Abstract
Much of the research regarding Latino men’s health tends to focus on specific health outcomes (e.g., HIV or diabetes). Few studies have examined how Latino men perceive factors that influence their health and/or health-related behaviors. This study explored rural Latino men’s experiences and attitudes toward health, using photovoice, in the context of a community-based participatory research partnership. We recruited nine Latino men living in a small town in Southeastern Iowa. Four to nine men attended four sessions and led a community forum. All the men were foreign-born, identified as Latino, aged between 34 and 67 years, and had lived in the United States for at least 7 years. Five themes were identified: (a) cultural conflict, (b) too much and discordant information, (c) lifestyles conflict, (d) sacrifice, and (e) family connectedness. An important implication of this study derives from familial and community connections and sacrifice. Feeling disconnected from family may impact physical and mental health and health-promoting behaviors. Future research should explore ways to inform community- and family-level interventions to connect rural Latino men more strongly to their family and local community and help them to take better control of their health.
Latinos are the largest ethnic minority group in the United States. In 2020, Latinos were estimated to represent 18.7% of the U.S. total population (U.S. Census Bureau, 2021). In the past 2 decades, many Latinos have moved to new destination communities, particularly in rural areas of the South and Midwest (Caballero, 2011; Krogstad, 2016; Suro & Singer, 2002). In these communities, rapid demographic changes have contributed to a gap in the development, implementation, and sustainability of culturally and linguistically appropriate health-care services and community-based programs for Latinos (Rhodes & Hergenrather, 2007). This scarcity of resources may worsen the existing disparities in health insurance, access and delivery of health-care services, and quality of care for Latinos (Alarcon et al., 2016, Alcala et al., 2016, Cristancho et al., 2008; López-Cevallos et al., 2014).
According to the National Healthcare Disparities Report (Agency for Health care Research and Quality, 2019) and Department of Health and Human Services (2021), health-care inequalities in morbidity and mortality continue to persist among Latinos, particularly among Latino men who are less likely to seek medical care than Latinas (Schmidt et al., 2011). Rural Latinos have also been reported to be disadvantaged in disease prevalence (Mueller et al., 1999), health insurance coverage (Monnat, 2017), and health-care access (Berdahl et al., 2007), when compared to their urban counterparts. As a group, Latinos suffer disproportionally from diabetes, end-stage renal disease, colorectal cancer, liver disease, and HIV (Boen & Hummer, 2019; Centers for Disease Control and Prevention [CDC], 2015; Diaz et al., 2013; Glasman et al., 2011; Schneiderman et al., 2014). Studies have reported a higher incidence of obesity and hypertension among Latinos (Cowie et al., 2006; Flegal et al., 2010). Despite interventions to address health-care disparities, Latinos, particularly Latino men, continue to face barriers to health-care services, which include lack of health insurance, low income, lack of adequate transportation, and lack of care providers who are bilingual and culturally competent (Carbone et al., 2007; Uebelacker et al., 2012).
Although there has been some evidence supporting the link between masculine identities and norms and health behaviors and consequences, few interventions incorporate masculine identities or norms in the development of interventions to address health disparities (Sobralske, 2006). According to the literature, Latino men strive to be recognized and esteemed as men and are expected to follow certain culturally determined roles, attitudes, and norms to prove their manhood within the family unit and the broader community (Hoga et al., 2001; Sobralske, 2006). In addition, the literature has drifted away from examining masculinity and machismo as a negative set of ideals and attributes and moved toward depicting it as a bidimensional construct with both positive and negative attributes (Arciniega et al., 2008; Neff, 2001). Negative qualities include aggression, antisocial behavior, and poor coping strategies (Arciniega et al., 2008). Positive qualities include nurturing, protecting the family, having integrity, exhibiting a strong work ethic, and providing family support and guidance (Sobralske, 2006). The positive attributes of machismo have been associated with caballerismo, which is a Spanish term that resembles and signifies a courteous, modest, and honorable man (Arciniega et al., 2008). More recent work has positioned the debate over machismo and caballerismo away from a positive–negative dichotomy and toward a continuum that needs to account for regional factors (rural and urban), the evolution of relationship definitions and expectations, and evolution of how individual men define masculinity (Daniel-Ulloa et al., 2019; Falicov, 2010).
