Faith and Masculinity : A Discussion on Raising Awareness and Promoting Cancer Screening Among Latino Men

Males may experience several barriers to seeking health care, including unfamiliarity with procedures (e.g. colonoscopy), stigma and fear of a given health issue, perceived breach of masculinity (machismo), and fear of feeling vulnerable. Evidence suggests church-based interventions are an effective way to strengthen the connection between promotional message content and participant conceptualization of the risks and benefits of health screenings. However, there is a lack of evidence demonstrating such effectiveness in men’s health, and there is even more of a dearth of research focusing on Latinos. This discussion presents trends from a series of 4 community-based seminars during the 2010-2011 academic year conducted with Latino faith-based groups on men’s health issues. Approximately 70 Latino men attended a series of seminars on health and wellness as it pertains to cancer screening procedures offered after church services. A particular emphasis was placed on perceived masculinity (machismo) and gender roles within the social environment, and how they influence health screenings among men, particularly for colorectal, prostate, and testicular cancer. The seminar series were a first step in laying the foundations for future formal effectiveness testing of faith-based facilities serving as a conduit for health promotion efforts among Latinos. This paper presents lessons learned from this new approach in community health outreach efforts. We advocate that faith-based groups can be an efficient and effective way to raise awareness and promote wellness among Latino men. © 2012 Californian Journal of Health Promotion. All rights reserved.


Introduction
Compared to women, men, in general, have disproportionally higher rates of cancer incidence and mortality (Evans et al., 2005).A number of health risk behaviors are more prevalent among men compared to women, such as smoking, alcohol consumption, and workplace exposures, and contribute to the gender disparity in overall health and wellness (Pinkhasov et al., 2010).Moreover, minority men (e.g.Latinos) are at an even greater disadvantage when it comes to health outcomes (MacNaughton, 2008).
Latinos are the largest minority group in the United States and bear a disproportionate burden of certain causes of mortality, morbidity, and disability in our society (CDC, 2004b;MacNaughton, 2008;Abraído-Lanza et al., 2005;Markides & Eschbach, 2005).Latinos accounted for more average age-adjusted years of potential life lost compared to non-Latino Whites, and were more likely not to seek medical attention (MacNaughton, 2008).Further, morbidity and mortality rates for Latinos have increased (Afable-Munsuz et al., 2009) over the years, as a direct result of receiving minimal to no medical attention or preventive health services for various diseases.This is possibly due to a lack of knowledge/awareness of the given health topic (Afable-Munsuz et al., 2009), cultural and language differences between patient and providers (CDC, 2004a), and economic barriers (Zsembik & Fennell, 2005).

Informed Decision-Making and Active Participation in Cancer Screening among Latinos
Men often ignore learning about health risks (including cancer) and overall wellness for fear of normative judgment (e.g., ridicule), thereby making them less knowledgeable of their options for treatment and screening (Rovito et al., 2011).Duly, there has been a recent shift in cancer research focus.Men's health scholars are now refocusing their efforts from promotion of screenings and treatment to the promotion of patient informed decision-making and active participation regarding health maintenance and disease prevention (Joseph-Williams et al., 2010).
Another barrier to screening is the uncertainty of screening outcomes in regards to false positives and false negatives (Chan et al., 2003a;Chan et al., 2003b;Steadman & Quine, 2004).In fact, the U.S. Preventative Services Task Force (USPSTF) has given both PSAs and testicular self-examination (TSE) a "D" rating as secondary prevention measures due to the above concerns.Nevertheless, men's health scholars and urologists continue to promote these tests as viable methods to assess risk of prostate and testicular cancer, respectively.PSA's and TSE are not the sole criteria that physicians use for risk assessment and diagnosis of the disease.risk from cancer and/or diagnose the disease.Rather, they are used in combination with other factors, such as family history and digital rectal exams (for prostate cancer), to create a risk profile for each patient.Based upon composite results, the physician discusses treatment options with their patients.Among Latinos, rates of active participation in prostate health maintenance among Hispanics is among the lowest in all males (Chan et al., 2003b), thereby putting this population at very high risk for increased mortality.While over nearly 50% of eligible American men have been screened in the past five years (ACS, 2010), only approximately 40% of all Hispanic men have been screened.Felix-Aaron et al. (2005) indicate that Hispanic men were less likely to receive colorectal cancer screening compared to Whites and Blacks.From 1995 through 2004, the number of newly diagnosed cases of colorectal cancer decreased for non-Hispanic Whites while the trend for Hispanics increased (Hao et al., 2009).
The notion of Hispanics being screened less for cancers than other racial/ethnic groups, but at the same time having higher incidence rates for the disease, makes this even more of an alarming public health issue.As a result, a more concentrated effort in developing culturally sensitive campaigns to increase informed decision-making skills among minority populations is currently trending (see Yanek et al., 2001;Hess et al., 2007;Chan et al., 2003b , n.d.).
Given the sensitive nature of the topics of men's health (i.e.DRE, TSE, colonoscopy adherence), researchers and community health professionals need to take into account male-specific variables that could potentially influence behavioral modification efforts in addition to the cultural considerations.
Specifically, perceived masculinity is the recent focus of men's health scholars with an every-growing body of literature suggesting its role in influencing health behaviors among men.

