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Abstract

Hispanic Americans are the fastest growing minority group in the United States. They face a distinct set of health challenges, resulting in persistent health disparities. Chronic disease self-management programs hold promise in addressing individual-level, behavioral risks factors, such as dietary habits and physical activity patterns. In light of the unique barriers Hispanic men face, including low participation in evidence-based health intervention research, this article argues for a gendered perspective when approaching Hispanic men’s physical and mental health needs. Through the analysis of data collected from male-only focus groups (N = 3, n = 15) with Hispanic Americans in west central Florida, this study identified that masculine identity is influenced by chronic disease and comorbid depression status. Diagnosis with a chronic disease and/or depression is accompanied by lifestyle adaptations, activity restrictions, and changes in income and health care demands that can undermine traditional notions of Hispanic masculinity. Consequently, masculine identity is associated with self-management strategies in complex ways. Public health interventions aimed at addressing comorbid chronic disease and depression among Hispanic men must take into consideration the role of gender identity and relevant conceptualizations of masculinity in order to better serve this underserved and understudied population.

Keywords

Hispanic American men men’s health mental health chronic disease self-management masculinity

Introduction

The Hispanic American population is the fastest growing minority group in the United States. According to the most recent U.S. Census data, Hispanics accounted for 16% of the U.S. population (50.5 million people) in 2010, up from 13% (35.3 million people) in 2000 (U.S. Census Bureau, 2010). As research on health disparities and inequalities grows (Centers for Disease Control and Prevention [CDC], 2010), it has become apparent that Hispanic Americans face a distinct set of health challenges, including disproportionately higher health risks, decreased access to health services, reduced likelihood of receiving needed health care, and lower quality of care as compared to non-Hispanic Whites (Burner, Menchine, Taylor, & Arora, 2013; Caballero, 2005; Elder et al., 2006; Gary, Narayan, Gregg, Beckles, & Saaddine, 2003; Lorig, Ritter, & Gonzalez, 2003; Munoz & Mendelson, 2005). These health needs demand increased research regarding avenues for addressing disparities among Hispanic Americans. Although tackling macro-level issues of access and quality of care may be difficult to achieve, micro-level chronic disease self-management programs (CDSMP) hold promise in addressing individual-level, behavioral risks factors, such as dietary habits and physical activity patterns (Lorig et al., 2003). While research into and application of CDSMPs are gradually expanding among the Hispanic American population, the health needs of Hispanic American men remain poorly understood and underresearched, particularly as a result of low Hispanic male participation in evidence-based health intervention research (Ai, Noël, Appel, Huang, & Hefley, 2013; Larsen, Noble, Murray, & Marcus, 2015; Marquez & McAuley, 2006). Gender-specific research among Hispanic American men regarding their chronic disease experiences is scant. Relevant studies have identified that Hispanic males face unique barriers distinct from those of their female counterparts, including inflexible work hours, lack of knowledge regarding food preparation, and fatigue and other somatic complaints related to occupational stresses (Burner et al., 2013; Cherrington, Ayala, Scarinci, & Corbie-Smith, 2011).

Given these growing health disparities, the unique barriers Hispanic men face, and their reduced participation in evidence-based interventions, there is a notable need for exploring Hispanic American men’s experiences with chronic illness and comorbid depression to better understand the effect of these health factors on their daily lives. This article examines issues identified during focus group interviews with Hispanic men regarding experiences of comorbid chronic disease and depression, including lifestyle changes, financial stressors, and employment restrictions. These changes were associated with renegotiating concepts of masculinity and reconceptualizing individual, Hispanic male identity, shedding light on important and distinctive issues that must be addressed to meet the growing health needs of Hispanic American men with comorbid chronic disease and depression.