Because of the lack of scientific inquiry into Latino men’s health in general, and rural Latino men in particular, there is a need to gather information that will lead to better informed interventions addressing the health and health-care needs of Latino men. For example, in traditional settlement areas (e.g., Chicago or Texas), men would have large social networks to tap into, but these networks are smaller, newer, or nonexistent in new settlement areas (e.g., Siler City, North Carolina, or Storm Lake, Iowa). How does the lack of social networks impact the health and wellbeing of Latino men? Past efforts that have included community organizing and social networking among Latinos have utilized a diverse degree of methods and had varying levels of success (Devia et al., 2017). Some approaches include partnerships with community members, community- and faith-based organizations, business owners, and local government leaders and stakeholders. Yet, the majority of the research examining the correlation between health-care-seeking behaviors among Latinx communities has focused on women and children (Sobralske, 2006).
Purpose
To help fill this gap in the literature, we explored rural Latino men’s experiences and attitudes toward health. Using photovoice and community engagement strategies, we explored how men describe and think about their health.
Methods
Setting
This study was conducted in a new destination in rural Iowa city, which experienced a 200% increase in Latinos, most of whom came as part of a meatpacking labor force, between 2000 and 2010. In 2000, a local meatpacking plant informed the city officials that they would be hiring a relatively large number of Latinos to work in the plant. Seemingly overnight, Latino-owned businesses were started, including auto repair and used car dealerships, bakeries and tiendas (stores), and restaurants, as the Latino populations topped 3,000 in the 27,000-person town (Jordan, 2012; Kim, 2016).
This study was funded as part of a pilot research program for the University of Iowa Prevention Research Center for Rural Health (PRC). Because the Latino population was relatively new in the area, there were no Latino-specific grassroots organizations to collaborate with, as would be typical in a community-based participatory research (CBPR) partnership. Thus, this pilot study was initially conducted in partnership with the PRC Community Advisory Board, which provided contacts within the Latino community. The study was conducted over several months of 2013. The study was conducted simultaneously with the main PRC project, a community-wide physical activity intervention (Baquero et al., 2018), and approved by the University of Iowa Institutional Review Board.
Establishing Trust and Partnership Building
As suggested in CBPR literature (Israel et al., 2010), our first step in preparation for this project was to identify and meet with Latino opinion leaders in the city. The principal investigator (PI) of the pilot and the PI for the PRC research project, both Latinos, led this phase of the work. Typically, in CBPR studies, we would have sought out and partnered with local organizations. As the Latino community was still relatively new, there were no such organizations to work with; thus, we sought out individual leaders. Our first contact was with Sister Irma, a bilingual Latina nun at the local Catholic Church, who has lived in the town for decades (names have been changed to maintain confidentiality). We met with her several times before starting, during, and after the project. Our second contact was also a longtime area resident (Henry), which led the Iowa State Extension (https://www.extension.iastate.edu/) program in the area. Henry is a bilingual/bicultural Latino who served on the PRC Community Advisory Board. Sister Irma and Henry introduced our team to several other local leaders, including a Latino couple that ran the local Spanish language radio show and two Latinos working for Iowa workforce specifically with the Latino community. Finally, they introduced our research team to Ella who worked with Latino children and families for the school district.
Introduction to the Community
The PIs met multiple times with each of the community leaders. The first meetings focused on introducing the team to the community leaders, defining the purpose and goals of our research, and discussing strategies to include community input into our research agendas. We met at the workplaces of the community leaders, in public places (e.g., local library), and at local Latino-owned restaurants. Over several meetings, we began to explain the potential photovoice project and to obtain their input. Once they understood our motivations and goals, they all agreed that exploring Latino men’s health priorities was a good idea and that the photovoice would be a beneficial way to do that. Based on stakeholder advice, we approached three local men to lead and recruit others into the project. The first was Henry, the second was the president of the local Latino soccer league, and the third was a local DJ for a Spanish radio show. All three men were paid as staff. The second and third men were initially supposed to take turns facilitating sessions with Henry. However, they did not feel confident enough to run the meetings. Hence, their roles were adapted to focus on maintaining contact with the cohort, setting meeting dates, and reminding cohort members about meetings.
