural satellite communities beyond
these outskirts and constitute a large portion of the population of Oaxaca
(see figure 1). 17
Note that in Valles Centrales, the location of Oaxaca de
Juárez, a greater number of people reside in an urban setting.
A large number of Oaxacan citizens are monolingual, speaking an
indigenous language, and according to the 1993 governmental census,
sixty-eight percent retain Indian heritage.4
Indigenous roots of traditional
thought and practice are also common and they powerfully influence
contemporary culture, even in major rural region.
Traditional medicine is common throughout the world with origins in pre-
colonial Indian, European and African heritages.4
Within Oaxaca traditional
medicine is formally defined “the sum total of the knowledge, skills, and
practices based on the theories, beliefs, and experiences indigenous to
different cultures, whether explicable or not, used in the maintenance of
health as well as in the prevention, diagnosis, improvement or treatment
of physical and mental illness.”3
The terms traditional, allopathic and alternative are not equivalent, and
uniquely, the major practitioners of traditional medicine include shamans, parteras (midwifes) and
curanderos (healers).4,6
Allopathy is any type of medicine involving biomedical, westernized or modern
substance intake (i.e. pill or vaccination). Culturally prevalent health concerns in Oaxaca include
gastrointestinal, spinal, oncologic, infectious, spiritual and mental affliction.5,8
Traditional practitioners
often classify these ailments as a state of “disequilibrium” and unlike allopathy, include spiritual and
mental factors in diagnosis. 7,8
Many Oaxacans prefer a combination of healing ideologies to cure these
states of ailment. This dualistic approach is known as medical pluralism.7,9
Even more so, within the spectrum of medical pluralism, all consultations with allopathic doctors
depend on a healthy doctor-patient relationship.11,15
The doctor-patient relationship’s impact extends to
include actual patient health, prescribed regiment compliance and (indirectly) healthcare costs.11,12
Some studies highlight a single thematic component of this relationship, in which the patient expresses
her own values, increasing her involvement in the treatment process, which concomitantly augments
treatment satisfaction.10,11,16
So, often effective doctor-patient relationships include a doctor
interpreting the psychological, the desires and the explicit requests, in context of each particular
patient’s ailment and values, to pragmatically offer healing options.13
Fig. 1
4. METHODOLOGY
The fieldwork and materials consist of two parts. The first, a questionnaire (see below) completed by
ninety-two participants. The first fifty of these participants were from Hospital General, a facility under
IMSS, located northeast roughly 1.53 miles from the center of the city, Parque Central del Zocalo. The
following forty-two participants were from Parque Llano, a public park .64 mile northeast of this center.
All questionnaire respondents were approached in the same manner. Each participant was read the title
of the project and was briefly explained the premise of the project. If they met the selection criteria (see
below), they were asked to participate. To all participants it was made clear that the questionnaire
responses should only reflect their own thoughts, that any concerns or confusion should be directed to
the PI and that the questionnaire could be read aloud or independently. The gender of all potential
participants that were approached was not considered during selection; however, males did asked their
wives to fill out the questionnaire for them or in place of them periodically. Illiterate (apparent or
stated) persons at IMSS were excluded from questionnaire submission even though they did satisfy all
participation requirements because of the complexity of certain questionnaire questions and time
constraints. This selectivity sped the collection process and also accurately focused the sample
population to represent an urban majority.
Difference in methodology between the two questionnaire locations includes: participant selection
criteria (but not participation requirements) and temporal factors. At IMSS, all individuals were waiting,
not busy. Therefore, selection was based upon ability to communicate and understand Spanish;
consequently, at IMSS persons appearing “elderly” (45+years) were specifically avoided, whereas
participants appearing “younger” (21-45years) were presumed more likely to be able to answer the
questionnaire accurately, with greater comprehension. In contrast, at Parque Llano, the apparent age of
potential participants was not considered, and instead, unoccupied (not engaged in conversation or
playing soccer, for example) persons were selectively approached. Temporal implementation differed in
that each IMSS participant was approached between noon and five post meridiem on weekdays
between June 28th
and July 9th
, 2010. However, each Parque Llano participant submitted their
questionnaire between July 6th
and July 11th
, 2010 between five and ten post meridiem; this includes
weekend and weekdays. With these two differences, little unavoidable bias is introduced.