Background

Examining causes of mortality among Hispanic Americans highlights the significant burden of chronic disease among this population, with chronic conditions accounting for four of the five leading causes of death, including cancer (No. 1), heart disease (No. 2), stroke (No. 4), and diabetes (No. 5; Kochanek, Xu, Murphy, Minino, & Hsiang-Ching, 2011). Hispanic Americans face high rates of chronic disease risk factors, including obesity, hypertension, and high blood pressure, all of which are associated with increased risks for heart/cardiovascular disease (CVD), diabetes, and stroke (Flegal, Carroll, Ogden, & Curtin, 2010; Medina, Balcázar, Hollen, Nkhoma, & Mas, 2007). The age-/sex-adjusted prevalence of diagnosed diabetes among Hispanic Americans is almost twice as high as non-Hispanic Whites (12.1% vs. 7.1%; Schiller, Ward, Freeman, & Peregoy, 2013). Among Hispanics, differences also exist between males and females, with higher rates of diabetes reported among men in each subpopulation (i.e., Puerto Rican, Cuban), with the exception of the Mexican population (CDC, 2014). High rate of diabetes also further exacerbates Hispanic Americans’ risks for heart disease and stroke (CDC, 2011).

Compounding these physical health challenges is the common co-occurrence of depression alongside chronic diseases such as CVD and diabetes, with rates of comorbid depression ranging from 10% to 30% (de Jonge et al., 2007; Lester & Howe, 2008; Mallik et al., 2006; Robinson & Krishnan, 2002). The stress of coping with a chronic disease can lead to related depression, resulting in emotional and psychosocial difficulties that may diminish self-efficacy and disrupt disease management routines, developing a cyclical relationship between poor physical and mental health (Moussavi et al., 2007). For example, Fisher et al. (2004) identified an inverse relationship between depression and disease management and lower perceived self-efficacy among men with type 2 diabetes.

Research has identified that gender is differentially associated with medical management behaviors (Jack, 2004), demonstrating the importance of a gender-specific examination of men’s needs when coping with comorbid depression and chronic disease. Much of the literature examining men’s experiences with chronic diseases such as diabetes and cancer focus on men’s physical and psychosexual health needs (Jack, 2005; O’Brien et al., 2010; Penson & Wessells, 2004; Plaud et al., 1996), but less literature is available evaluating men’s informational and support-related needs, particularly among Hispanic Americans. Thus, understanding masculinity and the role of male self-identity as factors in Hispanic men’s experiences of comorbid depression and chronic disease is crucial to understanding their specific psychosocial and physical health needs. This article explores the results of focus groups with Hispanic men who have comorbid chronic disease and depression to better understand their lived realities in an effort to specifically target their distinct needs.

Method

Project Background

This study focused on Hispanic Americans living with both a chronic illness and minor depression in Hillsborough County, where Hispanic Americans account for over one quarter of the population (U.S. Census Bureau, 2014). Despite constituting a significant portion of the population, Hispanics in Hillsborough County face persistent linguistic and cultural barriers to accessing health care as well as lacking access to comprehensive and specialized health services. Thus, eligibility for participation in this study’s focus groups was based on the presence of depressive symptoms, as measured by the Patient Health Questionnaire–2-item screener (Diez-Quevedo, Rangil, Sanchez-Planell, Kroenke, & Spitzer, 2001), and self-reported CVD, diabetes, or hypertension. To be eligible participants also had to self-identify as Hispanic/Latino. Access to this population was established through university–community partnership and the establishment of a community advisory board that oversaw all phases of research. Community partners lead the recruitment efforts. Individuals were recruited through activities at partnering organizations and local community events. Due to the sensitive nature of focus group discussion, groups were divided by gender. This article focuses specifically on the male focus groups.

Focus Groups

As a part of a broader investigation on comorbid chronic disease and depression, conducted between April 2009 and December 2013, three exploratory, male-only focus groups were conducted with a total of 15 male participants to better understand Hispanic American men’s experiences of living with a chronic disease and depression. Focus groups were conducted to develop a better understanding of the needs of Hispanic Americans with comorbid chronic disease and depression as well as the barriers and facilitators to CDSMP participation. Focus group interviews provide insight into behavior and decision making by creating an open and permissive environment. Such an environment allows participants to share their own stories and experiences that may spark the memory of other participants and encourage them to do the same, allowing for an examination of a range of personal realities (Krueger & Casey, 2015). In accordance with recommendations by Krueger and Casey (2015), three groups were conducted to allow for cross-group comparison to ensure the relevance of themes, and no more than six men participated in each group to optimize participants’ opportunities to share their insights and experiences in depth.

