Year of Publication

2014

College

Public Health

Degree Name

Master of Public Health (M.P.H.)

Committee Chair

Katherine Eddens, MPH, PhD

Committee Member

Robin Vanderpool, DrPH, CHES

Committee Member

Mark Swanson, PhD

Abstract

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer death in the United States (U.S).1 Although early detection and treatment can reduce CRC-related morbidity and mortality, almost twothirds of patients are diagnosed with advanced stage disease indicating non-adherence to recommended screening guidelines.1 Indeed, less than half of individuals over 50 years of age get screened at recommended intervals.2 More specifically, lower rates of CRC screening exist among these groups: those identifying as being of Hispanic origin, the uninsured, disabled individuals, and women.3 In a 2011 report from the National Center on Health Statistics capturing the impact of socioeconomic status (SES) on the health of the nation, only 47% of Hispanic or Latino respondents reported any colorectal cancer screening procedure (2010) compared to 59% of all adults, ages 50 – 75 years, regardless of race.3 Evidence suggests that screening for CRC can reduce CRC mortality rates.5 The malignant form of CRC develops from a benign polyp that can be detected through screening methods.5 The primary screening methods for CRC include the fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy and the recommended screening intervals for each include one year, five years, and ten years, respectively.6 Despite strong evidence supporting the benefits of CRC screening and resulting reduction in mortality, low rates of screening among at-risk individuals will result in a projected 50,830 deaths from the disease this year.7 With such an enormous burden caused by a potentially preventable disease, the U.S Department of Health and Human Services (DHHS) has established goals and objectives to increase CRC screening via its Healthy People 2020 initiative. From 2008 2 to 2010, DHHS reported an increase in CRC screenings from 52.1 to 59.1 percent. By 2020, DHHS aims to increase screening to a rate of 70.5 percent.4 To improve CRC screening rates, especially among populations where screening rates are lower, we need to increase our understanding of what factors influence screening among these populations.5 DHHS noted that the burden of CRC disease is distributed unequally among poor and ethnic and racial minorities because of multiple factors, including language or cultural differences with healthcare providers.2 This language barrier, known as limited English proficiency (LEP), has been documented in the literature as a barrier to CRC screening among differing subgroups of Spanishspeaking Latinos.8 For example, in a study analyzing data from the Medical Expenditure Panel Survey (MEPS) aimed at understanding patient-provider communication and language barriers influencing CRC screening, non-English speaking patients experienced less than half the likelihood of being screened for CRC than did the English-speaking patients.9 In a cross-sectional study analyzing the factors associated with CRC screening disparities observed between Whites and Hispanic national origin subgroups, authors note that the variations in health behaviors may be as great among individuals within major racial/ethnic groups.10 Therefore, analyzing cultural barriers within a specific ethnic group could help us understand how to reduce those barriers. Specifically, understanding cultural barriers could result in the creation of personally-tailored interventions.10 In a systematic literature review highlighting interventions published from 1950 to September of 2010 aimed at the improvement of CRC-related care among racial and ethnic minorities, researchers found that interventions involving patient 3 education by phone or in-person contact, combined with patient navigation, leads to improvements in CRC screening rates among minority populations.11 Furthermore, promotoras, or trusted members of Hispanic communities vested in the promotion of health, have been used to improve the health of Hispanic populations since the 1960’s.12 Acting as a bridge between the health care system and members of Hispanic communities in the U.S, promotoras have led many public health interventions.12,13 For example, in a recent quasi-experimental study evaluating a promotora-led intervention on CRC-related perceptions and communications among Hispanics in the Lower Yakima Valley of Washington State, researchers found a significant increase in the percentage of participants who asked their doctors for a CRC screening test after promotora-led intervention at follow-up.12 One cultural element observed as having a negative influence on CRC screening among Mexican males is Machismo.14 Evolving during the 19th century after Latin American