The complete week following collection at Parque Llano involved interviews, and can be considered the
second part of fieldwork. A total of six doctors were interviewed. One homeopath (originally a
allopathic practitioner) and five allopathic, federally employed doctors. The structured interviews (see
below) contained two areas of concern: personal thoughts on traditional/allopathic medicine and
pluralism’s bearing on the doctor-patient relationship. Three (of five) allopathic doctors were
interviewed simultaneously in conversational manner, allowing each doctor to both respond to the
original question and other responses. All interviews were structured, but dynamic; the PI responded to
the provided answers, probing in-depth for clarification or details.
The data collected in each part of fieldwork was recorded differently. The questionnaires were stored
both as hard copies and digitally within an encrypted database; whereas, the interviews were recorded
on a digital recorder, formatted mpeg. Finally a minor note, ample preparation by the PI included:
5. cultural acclimation; extensive Spanish communication studies spanning a complete month in the
classroom setting of Instituto Cultural de Oaxaca (ICO); professional and personal networking; two days
shadowing allopathic doctors from an Anti-SIDA clinic and a major ISSSTE hospital; and review of
fieldwork materials by multiple ICO, native Oaxacan, instructors.
Questionnaire
11. A
The averaged scale-measured calculation derives from the three value-types measure: útil, eficaz and valiosa. All
of these averages are derived from all three value-types, two or just one (dependant on the participant’s choice to
respond or not).
B
Pair-wise, meaning the participant also responded to the scale-measured value-type set as described, whether
útil, eficaz, valiosa, or averaged scale-measured preference.
C
An effective total is the number of participants, partitioned from the original 92, that provided sufficient data by
responding to the involved questionnaire questions (Qn). For example, all participants not answering Q30 or at
least one question of Q18, Q20 and Q23 are excluded from all effective totals in the first two data tables because
respectively Q30 measured the participant’s years of education and Q18, Q20 and Q23 all measured the
participant’s daily income (pesos).
Interview Data
The interviews each contain details and idiosyncratic tonal regard best summarized into main ideas,
which for the most part are shared by each of the interviewees and focus on:
The cultural definition of traditional/allopathic medicine.
o The major difference resides within the origin of traditional medicine, how its historic
prominence within the culture makes it almost an automatic aid to treat any primary
symptoms. This can lead to poor prevention of serious diseases, and the doctors
clarified that this historical prominence and its effects are best exemplified when
parents or grandparents repeatedly treat their children with traditional treatments. The
influence of immediate family is so strong, one of the doctors I interviewed saw his
father suffer with additional epileptic seizers because his mother encouraged him to
stop taking his prescribed allopathic pills, replaced by a simple tea composed mostly of
lemon and water.
Superior nature of experimentally tested medicine.
o All of the doctors I interviewed believed that when responsible for the life of a patient
and when scientific data or experimentation supports the use of a particular
medicine/practice, that the rigorously tested treatment-type is preferred over a
treatment-type without records, and that traditional medicine lacks this type of rigorous
testing.
Elements of patient faith.
o A patient that truly believes in traditional medicine has faith in these practices. The
example provided by one interview is a man that trips and falls, injuring himself. The
man might visit a doctor and be prescribed powerful pain medicine and a cast; however,
might not feel comfortable that the injury has been resolved until he travels back to the
place he tripped to pour out mezcal on the ground. This ritual is a part of a complete
treatment for the man, and his perceived condition is not fixed until it is complete.
Effective ways of handling conflictive pluralism.
o Tactful honesty with the patient will always be best. If a patient with cancer, left
untreated it will metastasize, asks the allopathic doctor about an herb tea to cure the
cancer, then the doctor must tell the patient what information she has about cancer and
what she knows about the tea. In cases like this, the doctor must decide how strong to
condemn the usage of traditional medicine.
12. Effects of endemic low education, specifically related to preventative measures actively sought
by the patient.
o Many people prefer to use traditional medicine until symptoms worsen, until necessary
to use allopathic medicine or visit the hospital.
The harmonious nature that can pervade a doctor-patient relationship with pluralistic co-
prescription and understanding of the patient’s culture and beliefs/faith in this culture.
o The only concern mentioned regarding co-prescription is the continued belief, if not
strengthening of trust, in traditional medicine or allopathic medicine when only one
medicine actual effectively treats the ailment because the treatment effects cannot be
attributed with certainty to either medicine. This can lead to inflated faith in less
effective treatment; the ensuing damage can expand to include large groups of people
or entire communities because of misdirected treatment-praise shared with others.