Focus groups were conducted in Spanish by a trained, male moderator guided by a semistructured guide focused on issues of self-management, sources of support, participants’ perceptions of and reactions to diagnosis, and the effect of chronic disease and depression on the participants and their families. The focus group guide was designed in English and translated by a professional translation company to Spanish. Then a bilingual, bicultural research team reviewed and back-translated the guide to ensure fidelity before piloting the guide, after which the guide was further revised prior to the commencement of data collection. Prior to beginning data collection, this research was approved by the institutional review board at a large metropolitan university in Florida (No. 107512). Additionally, informed consent was obtained from each participant, and to maintain strict confidentiality, all data were de-identified and analyzed in aggregate.

Analysis

All focus groups were audio-recorded then transcribed by a professional transcription agency. All transcripts were organized and systematically coded in Spanish by a bilingual researcher using Atlas.ti 7 qualitative data management software. As this research aimed to explore Hispanic American men’s experiences with comorbid chronic disease and depression, analysis comprised a mix of inductive and deductive coding to frame the results within the focus group guide topics while remaining open to the emergence of novel issues rooted in the data and informed by the principles of grounded theory (Bernard, 2012). Deductive coding was completed according to themes covered in the focus group interview guide while inductive coding, typically used for exploratory research, allowed for understanding to emerge from the data itself, leading to the development of a theoretical framework grounded in the data itself (Bernard, 2012). Prevalent and reoccurring codes were organized into themes for inclusion based on the extent to which various participants discussed them and the specificity with which they were discussed (Krueger & Casey, 2015).

Sample Characteristics

Fifteen men participated in focus group interviews. They ranged in age from 35 to 67 years, with a mean age of 48 (SD = 8.7). All participants reported at least one chronic disease, including CVD (n = 3, 20%), diabetes (n = 9, 60%), and hypertension (n = 9, 60%). Mean length of treatment for CVD was 6.1 years (SD = 5.1), for diabetes 4.2 years (SD = 3.6), and for hypertension 3.9 years (SD = 3.9). The majority participants were married or living with their partner (n = 13, 86.7%). The majority of participants were born outside of the United States (n = 13, 86.7%), in countries such as Mexico (n = 3, 20%), Cuba (n = 3, 20%), and the Dominican Republic (n = 2, 13.3%). Those born outside the United States had lived in the United States for an average of 15.2 years (SD = 13.5), with a range from 1 to 40 years. The majority of participants reported speaking English “not well” (n = 8, 53.3%) or “not at all” (n = 3, 20%).

Most participants had completed high school or had their GED (n = 13, 86.7%) and about half were employed either full-time (n = 4, 26.7%) or part-time (n = 4, 26.7%). The vast majority of participants worked in labor-based employment, such as farm work, construction, and maintenance. The remaining participants were unemployed due to disability (n = 2, 13.3%), unemployed and looking for work (n = 4, 26.7%), and retired (n = 1, 6.7%). Two participants (13.3%) reported an average annual household income below $10,000, and 12 participants reported an average annual household income between $10,000 $39,000. Two thirds of participants (n = 10, 66.7%) reported no health insurance coverage whatsoever. Moreover, only one third of participants reported discussing feelings of depression with their health care provider, and 80% (n = 12) reported no access to a mental health provider (see Table 1).

Table 1.

Focus Group Demographics (n = 15).