Machismo
For Latinos, machismo is loosely defined as the qualities deemed typical of a man (e.g., perceived masculinity).Pertaining to men's health issues, testicular cancer, prostate cancer, sexual performance, and screening procedures are relatively sensitive topics for which a man may feel his "manhood" threatened if they are openly discussed (Athi & Debney, 2001;Wynd, 2002;Singleton, 2008).Torres et al. (2002) suggests that perceived masculinity may be protective in some regards to healthy lifestyles, but for the most part acknowledges the negative affect it has upon certain subcultures of men and how they perceive societal gender roles.
Relative to masculinity in general, machismo may pose additional barriers to Latino men acknowledging specific health issues and/or opening up and freely discussing such topics with their friends, family, and physicians.Researchers suggest that machismo may be associated with repressing emotions, failing to report symptoms of disease, and suppressing the desire to seek help from others (Nicholas, 2000), while increasing the hypersensitivity of men in feeling 'unmanly' (MacNaughton, 2008;Singleton, 2008;Winterich et al., 2009).
Machismo is suggested to be a major barrier for prostate and colorectal cancer screening, specifically digital rectal exams and colonoscopies, due to the invasive and more intimate and perceived sexual nature of the procedures (Vargas Bustamante et al., 2010).Men reported fear and the stigma associated with rectal exams as being a primary barrier to colorectal screening, as it is perceived to be a breach of their masculinity (Goldman et al., 2009).Therefore, when discussing healthy lifestyles pertaining to said men's health topics, one must take into consideration the influence of perceived masculinity upon Latino behavior.

Faith-Based Health Initiatives
Researchers are calling for new and innovative methods to help raise active participation among patients, especially among Latino groups, due to the possible unique challenges presented by perceived masculinity.However, the question remains: Which method is best?Neff et al. (2005) argues for the existence of a 'spiritual activities, beliefs, and rituals' dimension in the human psyche.A growing body of research indicates that if properly addressed, an individual will be more apt to comply with a given health promotional message if it is coordinated through a faith-based venue or message.DeHaven et al. (2004) indicates that primary prevention measures, as well as general health maintenance, can be improved through faith-based organizational health programs.Daniels et al. (2007) demonstrated the effectiveness of a faith-based intervention to increase adult vaccination compliance, while Margolis et al. (2006) offers evidence that faithbased organizations can serve as a transitional venue for societal reintegration of incarcerated men.Bopp et al. (2011) advocates for an expansion of faith-based health promotion campaigns among Latinos.What is important to note here is that this method of message delivery is relatively new to the men's health arena, and especially in the prevention of prostate and testicular cancer in the Latino population.Therefore, we suggest that if this 'spiritual' dimension is used as a conduit to connect with Latino men on health topics, and researchers utilize faith-based organizations' monthly or weekly where men gather, this 'captive audience' can serve as an ideal opportunity to effectively connect with the audience to institute health behavior changes among participants and address Healthy People 2010/2020 overarching goals.Campbell et al. (2007) suggests that the reason why such venues 'work' is because the men fall within each other's social circles.In other words, as these men share a spiritual connection attending and participating in the same church, said venues could serve as health and wellness centers for these men where they can disclose health or disease experiences among fellow community members, not strangers, thereby increasing comfort levels.Given so, there needs to be more an outreach by community health and wellness organizations to explore the use of such a venue to promote healthy lifestyles.