DISCUSSION
Unique benefits of the questionnaire include “historical” and hypothetical question types, a comments
section and integration of checks/averages. The advantage of factual and hypothetical questions is the
distinction between actual behavior versus insight into participant consideration or thought, reflection.
The most striking example, the ratio of participants that prefer traditional or allopathic treatments more
but visit allopathic or traditional practitioners (equally) or more often to participants who consult their
preferred type of doctor more often (Table 5, Q3, Q10, Q11). This question directly compares
participant thoughts to their “historical” actions. The comment option expanded the possible
information to glean from each participant’s response and some of the most insightful comments
include clarification on why some questions were left blank and how the cultural concept of both spirit
and body apply to preference. The similar, repeat-questions of the questionnaire allowed for averaging
and more accuracy of effective data. The integrated checks confirm data; for example, if a person
indicates that a final level of education was primaria, the reported number of years of education should
be no greater than 7 years, which includes an additional year of leeway, based upon public schooling
tiers. These facets increased the investigation-value of the questionnaire data.
The questionnaire spans numerous topics of interest and measures income, preference and level of
education. The application of the analyzed questionnaire data clearly supports the statement: Pluralism
in the city of Oaxaca (Table 5, Q4, Q5) is not composed solely of static preference (Table 5, Q12), and
considering that many patients do not receive their most preferable treatment-type (Table 5, Q10, Q11,
Q3) and that the population feels more scientific information (Table 5, Q36) and/or income (Table 5,
Q24) can affect preference, then, to improve the healthcare, an increase in the doctor-patient science-
based information exchange and decrease cost of treatment would help. The first note regarding this
statement is that further investigation is necessary to better understand what these induced preference
changes might be; particularly, would the preference of an individual with increased income favor
traditional or allopathic treatment-type. Regardless, it can be assumed any person with more knowledge
(correct information) and financial freedom will select the most improved treatment-type, which no
matter what equates to better healthcare, at least from the perspective of the individual. Secondly, this
13. statement does not conflict with other project data, graphically demonstrating little correlation between
treatment-type preference and education and income level (graph 1 and 2). Based upon interview
extrapolation, during which nearly all doctors (also) agreed that increased education would alter patient
preferences (specifically toward preventative medicine and to a lesser, biased degree, allopathic
treatment), one main subtly explains why the graphs merely appear to be discrepant. The subtly:
interviewed doctors consider the factor of time and possible trends dependent on time, which includes
any “cascading” cultural changes; statistically, too, correlation does not determine causality. An
explicative example regarding the first subtly, the same correlation values could be obtained ten years
from now, even if the linear regression lines (in black) shift upward (or downward) on the y-axis; this
shift equals change due to some force, that regardless of the correlation constant, is hypothesized to
possibly be augmented scientific education or income by the very people that would experience the
change. Everything, this statement, all the data and the project in whole only retain investigational
value, though, if the sample population precisely models the stated research population of Oaxaca
without major deviation.
To obtain a more reliable sample population with minimal bias from the research population (see
Introduction) methodological changes were made as necessary. Primarily, the discovery that ~81% of
the possible participants on the premise of IMSS traveled from pueblos, required the PI include another
questionnaire location with more urban participants, the Parque Llano participants. Another population
detail accounted for, the correlation between socioeconomic disadvantage and site of questionnaire
collection; the first fifty surveys from IMSS represented participants with a lower spectrum of reported
daily income. Thus, collection at Parque Llano offered an alternative pool to randomly (as possible)
select from to add to the (should be primarily urbanite) sample population. Even with these
acknowledgements and improvements, the sample population in future studies will be predefined based
upon contemporary census data from the federal government. This will have immense effects on the
veracity of the results and applicability of the investigation, and it is worthwhile to compare these
investigation results to this census data. Overall, the challenges of this project reduce the accuracy and
precision of data, but do not render the results insignificant.
Specifically, some challenges include: unexpected language barriers, mildly frequent low participant
literacy in Spanish and weak questionnaire methods. The language barrier includes (Spanish to English)
translation by a non-native PI and a high number of participants, whom primarily spoke an indigenous
language (in addition to Spanish). However, the interference of Spanish to English translation are nearly
negligible because assistance from several native Spanish and Oaxacan professionals familiar with the
cultural intricacies of healthcare, guided and proofread both the questionnaire and the structured
interview. Also, participation required a level of Spanish literacy enabling comprehension of read or
spoken questionnaire questions. In particular, participants at IMSS required more explanation and
found it more difficult to understand some questionnaire questions. This is attributed to a greater
presence of rural dwelling participants—therefore greater indigenous language usage, lower levels of
Spanish language education—that traveled, often several hours, seeking hospital care for a family
member. In the future, either a translator or more linguistically inclined PI could serve to rectify these
language hindrances.