Characteristic	M	SD
Age, years	48	8.7
	N	%
Chronic disease
Cardiovascular disease	3	20.0
Diabetes	9	60.0
Hypertension	9	60.0
Marital status
Married/living with partner	13	86.7
Single, never married	1	6.7
Separated/divorced	1	6.7
Country of origin
Mexico	3	20.0
Cuba	3	20.0
Dominican Republic	2	13.3
United States	2	13.3
Other	5	33.3
Length of time in the United States (years)
<5	4	26.7
5-15	3	20.0
>15	6	40.0
U.S.-born	2	13.3
English-speaking ability
Well	4	26.7
Not well	8	53.3
Not at all	3	20.0
Education
Less than high school	2	13.3
High school graduate/GED	7	46.7
Vocational or some college	3	20.0
Graduate school/professional	3	20.0
Current employment status
Full-time	4	26.7
Part-time	4	26.7
Retired	1	6.7
Unemployed, looking	4	26.7
Unemployed, disability/illness	2	13.3
Income, $
<10,000	2	13.3
10,000-39,000	12	80.0
Unknown	1	6.7
Health insurance coverage
No	10	66.7
Yes	5	33.3
Access to mental health provider
No	12	80.0
Yes	3	20.0

Results

This article examines the major themes identified through focus group interviews (n = 3) with Hispanic men (n = 15) who have comorbid chronic illness and minor depression in west central Florida. Participants shared a variety of challenges, including lifestyle changes, struggles with physical and mental health, and work and financial stressors. Across all of these domains, a major theme emerged from the data demonstrating that a significant identity shift is involved with learning to live with comorbid chronic disease and depression. This section will examine each of these domains independently, followed by a discussion of their association with Hispanic American men’s masculine identity and how this shift influences their physical and mental health.

“A Daily Battle”: Lifestyle Changes and the Cycle of Physical and Mental Health

A major theme among focus group participants was the long-term, lifestyle changes associated with chronic disease and/or depression. Among these sentiments, participating men described chronic diseases as “incurable,” “lifelong,” and “a daily battle” and explicitly distinguished them from acute conditions. One participant noted, “With the problems we have, they’re not just about health . . . they are problems of daily life,” demonstrating how his condition affects not only his health but his everyday life as well. Another participant emphasized the compounded struggle of chronic disease and depression, describing his experience as “a daily battle . . . two battles. One must fight against depression and fight with the disease you have.” Clearly, participants found that struggles with physical and mental health were interrelated and that poor outcomes in one area were associated with persistent struggles in the other. Demonstrating this cycle, one man explained,

Well, I would say that depression is a state of mind that can lead to unfortunate consequences because the person loses focus of what should be: positivism, reality, seeing the adverse situation that presents itself, and falls into a state that often results in, let’s say, “side diseases” [comorbid depression and chronic disease].

In addition to struggling with symptoms of chronic disease and depression, participants often discussed that they were concerned about their long-term nature—the notion of potentially living with their illness and depression indefinitely. Alongside these concerns were associated lifestyle and behavioral changes, including modifying dietary habits, abstaining from alcohol consumption and cigarette smoking, taking daily prescription medications, and work-related restrictions. Many of these changes were novel to participants, such as the need to adjust their dietary habits. Men often noted that their foods now lacked flavor and their portion sizes were smaller. Participating men reported that these changes were difficult to adjust to, and that resisting temptations and indulgences was especially hard when they were already “feeling down” and struggling with depression. One man shared,

The only form of control I have for my hypertension when I feel bad is to try not to do anything courageous [risky], trying not to eat fatty food, nothing. Before, no, we would go to the store and buy a piece of pork and cook it, some ribs, all of that. Now, I can’t eat any of that because when I eat it . . . that moment, I feel good, but then a little later . . . I start to feel bad. I have to quit it all.

Additionally, men reported having to abstain from alcohol and tobacco and how this negatively impacted their social lives.

The truth is that sometimes you have to drop some friendships. I did with many. I had many friendships, but that was when I drank. But I quit drinking about 12 years ago. Now I don’t drink at all. It ended those friendships.

It is clear that these changes go beyond the individual, intrapersonal level to also affect interpersonal relationships, which can, in turn, affect an individual’s social identity and support system.