Orientation and Recruitment
Researchers find it difficult to recruit Latino men, especially for longitudinal studies and in rural communities (Eakin et al., 2006; Rodriguez et al., 2006; Tucker et al., 2010). Following community advice, we relied on the three aforementioned men to recruit other men into our project. In initial meetings with our recruiters/staff, we made several decisions about the project, which included where and when we would meet, that we would provide dinner, and that the meetings would be in Spanish. The recruiters met and discussed who they would invite. The team, now including the local staff, decided that only the recruiters would contact men to participate. Eligibility criteria included being male, older than 18 years, and living in the rural Iowa city town.
Photovoice Methods
Photovoice is a structured form of a longitudinal focus group (Baquero et al., 2014; Rhodes et al., 2015) and based on principles of constructivism, critical theory, and empowerment education (Freire, 1972; Green et al., 1999; Morrow & Brown, 1994; Patton, 1990). This process facilitates community members to document their perspectives, reflect on and prioritize community needs, and share their expertise and knowledge through photographs. In addition, photovoice has been successfully used in many settings to explore community perceptions and priorities related to social, political, and health issues (Freire, 1972; Patton, 1990; Wang & Burris, 1997). Participants are recruited to engage in, typically four to eight photo sessions. The project was broken into several parts: an orientation, four photo sessions, group feedback on results and interpretation, forum planning, and a community forum.
The orientation session was 3 hours long and covered the project goals, activities, ethics of photography, project length, and the first photo assignment, which was conducted in Spanish by the group facilitator. Participants received an explanation of the study procedures and were trained to take photos for the session with digital cameras. They were originally asked to take photos from their surroundings and daily lives that addressed the photo assignment. Photo assignments are activities in which participants take photographs on a particular topic, typically agreed upon by the participants, serving as a trigger for discussion to examine needs, obstacles, assets, and priorities (Rhodes et al., 2015; Schell et al., 2009). All participants provided written consent in Spanish, following institutional review board requirements. A short demographic survey was administered to participants, which collected data on nativity, time in the United States, job status, and relationship status.
Photo Sessions
A total of four group photo sessions were held. Initially, following standard protocols with photovoice in other settings, the research team worked with the group to identify photo assignments (i.e., topic of the next session). In the first two group sessions, the topics were diabetes (Session 1) and cholesterol (Session 2). After reflecting on the process as a research team, it was determined that a more proactive and structured approach was needed if the process was going to elicit in-depth dialog. In response, for Sessions 3 and 4, the research team developed a series of 10 possible questions that the photovoice group could choose from. The men in the group agreed to the compromise. The men chose two questions: for Session 3, “As a Latino man living in Ottumwa, what have you lost or gained in the process of moving/immigrating to the United States?/Como hombre Latino viviendo en Ottumwa, ¿Qué has perdido o ganado en el proceso de mudarte/inmigrar a los Estados Unidos?” and for Session 4, “What does working or your work mean in your life and your health?/¿Qué significa trabajar o su trabajo, en su vida y para su salud?”
Photo sessions were preceeded by 15 to 20 minutes of casual conversation, updating each other on family events, local politics, gossip, and work issues while eating. The photo session then would start as a natural process of moving the discussion to a review on concepts that emerged from the previous photo-discussion, followed by an in-depth discussion on each participant’s photographs based on the photo assignment decided upon during the previous photo session. Following this discussion, the conversation began to be more structured via the use of the six key questions linked by the SHOWED process (Wallerstein & Bernstein, 1994) or VENCER in Spanish (see Baquero et al., 2014, or Rhodes et al., 2015, for a detailed description of the VENCER process). Not all men brought photos; some of the photos were pictures they downloaded from the internet. The group chose one or two photos to discuss more profoundly. Per this process, the questions progressed from descriptive observations to critical analysis and action, which included “What do you See in the photo?”, “What is really Happening here?”, “How does this relate to our lives?”, “Why does this situation exist/occur?”, “How can we become empowered to do something about it?”, and “What can we do about this situation”? After the final group photo session, the group continued to meet to work together to further refine findings and key themes and to organize and finalize a community forum (Figure 1). A total of nine men participated, and six attended all the sessions. The main reason for dropping out was that meeting time would conflict with job schedules.
SHOWED/VENCER.