countries asserted their independence from prior Spanish rule, Machismo was initially formed as a concept that defined male dominance over women and can be described as the “attitudes and identities associated with masculinity” seen among Hispanic men.14,15 This cultural factor is still prevalent among Hispanic males today and has been documented as a particular barrier to seeking preventative health care measures. Recently, a qualitative study investigated the influence of Machismo on CRC screening rates among two different subgroups of Hispanic men: first-generation Mexicans and Hispanos residing in New Mexico.14 Individuals identifying as being Hispano in this study trace their ancestry back to 16th century Spanish colonists who arrived in New Mexico and consider themselves “pure blooded” Spanish conquistadors.14 This 4 qualitative study found Machismo to be an inhibiting factor only for Mexican men.14 Mexican men felt that getting a colonoscopy was “embarrassing”, and Machismo, rather than a concrete personality trait, was found to be a trait exhibited during particular situations in Mexican men.14 The evolution of Machismo has had a contrasting effect on the cultural identities of Hispanic women, in some instances leading them to develop a submissive and inferior identity to their male counterparts.15 This cultural characteristic exhibited among some Latin women is termed Marianismo. Less well-known than Machismo, Marianismo is a term used to imply the “idealized view of femininity based on the image of Mary, the Virgin Mother”.15,16 Women that exhibit the Marianismo characteristic pride themselves on being a good wife and mother and remain “respectful and dependent” on their husband.17 This ideology of gender roles has resulted in the belief that “women are the weaker sex” among Latin men and women in countries where Machismo and Mariansmo are prominent.15 In middle-class Latin America, women exhibiting Marianismo are exclusively identified with the home, tied to the domestic responsibilities and are discouraged from working outside the home.18 This aspect of Marianismo may cause women that exhibit these characteristics to be economically and socially vulnerable.18Although research has been conducted and evaluated on Machismo as a barrier to CRC screening for Hispanic men, Marianismo and its effect on Hispanic women to seek CRC screening has not yet been evaluated. As Hispanic women have migrated to the U.S and have acculturated to the U.S environment, many of these women may still face cultural oppression by continuing “to adhere to their traditional patriarchal culture.”15 One result of this adherence to culture may be that many Hispanic women still 5 remain in the household as a homemaker, and in result may feel that because they are not bringing home an income, seeking primary health care services is not their choice. This situation may keep them a “vulnerable and disenfranchised population” in terms of healthcare.15 Studies have been conducted to understand the implications of Machismo exhibited among Hispanic men surrounding topics such as breast cancer survivorship and HIV prevention.17,19 For example, in a mixed-methods design study investigating the perspectives of a group of low-income Chilean women regarding HIV, Machismo and Marianismo were found to be major barriers to HIV prevention.17 Socio-cultural aspects of Machismo and Marianismo include the inability of women to make personal decisions; this study resulted in these aspects impacting low-income Chilean women to seek HIV preventative actions.17 In a qualitative cross-sectional study investigating the cultural, social, and healthcare system factors that impact quality of life and survivorship of a group of immigrant Latina breast cancer survivors in the metropolitan District of Columbia, researchers found that many women with male partners exhibiting Mashismo noted “their male partners had difficulty demonstrating support and coping with the emotional aspects of having a spouse with a cancer diagnosis”.19 Being that there has been little research investigating the role of Marianismo on preventative health screening behaviors among Hispanic women, this study seeks to understand whether Marianismo influences the CRC screening behaviors of Hispanic women ages 50 and older in the U.S.15 Specifically, data from the 2012 Behavioral Risk Factor Surveillance Survey (BRFSS) will be analyzed to compare Hispanic women ages 50 and older exhibiting Marianismo characteristics and Hispanic women ages 50 and older not exhibiting 6 Marianismo characteristics. Marianismo characteristics will be distinguished by three reported demographic characteristics: marital status (being married), employment status (being a homemaker), and primary language spoken (Spanish).

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