Another major change was the introduction of prescription medications and their incorporation into one’s daily routine, which appeared to embody a marked change in identity. For example, one participant shared, “All my life, I never took medicine. Never.” Medications as a new part of daily life were described as a “new dependence” accompanied by side effects that also must be addressed, including fatigue and weakness as well as concerns about liver health. One participant described himself as “addicted to them [his medications],” and another man explained, “Some medicines help me with one thing and put me at risk for another.” The introduction of daily medications appeared to be concerning to participants, as a result of potential side effects as well as the idea of dependence on them, making them a new source of stress and worry. As one man shared, “He [the doctor] told me that if I don’t take my medicine, something could happen to me. So now I am taking my medicine for real because it worries me.”

Participants also discussed the affordability and added costs of daily medications and medical supplies (i.e., diabetes testing strips, etc.), which were particularly challenging for those who were already on tight budgets as well as those who had to adjust to new restrictions on their physical activity, which primarily affected their employment options, work hours, and ability to maintain more physically demanding work. A few participants explained that the struggle to find work was further exacerbated by these health challenges, and these difficulties instigated the onset of their depression or exacerbated existing depression, which in turn further aggravated their difficulties in the search for work.

Finally, participants reported that these concerns about the changes to their daily lives and the permanence of them led participants to feel depressed and constantly worried about their health. The demands for maintaining their health were challenging, but participants reported that the possibility of worsening health further exacerbated these difficulties, leading to a persistent cycle of poor physical and mental health, especially as depression and negative feelings contributed to noncompliance with disease self-management strategies. As one participant explained, he stopped taking his “chemical medicine” because he thought natural remedies would be better but then returned to his prescription medication when his health began to decline.

I stopped taking it for about a month, then that’s when I think my sugar went up. Now that I have spent two weeks taking medicine, and I am feeling better, but I changed all that, not to take medicine.

As this participant makes clear, he was willing to risk feeling ill and worsening health in order to avoid his prescription medications, demonstrating the negotiations participants make in finding a balance between various health and disease self-management strategies.

Financial Stressors and Familial Dynamics: The Demands and Limitations of Comorbid Chronic Disease and Depression

Chronic disease and depression were reported to have negative impacts on employment. Restrictions on physical activity reduced occupational options, forcing some participants to leave their current jobs and making it harder to find jobs in already difficult job markets. For example, one participant shared, “I worked in construction. I worked in workshops. I worked as a mechanic. Now I can’t do any of that anymore. And then comes the depression. How could I not? I had always been very active [before my illness].” As this quote demonstrates, the significance of financial demands emerged as a major stressor among participants, and occupational changes were reported as instigating and/or exacerbating poor mental health, particularly depression, which participants reported manifested as anxiety, the inability to sleep, the desire to isolate oneself, and feeling useless and like a failure. One man stated plainly, “Without work, you have nothing.” Participating men placed notable significance on their ability to work and contribute to the household economy.

Participants also discussed how the health-related difficulty in obtaining and maintaining work was further intensified by experiences of discrimination and stereotyping of Hispanic Americans in the United States. For example, during a focus group with all non-U.S. born men, one participant shared,

We need to fix migration because we arrive looking for work, and they see us as thugs, they see us as thieves, they see us as incapable, useless, because we don’t have a simple piece of paper that says our social security number.

These financial stressors were further exacerbated by the costs of new prescription medications, increased health care visits and related expenses, and the higher costs of foods related to diet change, such as fresh fruits and vegetables. One participant noted of this increased expenses, “All of it is so expensive, too expensive.” Another participant explained the necessity of having enough income in order to maintain their health, “Sometimes they say that money isn’t everything in life, but yea, it is . . . because if you don’t have money, you’ll die.”

Participants also reported feeling guilty for increasing household financial strain as a result of their health condition(s) and/or their reduced ability to work. One man explained these sentiments as such, “One feels incapacitated . . . living shut-in . . . then there are more problems, which affects the problems you already have. You’re the cause of the problems for your family.” Participants reported feeling guilty about the increased costs related to their health care, medications, and dietary changes, as well as feeling frustrated with their reduced ability to support the household income, which further contributed to their depression. However, participants also found comfort, support, and understanding among their family members. One participant explained that “something that makes me feel much better is when I can communicate with my family, my siblings that are far from here [out of the country].” Familial and social communication, even without problem resolution, appeared to be important to participants’ coping strategies, with one man clarifying that even though “I have not resolved any problem. . . . I feel like inside me [I am] eased somewhat, as if I’ve freed something that was inside.”