Data Interpretation
Analysis
Each session was transcribed from audio to written Spanish and then translated into English. The translation was completed by staff with experience and training in transcribing audio interviews and focus groups. Transcripts were subject to thematic analysis by three research assistants and two investigators. The analysis involved several steps. First, the transcripts were read, and segments of the text were given codes and subcodes and discussed by the research team until a final codebook was developed. Then, an inductive interpretation process was used to code and compare for areas of consensus and discrepancy that included bilingual and bicultural staff and investigators. Coding and interpretation were conducted using a grounded theory approach (Glaser & Strauss, 1967) using open coding to develop multiple codes, which were collapsed and clustered into broader themes. A summary of the key themes, exemplified by relevant quotes, are reported. No a priori theories or codes were developed before coding.
Feedback and Community Data Interpretation
Once the research team agreed on major themes that evolved from the data, investigators met with the group. Of the nine men that participated, four agreed to meet with our team to help with data interpretation. The facilitator, two bilingual research interns, and the two PIs were present as well. The research team presented the codes and themes along with printed deidentified copies of the session transcripts. The themes presented were verified by the participants, with some refining.
Community Forum
Several meetings were held with the participants to plan a community forum to share the study results. The participant men were given the option to present themselves or have the research team members present. The men agreed to present, with the condition that each of them would choose a role for the forum and that we would help them write scripts they would read to the audience. The four men that participated in the data interpretation stage were involved in the forum planning. Our research staff met with the men several times to develop the scripts and plan the forum. One member was a member of the local Knights of Columbus (KOC), a Catholic men’s organization, and it was decided that the meeting would be held at the KOC hall. The men developed an agenda and planned for food and how they would make the community aware of the forum. A local food vendor was contracted to cook food at the KOC hall. We developed a two-page summary of the study and results for community members, which had been distributed at the forum and subsequent fairs and events for publicity.
Approximately 40 people attended the forum, including representatives from several local organizations. The PIs delivered the welcome address. The overall findings and the presentation of each of the themes were all conducted by participants. Toward the end of the forum, one of the PI led a question-and-answer session. The participants were adamant about the PI participating in the forum. In their opinion, having the two university professors involved was important to add credibility to the forum. A reception followed the last session.
Results
Photovoice Participants
A total of nine Latino men participated in the photovoice. All but one of the participating men were born in Mexico, with the one participant born in Guatemala. The age of the men ranged from 34 to 67 years, and they had lived in the United States between 7 and 40 years. One participant worked part-time for himself, and the rest were employed in full-time jobs. All men spoke Spanish as their primary language (See Table 1).
Demographic Characteristics of Latino Men Participants.
The goal of this study was to explore rural Latino men’s experiences and attitudes toward health and health care, using photovoice, in the context of a CBPR partnership. Nine major codes emerged, which were collapsed into five themes. The themes were loosely clustered around (a) difficulties in maintaining health and (b) impact of U.S. culture on family and relationships.
Codes
Beliefs
Initially, the text was broken into major codes, broad topics that emerged from the coding process; nine codes were identified (see Table 2 for codes and subcodes). The first code was beliefs and included beliefs or attitudes about fatalism, perceptions of prevention and control of disease, cultural beliefs about disease, linking health to maintenance or repair, and feelings of invincibility.
Identified Codes and Subcodes.
Health Behaviors
Under health behaviors, habits that promote or prevent health, access to or understanding healthy alternatives (i.e., olive oil vs. lard), and having unhealthy behaviors were discussed.
Family
Family was a common topic of discussion. Participants reported how being healthy requires the whole family. If one person has a dietary concern, then the entire family was required to change their dietary habits. For example, one participant stated, “But it’s bad, let me tell you, that in a poor family, how are they going to cook for you separately and what about the rest of the people?” (Session 1). Family also was discussed as a factor not only impacting health but also being impacted by health and that their lives seem to lack the social bonds and connectedness that they wanted.
Economics
Economics was related to cost of health and prevention and the impact of poverty on health. Money, cost, and loss of income were discussed as potential barriers to attending to health issues.
Struggles
Struggles were related to self or others blamed for their health, internal conflicts about health, hypocrisy (smoking but pointing out another’s poor diet), sacrifices required to be healthy, and stress as a struggle. For example, around hypocrisy, one participant stated, “And then you go smoke a cigarette for every Pepsi” (Session 1). Regarding stress as a struggle, another participant stated, “You are always in a rush here because you are obligated to finish a certain job in a certain amount of time. Some people work 10 or others work even 12 hours a day” (Session 2).