The Men's Health Initiative's Faith-based Outreach to Latino Males
The Men's Health Initiative (MHI) was founded in June 2010 and is headquartered in Philadelphia, PA.MHI promotes healthy behaviors through three primary approaches: informing men about health and wellness, identifying risks unique to men, and implementing behavioral interventions.MHI sets as its primary goals: (a) to reduce the health disparity between the sexes and (b) promote awareness and action among males.MHI offers men's health information and promotional services regionally and nationally.
One particular focus of MHI is a communitybased, grassroots effort to reach out to the local Latino population to promote men's health issues and bring about a general discussion on healthy lifestyles and overall wellness, including cancer screening awareness and informed decision-making skill development.MHI's Latino outreach efforts center upon faith-based organizations in order to access a captive population and to serve as a message medium, as demonstrated by previous research.This project's goal was to learn lessons from a faithbased message delivery program among Latino adults.
MHI conducted a seminar for parishioners and pastors of Latino faith-based organizations in Philadelphia about health and wellness issues affecting men.Topics on what men's health is, what are some major men's health issues affecting male populations today, what can be done to help increase a healthy lifestyle among men, and the importance of discussion among men with their physician, family, and friends on health and wellness topics (cancer and cancer screenings, in particular) were discussed.
Groups were encouraged to speak freely on what health and wellness meant to them, how they approach illnesses, what family meant to them, the role of being a man in society, and how the role of men contributes to overall healthiness or illness in a family.A professional Spanish translator was present to co-conduct all discussions and lectures in order to assuage any English-language barriers.
A discussion protocol helped steer the flow of communication, but was not binding.We aimed to determine how participant Latino males discussed perceived masculinity/machismo and how they navigate the health care system, how they confront health and illness issues, and how comfortable they feel discussing health and illness with their physicians, family, and friends.Of particular importance was our assessment of how comfortable Latinos were in the faith-based setting and if it fostered a rich discussion.
Approximately 70 adult members of the Philadelphia metropolitan area Latino community participated in MHI's discussion groups.Three Latino parishes served as venues for the discussions with approximately 20 to 25 participants per discussion.Each parish made announcements of the event during weekly service announcements leading up to the seminar.

Roles of Machismo and the Use of Faith-Based Organizations in Health Promotion
The discussion trends of how machismo affects health outcomes and health promotion efforts among the participants were striking.In all three sessions, the overwhelming majority of men hinted, or outright stated, that Latino men are sometimes encouraged to hide their pain, worries, concerns, and questions in order to properly serve their family and friends as the man of the family.Some of the key trends of the three group discussions included: role of men in society, familial obligation, fear of procedures, lack of knowledge, and peer judgment.
In regards to role of men in society, familial obligation, and peer judgment, these concepts represent a deep-rooted Latino cultural value system where men are the public figure of the household and should provide for their family.These discussion points related to the work of Allen et al. (2008), Nicholas (2000), MacNaughton (2008), Singleton (2008), and Winterich et al. (2009), all of who suggest that men's hypersensitivity to serve in traditional gender roles assists in repressing emotions, failing to report symptoms of disease, and suppressing the desire to seek help from others.Further, the work of Torres et al. (2002) is at least partially supported within these discussion groups when they assert that masculinity can negatively influence the actions of men as they attempt to live up to the traditional societal standards of a "man".
In regards to fear of procedures and lack of knowledge, these concepts are not unique to Latino men.A plethora of previous research ranging from testicular self-examination (Rovito et al., 2011) to active participation in prostate health maintenance (Chan et al. 2003b) suggests that a general lack of information or awareness of a given men's health topic contributes to a lack of compliance to health behaviors and the success of health promotion interventions.These discussion points surrounding knowledge and awareness provide more evidence that men are generally uninformed on health topics specific to them.When coupled with any potential sociocultural barrier (i.e.machismo), compliance to, and/or maintenance of, healthy behaviors could be greatly limited.If health promotion interventions are implemented in the Latino male population, researchers must put ample effort towards more effectively and efficiently translating information of the given topic to make comprehension and familiarity of the health behavior or health risk more readily achievable.
The use of faith-based venues was convenient to have such discussions.As many Latino faithbased organizations have men's bible study or discussion groups already established within their parish life, obtaining a 'captive audience' for health and wellness discussions should not be as daunting as researchers might perceive.
Participant men were open and receptive to discuss health issues, even topics known to cause some apprehension, such as digital rectal exams, impotence, and sexual behaviors.Again, we believe they were receptive to discuss said issues due to the social circle familiarity.
The group discussions on the use of faith-based groups as a means to discuss health topics were overwhelmingly positive.Many men acknowledged that this venue was ideal to discuss such issues.They specifically mentioned the convenience and comfort of speaking about these sensitive issues among fellow parishioners and their trusted pastor/priest versus speaking about these topics with some stranger or a group of strangers was something they found to be attractive.The positive participant reactions to using faith-based groups as a venue for health promotion directly supports DeHaven et al. (2004) and Daniels et al.'s (2007) research that demonstrate the positive value in using such a matrix for men's health information exchange.