With regard to financial issues, a large source of stress is the shift in occupational opportunities that men with chronic disease may undergo, leading to potentially reduced contributions to the household income and increases in health-related spending. However, while feelings of stress and guilt arise from this increased strain on the household and family members, family also presented themselves as sources of support and catharsis in the face of both mental and physical health struggles.

Chronic Disease and Comorbid Depression: Reconceptualizing the Masculine Self

Challenges discussed by focus group participants lead to the emergence of an overarching theme of shifting self-identity as a result of comorbid chronic disease and depression, while highlighting the struggles associated with such change. This was demonstrated in participants’ repeated references to how they were before and how things had changed since their diagnosis. “I had never been a sick person,” one man shared. Another man explained, “The truth is that I have almost never been to a doctor because I have never been sick. No, I was never sick. . . . I was never a sick person,” and another participant responded, “Me, no, I’m not accustomed to visiting doctors either.”

The financial stressors due to their comorbid chronic disease and depression were also associated with their personal identity. “It’s simple, right? I earned my money and worked honorably and maintained my family.” This participant felt that earning a living to support his family was the honorable thing for a man to do. However, because of work restrictions, many men reported being unable to fulfill their previous role as household provider. Additionally, these financial concerns expanded beyond the local household to include family members abroad, expanding the notion of the male as a provider for the entire family, including extended family members. One participant shared, “I would say it [finances] is very difficult because all of us have our families abroad who are hoping you can help them.”

Recognizing mental health as an additional factor in men’s experiences appeared to be notably related to shifts in self-identity, as some men were resistant to admit their current struggles with depression during the focus groups, even though depressive symptomology as screened by the Patient Health Questionnaire–2-item was a criterion for participation. For example, when asked about his mental health, one man responded, “No, I don’t have depression. Not me.” When asked if he had experienced depression before, he responded, “No, none of that.” However, other men openly discussed their struggles with depression with direct references to their masculine identity.

I lock myself out there [in my room], and I get to cry. Even though I consider myself quite macho, I am not ashamed in front of them [others in the focus group]. I cry because I feel helpless to see that my children need me and I can’t [provide as I did before].

As these quotes demonstrate, men struggling with comorbid depression and chronic disease must also contend with identity issues on both an intrapersonal and an interpersonal level as they try to reconceptualize themselves as someone who is susceptible to illness and may need additional support and assistance, physically, socially, and financially.

Discussion

The results of this research demonstrate that comorbid chronic disease and depression can lead to an assortment of challenges among Hispanic American men, including lifestyle changes, ongoing and cyclical struggles with physical and mental health, and increased work and financial stressors. Similar to other research, this study reported that the cost of medical care and related-financial problems are top concerns among men with regard to their health (Fletcher, Higginbotham, & Dobson, 2002; Sandman, Simantov, & An, 2000). Unlike some research regarding men’s struggles with chronic disease, physical and psychosexual concerns did not arise as primary issues among this study’s participants, indicating that current research must expand beyond these subjects to better address the broad range of topics and concerns of men with comorbid chronic disease and depression, such as lifestyle adjustments, coping strategies, and related identity shifts.

As participants shared, adjusting to the new habits and restrictions of life with a chronic disease, such as dietary changes, tobacco and alcohol cessation, and physical activity limitations, can be difficult, especially when many of these changes imply associated reconceptualizations of one’s own masculine identity. As this research and others report (Charmaz, 1994; Pleck, 1981; Smith, Braunack-Mayer, Wittert, & Warin, 2007), this reconceptualization of one’s masculine identity is linked with the lifelong implications of chronic disease, which men in this study often cited as a concern and a novel concept to which they had to adjust (see Figure 1).

Figure 1.

Diagram of interacting factors.