Information
There were many ways that information interacted with health, including getting too much information, conflicting information, not knowing information source credibility, getting misinformation, and not having the necessary information. One person commented, “They [insurance companies] are throwing so much information at us so that they don’t have to pay so much in the future” (Session 1). The men also commented on their relationship with food; cultural or emotional ties to foods high in fat and salt and having access to more, cheaper, and higher diversity of food, leading to poor diet, stating, “It’s just because with what you buy for a liter of oil, you can buy three to four kilos of lard” (Session 2) and “Mhmm there’s no party without lard” (Session 2).
Barriers to Health
Barriers to health were discussed as lack of time. One participant stated, “If you are always working, where are you going to have the time to exercise, to go out for a walk?” (Session 4). Another commented, No well, that’s why I’m saying even if you want to take care of yourself, with the work hours you have and with what you have to do … I sometimes work 10 hours. I go in at 3 and middle of the morning work and I don’t come back until 5 at night. You think that I’m in the mood to cook something healthy? No. (Session 2)
They also mentioned lack of social support and opportunity: I think with the lack of exercise, for example, today at noon I always—it’s the only way that I can exercise at noon. During the evenings I work or whatever and today I was going to go but I couldn’t because I left something at work. It’s difficult. (Session 1)
Action Steps
Finally, action steps for change individually or socially were discussed. Typically, these were in the form of increased education that account for problems with information barriers (Spanish, simple, multiple channels). One participant stated, “… it would be a good idea after every—not that I’m saying we should but—after church after the get-together, after service and there you have them all together to give them information ‘boom’” (Session 2). The men also suggested having more group exercise opportunities, “I think, to make everyone happy, we would do activities such as play basketball, another day play soccer, another time play whatever. Because not everyone likes the same things. But you know, rotate different activities so that everyone participates” (Session 4).
Themes
From the codes, five major themes were identified. Themes 1 and 2 arose primarily from the first two sessions in which the men discussed diabetes and cholesterol as major health issues. Subsequently, the themes were primarily food- and diet-related.
Theme 1: Conflict
The men described several types of conflict; conflict between living by Latino cultural norms and U.S. cultural norms and the apparent conflict between eating healthy foods and eating traditional Latino foods (which were perceived as unhealthy). The common perception is that foods like tacos and tortillas are unhealthy. For example, one participant said, “Let’s say in Hispanic food, something that is good in any dish is rice and rice is bad for us too” (Session 1). Conflict also came from healthy food availability and portions, knowing that they needed to eat healthier, either by increasing quality or by limiting quantity, but the social and physical environments not supporting healthy eating: There is another thing that practically with the [cornetas] of diseases where wherever you go to eat, although it is—we don’t know the amount of sugar of what we are eating. That’s a problem anywhere because you can go to any restaurant and you’ll be eating anything. I mean the most important thing is the portion size of what you eat. Or rather one can eat practically anything but you have to watch the portions you eat. That is what will … because bread and bread … with that [unclear] counting calories for each food is impossible. (Session 1)
Theme 2: Information
Related to the first theme, the men commented frequently on how much health-related information was available and that the information was confusing and often contradictory. They describe drinks, such as fruit juice, as confusing because some sources say that juice is good for you, and other sources say otherwise as demonstrated by these insights from Session 1, “Well, going along with the idea that is understood many times—that juice is better for you …”; “Don’t believe it, for us it has sugar”; and “An excess amount … well like everything else, it’s bad for you.”
It seems that participants do not know what or who to believe. It is not that they do not have the information, its that they are overloaded with information. In the following quote, a participant speaks about an abundance of information related to food, but not having the right information to make decisions: But there is that information already. Because there is a lot—what you are talking about is good, but there are let’s say many people that have just recently come from different countries, we over there don’t know many of the foods that they have here. (Session 1)
Themes 3 through 5 are intertwined and related to life in the United States, what they left behind, and what they expected for their lives.