Limitations
There were some limitations concerning the atmosphere of the discussion group format.Some participants may have been timid to speak in larger group settings, this taking away from a truly collective discussion on men's health issues among Latino men.Further, the sample was a convenience sample of Philadelphia Latino's, which severely limits the findings to be generalizable to larger groups of Latinos.Finally, the English-language barrier may have posed an issue to some of the participant's true understanding of the discussions.Although a professional translator was used, some of the message content may have been lost in the translation process.

Conclusion
It is clear from MHI's Latino men's health community lecture roundtable discussions that there is an overwhelming influence of machismo in Latino society and that sometimes it can negatively impact efforts to promote healthy lifestyles and adhering to health maintenance procedures.The discussions we had with men clearly supported previous research which has documented how Latino men often avoid health maintenance due to perceived familial obligations and loss of face/reputation (MacNaughton, 2008;Chan et al. 2003b).Further, the discussions support the underlying theory of how machismo and the perceived role of Latino men in society can contribute to potential problems with the success of health promotion efforts and health maintenance behaviors among the population (Torres et al.;2002Allen et al., 2008Winterich et al., 2009).Finally, the discussions support the literature of the effectiveness of message delivery within a faith-based organizational setting, as discussed in DeHaven et al. (2004) and Daniels et al. (2007).
We advocate for the inclusion of health promotion campaigns through faith-based organizations among the Latino male population.Concerning the actual practice of health promotion, using faith-based groups as a conduit to speak to Latino men about their health, while also addressing masculinity and gender role issues, appears to be effective in the sense that men are at least willing to discuss these topics openly (i.e. they are a 'captive audience').However, there is a lack of research using Latino faith-based men's groups as a venue for implementing men's health promotional efforts.Considering the disparities in cancer screening seen among Hispanics (Felix-Aaron et al., 2005;Chan et al 2003b), and the willingness for this study's Latino population to be receptive to, and share among peers, cancer screening information and wellness dialogue in faith-based settings, we implore researchers to explore the connection between faith-based venue effectiveness upon receptivity, and subsequent adoption, of cancer screening information among Latinos.
Many Latino men may adhere to the traditional boundaries of gender in society.If so, these issues will continue to serve as a major barrier to the successful promotion of healthy lifestyles among these men.We call upon researchers to explore the efficacy of faith-based organizations in promoting health behaviors among this population and to help address the negative health connotations and outcomes that may result from heightened senses of masculinity.The qualitative lessons learned demonstrated here is sufficient and necessary to lay the foundations for larger, more in-depth analyses on the use of faith-based organizations to promote men's health and wellness issues among Latino male populations.We echo Bopp et al.'s (2011) assertion that using faith-based organizations should be expanded in future health promotion campaigns to increase the effectiveness of message delivery and increase overall behavioral compliance.