Participating men’s increased reliance on medications and health care was associated with notable changes in their self-identity and the adoption of the “sick role” (Kleinman, 1988), which includes decreased independence and increased reliance on others for support and help. In the face of learning to accommodate uncertainty, attempts to preserve one’s self in order to retain control and identity through, for example, maintaining prediagnosis work and social life, can be strategies for reconciling emerging identity dilemmas as disease diagnosis can create situations of dependence that may undermine a man’s role within his family and social network (Charmaz, 1994; Gibbs, 2005). As participants shared, their disease diagnosis was followed by increased dependence on family members as well as medical providers for support and assistance in adjusting to lifestyle changes and increased financial stressors. Understanding such shifts in dependency and their association with male identity is imperative to better addressing the needs of men undergoing such transitions.

As this map illustrates, physical health, mental health, and financial struggles interact with men’s self-identity. For example, as men explained, the “daily battle” with chronic disease and depression often affected one’s ability to work, while also increasing financial strain due to increased health care costs, such as prescription medications. In turn, this financial strain was linked with men feeling like “the cause of the problems” rather than the one supporting the family. These shifts in identity fed back into men’s mental health, which in turn can negatively affect their physical health through decreased self-management and, as some men discussed, giving in to temptations and indulging in restricted foods. Relevant literature has reported that depression is significantly correlated with noncompliance to treatment regimens, including medications, dietary changes, and behavioral adjustments (DiMatteo, Lepper, & Croghan, 2000).

Charmaz (1994) also reported that men and women experience different identity dilemmas, further denoting the importance of understanding men’s specific experiences with comorbid chronic disease and depression and their struggles with conceptualizations of masculinity, which are often connected with notions of toughness, independence, and assertiveness (Jack, 2005; Lee & Owens, 2002). This is particularly important among understudied populations like Hispanic males. Looking specifically at Hispanic American conceptualizations of masculinity, relevant literature identifies that Hispanic masculinity is strongly associated with fatherhood, being a provider, contributing to the family income, and self-reliance (Mirandé, 1997; Vigoya, 2001). In the present study, participants referenced these characteristics, with a particular focus on how chronic disease and depression were inversely associated with their ability to financially provide for the family and meet the increased costs of health management. As this research and others report (Jack, 2005), losing control over some of these aspects of life can lead to lowered self-esteem, feelings of guilt, and a decreased sense of masculinity.

However, the concept of masculinity is not demonstrated through a single model but rather embodied in a range of possibilities that can vary along social, cultural, and ethnic groups, demanding a more focused investigation of Hispanic American men’s experiences of the identity shifts that may accompany comorbid chronic disease and depression (Berg & Longhurst, 2003; Gibbs, 2005; Jack, Toston, Jack, & Sims, 2010; Mirandé, 1997). Understanding this process is all the more important as relevant literature demonstrates that masculinity and identity significantly influence men’s health behaviors, such as care-seeking behavior, adherence to medication, and the establishment of new life skills (Courtenay, 2000; Gibbs, 2005; Jack, 2005; Jack et al., 2010). A particular focus on coping and empowerment strategies grounded in a masculinity-centered approach would be useful in redirecting a man’s sense of control, empowering him to manage and control his illness. Such coping and empowerment strategies have been reported to increase engagement in self-management and the long-term maintenance of healthy behaviors (Cockle-Hearne & Faithfull, 2010; Mattila et al., 2010; McCorkle et al., 2011).

Regarding avenues for the delivery of such strategies, some research has identified that health-related support groups could be conflated with notions of weakness, which could function as a barrier to male participation (Gibbs, 2005). Further investigation into Hispanic American men’s experiences of comorbid chronic disease and depression is warranted, particularly in light of the additional challenges that Hispanic men face, including health disparities and barriers to accessing care, in order to identify Hispanic males’ ideal and preferred methods of CDSMP delivery. Evidence-based research interventions must focus on Hispanic men’s distinct needs and barriers to better elucidate their specific physical and mental health needs. Such inquiry can inform the development of interventions that address the specific and nuanced needs of local populations, in an effort to improve medical management, sustain positive health outcomes, and ease the transitions involved in lifestyle adjustments.