Theme 3: Lifestyle
The men described their life in the United States as very different from that in their original country. They believe that kids and families are not as happy now, in comparison to their youth. There is always a routine, and it is fast paced; this repetitive routine is tiring and boring to them: I think that it’s the routine. The daily routine of work, of everything that you have to do, is a routine that is repetitive that you have to do the same that … you get up in the morning when you wake up and you do the same. You go to work and you do the same work. You return and you do the same. It’s routine. (Session 3)
They describe that although they are economically better off, they are not as happy. The lifestyle in the United States also impacts family interactions; the U.S. culture of materialism, new technology, new clothes, cars, and so forth. This requires more work and less time with the family. In response to this, one participant stated, Economically better. A Latino man living in Ottumwa would be economically better. But in terms of family and friends, it’s bad. It’s different making friends here, it’s not the same as in Mexico. The only really bad thing is the immigration state. There are so many injustices; you just have to take it. That is what it’s like as a Latino man living in Ottumwa, Iowa. (Session 3)
Theme 4: Sacrifice
The men talked about how they have left their families in their old country to come to the United States for a better life and more opportunities. They reported feeling sad when they think of the family members that they left behind. For example, one participant stated, “Well it’s true, but if you notice that those families were happy before. They were all together and when they were separated for different … well actually how would they be together again as a family … it’s sadness” (Session 3).
Participants stated that they moved to the U.S. to provide a better potential future for their children but think often of the people and lives that they sacrificed to move on. One participant said, “What we are saying is that we gain some, but we also lose something. We don’t leave without losing something, right?” (Session 3).
Theme 5: Family and Community Connection
The men spoke extensively about the loss of connection to people in their family, in their neighborhood, and so forth and also that the communities were less well tied together than they would have liked, and this also applied to the connection of family. This was a different focus than the lifestyle theme, but related. The U.S. “lifestyle” or value system did not, in their opoinoin, allow for strong family connections. They felt as if they worked very hard for their families, and in return, the family is hardly ever together. Working to keep up with their families’ expectations for material gain created a disconnect. And, when the men were home, devices such as tablets, video games, and mobile phones disconnected them from their wives and children. Characterizing this tension, one person stated, “It’s that, it’s like a competition, That if he buys something good, you want to buy something better and you push yourself more and a lot of times you stay in the effort and you lose everything” (Session 4).
The men felt that in the U.S., neighbors did not interact much; that people did not rely on people in the neighborhood, as they would have in their origin communities. In the following quote, the participant discusses the village as an extended family and remembers a safer, happier community: We gain some stability, but we lose family togetherness, that happiness that we have in our villages. They would go out without underwear, barefoot … you’d run, you’d tumble in puddles, you’d run in the hills. Really happy, even though you were hungry, but also very content. You get here, you have too much; you have everything, you always miss … (Session 3)
Discussion
Summary
In this study, photovoice was used to engage with Latino men about their experiences and attitudes around health and health care in a rural new destination city in southeastern Iowa. A group of Latino men were successfully recruited over several months to complete four photo sessions and a community forum. First, the men discussed and covered issues around gaining and understanding knowledge about health, diet, and healthy behaviors. Second, the men described the effect of living in the U.S. and their role as father and husband on their mental health. In addition, important lessons on the successful recruitment of Latino men were learned.
Reaching Rural Latino Men
As the majority of photovoice projects have been conducted with women and youth, adjustments had to be made to the typical protocols to better work with Latino men. In the lead-up and postfocus group discussions, the men talked about needing a group like Hombres (the group named the photovoice project Hombres Necios) and that they had no opportunity away from roles as father and husband to interact in groups of just men. They wanted a social group that met regularly around social issues; a place or group that would allow them to engage with other men outside of work and/or family. This may be particularly difficult in rural new destination towns that do not have culturally relevant social organizations for Latino men. In addition, we engaged with three local, well-known men and activated their network to recruit other participants. Similarly, Rhodes and Hergenrather (2007) conducted a successful HIV-prevention intervention among heterosexual Latino men within soccer team networks. In a sample of men who have sex with men (MSM), Rhodes et al. (2017) conducted a successful 12-month longitudinal study to reduce HIV risk among Latino MSM and retained 100% of the sample throughout the study period; this specifically focused on recruiting men and their social networks. Both of these studies and the current study worked in men-only groups that utilized the networks of the men. Thus, studies and public health projects will likely be better at recruiting Latino men if they can include culturally relevant, male-specific social aspects.