14. The weak questionnaire questions mainly refers to the scale measurement of preference in Q13,Q14,
and Q15; these questions were too complex. The error was discovered after initiation at IMSS, and was
not corrected mainly because the effects hopefully were controlled for during questionnaire
administration with extensive explanation and breakdown, if necessary. In the future Likert scales and
more straightforward means could be utilized, even if limiting the depth/range of answers.
The positive facets, shortcomings, solutions, and conclusions discussed above comprise the noteworthy
points regarding the questionnaire and general investigation results and procedures.
CONCLUSION
In Oaxacan allopathic treatment, respect of patient value or preference for traditional treatment by the
doctor remains a delicate situation centered on the patient’s wellbeing and faith. Because patients’
assign preference—which is not always in accord with “historical” accounts of treatment-type
received—on the basis of personal ideas, knowledge, experience and values, this component of the
doctor-patient relationship is highly variable and unique to each patient. The degree of
cumbersomeness a pluralistic treatment-type preference introduces to the doctor-patient relationship,
from the perspective of an allopath in Oaxaca, appears to exist only when co-prescription is interfering
with the allopathic treatment of a serious ailment. The interference often imputes to the lack of trust of
the allopathic treatment by the patient or actual unpredicted substance interference, and in both cases
more rigorously confirmed data on the traditional treatment-type would be valuable to the allopath.
Most often though, the patient is permitted to complement the treatment with any desired means and
the pluralistic conflict is minimal provided the patient informs the doctor about all other current
treatments. An extended investigation might attempt to determine whether the costs of pluralism
outweigh the benefits of this belief system for patients and/or allopathic doctors based upon population
health and livelihood, or explore the depth of cross-cultural translation of these current results to a
similar culture consisting of traditional and allopathic treatment-types or more specifically the
contemporary American healthcare system woven extensively with alternative, naturalistic and
allopathic healing methods
Unfortunately, due to the flood of patients receiving situational optimization of aid at IMSS, ISSSTE and
the like, a paternalistic model—the doctor elects the patient’s best interest12
—automatically dominates,
as there is only time to consider the patient’s physical pains and chart data.16
This means that the
element of the doctor-patient relationship that’s always unique to each patient because of personal
values, yet pertinent for the most effective treatment of both individuals in the short-run and the entire
Oaxacan people in the long-run—through generationally-rippling improvement, (potentially) inducible
through medical-health science education—is sacrificed. If so, the importance of increased doctor-
patient interaction, which includes information exchange during increased consultation time between
both patient and doctor of a scientific, culturally-relevant and value-based nature, will allow patients to
draw from their own augmented, updated stocks of knowledge, creating more satisfaction (plus the
medical health corollaries) while concomitantly adding benefit to the Oaxacan people in whole, through
promulgation of new information increasing both the faith in science and its exactitude and the
15. understanding of the beauty and nature of tradition and traditional techniques, and equally through,
bettering of lives by fostering a long life of health.
Currently, medical pluralism is undeniable within Oaxaca. The results that 46 of 82 patients are
receiving medical treatment-types they do not prefer most (Table 5, Q11, Q12, Q3) and that 78 percent
of participants believe more scientific information can change their preference (Table 5, Q36), both
conflated with findings from studies on patient satisfaction and values and from this investigation’s
clarified understanding of the culturally specific doctor-patient relationship, support the cruciality of
instructional interaction in every allopathic consultation. Whether faith in traditional treatment-type is
condemned or condoned by the allopathic doctors of Oaxaca, will largely affect the culture in the long-
run and the doctor-patient relationship in the short-run. Currently this faith appears to be handled with
an honest explanation of the allopathic doctor’s extent of knowledge. This should include sharing with
the patient how more modern scientific, allopathic treatment originates and the reliability of results
based upon extensive research that form the basis of allopathic treatment.
These study results warrant further investigation for two reasons. One, there is room for major
methodological improvement on sample population definition and on faulty or incomplete
questionnaire questions. Two, the opportunity exists to greatly improve the understanding of the
effects of medical pluralism and patient treatment-type preference, respecting the doctor-patient
relationship, to ultimately improve the lives and work of both patient and doctor.
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16. Shadowing two doctors, one at IMSSTE and another at a SIDA clinic in Mexico.
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