The results of this study’s male-centered focus groups were used to inform one such effort in west central Florida. Analysis of these data led to the linguistic and cultural transcreation of the evidence-based intervention Tomando Control de su Salud to include additional modules that addressed community-identified needs. This included added emphasis on goal setting, additional session focusing on sustaining positive program outcomes, and a focus on the patient–family dyad (Corvin et al., 2010). For example, the added emphasis on goal setting was manifested as motivational messages and goals (metas) written by participants during sustaining sessions. Session facilitators guided the development of measurable and feasible goals, which were later mailed back to participants as “cues to action,” which have been reported to support sustained lifestyle changes (Chou & Wister, 2005). Such community-driven adaptation maintains the ability to better address the target population’s needs. As the findings discussed in this article demonstrate, qualitative, community-focused research allows for the identification of previously unanticipated topics and issues for consideration, expanding the scope of research and contributing to further refining the literature on Hispanic American men’s experiences with comorbid chronic disease and depression.

Limitations

Focus groups were chosen to provide insight on the range of men’s behavior and decision making regarding their chronic disease and depressive symptoms. However, a limitation of this study is that focus groups interviews are conducted in groups, which may make it difficult to discuss sensitive topics, such as struggles with mental health. Focus group moderators were aware of this limitation and facilitated participant rapport building through opening, “warm-up” questions and the establishment of an opening and permissive environment, which is a fundamental component of focus group interviewing (Krueger & Casey, 2015). Another limitation of this study is that the focus group interviews were aimed at understanding the barriers and facilitators to participation in a CDSMP. While a grounded theory approach to data analysis led to the emergence of a theme of masculine identity as an important factor in participating men’s experiences of chronic disease and depression, the focus groups did not probe for an explicit examination of masculinity, culture, and disease management. Thus, rather than using a metanarrative of Hispanic masculinity as a focal point, this study examined men’s personal experiences of this identity shift. However, as this research demonstrates, further inquiry regarding the relationship between masculine identity, culture, and disease management is merited.

Conclusion

As this article demonstrates, notions of masculinity, including independence, control, and being the family provider, are intimately entwined with physical and mental health in a cyclical pattern that can prove to be difficult to address without clear insight into the dynamics of gender and health. Efforts at developing evidence-based interventions for Hispanics struggling with comorbid chronic disease and depression must be adapted with regard to not only linguistic and cultural accessibility and acceptability but also the gendered nuances of such an experience. These findings are only one step in a multistep process toward addressing the growing health needs and challenging health disparities of Hispanic Americans though the development of effective CDSMPs. While current interventions such as Tomando Control de su Salud have demonstrated positive outcomes for participants, further adaptation with regard to gendered experiences can allow public health efforts to better improve and sustain Hispanic men’s health outcomes, a particularly understudied and underserved population.

Footnotes

Acknowledgements

The study could not have been completed without the hard work of our dedicated community partners, including the Hispanic Services Council, Fundación Familia Sana, the members of our Community Advisory Board, the USF Research Team, and the promotores who assisted with this research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the Centers for Disease Control and Prevention (5R18MN000004-02; Gonzales/Corvin [PI]; 9/30/08-12/31/2012]. The title of the grant was Chronic Illness and Minor Depression: Community and CDSMP. This study represents data from Phase 1 of a three-phase feasibility trial of adapting an evidence-based intervention to meet the needs of Latinos struggling with comorbid chronic illness and minor depression. The funding agency had no role in the design of the study, collection and analysis of the data, or in the writing and dissemination of any publications associated with this work.

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Chronic Disease and Depression Among Hispanic Americans

Abstract

Keywords

Introduction

Background

Method

Project Background

Focus Groups

Analysis

Sample Characteristics

Results

“A Daily Battle”: Lifestyle Changes and the Cycle of Physical and Mental Health

Financial Stressors and Familial Dynamics: The Demands and Limitations of Comorbid Chronic Disease and Depression

Chronic Disease and Comorbid Depression: Reconceptualizing the Masculine Self

Discussion

Limitations

Conclusion

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Funding

References