Credibility and Understanding Health Information
The men in our study talked about the overall difficulty in discerning between poor and credible health information, understanding the health information they received, and how to translate that into behavior. For men that are more comfortable speaking and reading in Spanish, health information may be difficult to find and might come from a variety of sources, not all of which are credible. For example, a study in California reported that Latinos relied more heavily on television, printed material, and newspapers (Kar et al., 2001). However, few Spanish language resources may be available in rural new destination areas, with a relatively small proportion of Latinos. In Ottumwa, there is only a single program in Spanish held once a week, no local Spanish language print media, and only three to four statewide Spanish language periodicals. In discussion with two of the Spanish language publications, El Trueque and Hola Iowa, a significant barrier to publishing health-related information is a lack of writers capable of providing content. A 2014 study, targeting Midwestern Latinos, identified that Spanish language workshops conducted at schools and churches were the favored method to access health information (Cristancho et al., 2014). However, low-resource public health departments and the lack of bilingual health professionals limit the availability of such workshops. Health-care providers are considered to be credible sources of health-care information (Kaplan et al., 2016). Clayman et al. (2010) reported that Latinos, who are more comfortable speaking and reading English, are also more likely to seek health-related information and to be exposed to more messaging. Furthermore, Latinos that do not speak English may also have less access to credible health information and be less satisfied with health-care providers (Morales et al., 2001; Reyes et al., 2017).
Providing, Sacrifice, and Lifestyle
Themes arose around the concept of family provider and protector, acknowledged in concepts of caballerismo and familismo. As an important aspect of the men’s definition of themselves, these two roles seem to result in some internalized conflict.
New employment opportunities have incited the recent waves of migrant populations into U.S. areas of the Midwest and South, in addition to the perception of lower cost of living and safer communities (Garcia, 2009). The men in this study referenced moving to Iowa to provide better opportunities for their families, particularly for their children. However, this move was also a source of regret. The men described missing the culture and community they knew as children. In traditional immigrant settings, this may be offset by larger or established social networks. However, as new destination communities are characterized by a small or burgeoning Latino community (Suro & Singer, 2002), they lack the larger, more established Latino communities of traditional settlement areas, for example, Chicago, Los Angeles, and New York.
Participants described this scarcity of resources in several ways. For instance, the men mentioned not having a community including their neighbors, leaving them feeling isolated and lacking important social support. The men felt an increased pressure to earn and work enough to keep up with the “U.S. lifestyle.” Buying phones, tablets, games, and televisions for their family kept them working, sometimes multiple jobs. For these men, this workload kept them from being with their family and connecting emotionally with them. As Latino men in other research find connecting with family a source of coping with stress (Daniel-Ulloa et al., 2017), this disconnect could have serious implications for their mental health.
Study Limitations and Strengths
This study had several limitations. First, participant selection was based on a small convenience sample of Latino men aged 34 to 67 years in a rural Midwestern community. Therefore, the findings cannot be generalized to other Latino men within this geographic area or more generally in the rural U.S. Second, using a network sample may not reflect the perspectives and viewpoints of other rural Latino men, in particular men that have more recently arrived or second-generation men. That said, multiple methods were used to maintain rigor and trustworthiness (i.e., member checking and participant centering) throughout the study.
As a pilot study exploring the perceptions of health by Latino men living in the rural Midwest, this study does have several strengths as well. First, we used an established qualitative method (photovoice) that is demonstrated to elicit more authentic feedback from the participants’ perspectives. Second, this study was conducted within a larger CBPR partnership with participants who played a significant role in the data interpretation, strengthening the rigor and validity of the interpretations and conclusions. In particular, engaging community members in the data interpretation helped to center their expertise.
Study Implications
Several implications arise from this study. First, health literacy problems may make it difficult to receive important health information about mental and physical health. In addition, health messaging is complicated by media suggesting that culturally appropriate foods (tacos, tortillas, tamales) are inherently unhealthy (widening the perceived gap between the men and their culture). This study highlighted how conflicting messages about some foods being healthy and unhealthy (e.g., fruit juice) make it additionally difficult to make food choices. Competing with public health messages, Spanish language ads promote unhealthy herbal, surgical, or other alternative health options (e.g., Herbalife) that further complicate comprehension (Amirehsani et al., 2021; Nielson Diverse Intelligence Series, 2021; Wilkin & Ball-Rokeach, 2011). This became particularly obvious during the COVID pandemic (Long, 2021). Thus, messages specifically tailored to Latino men, in Spanish, circulated through the channels that these men are familiar with, that acknowledge the conflicting information, and are developed at an adequate literacy level will be important for engaging rural Latino men in health-related issues. Although these issues may not be unique to rural Latino men, the approaches to addressing them need to be more specifically tailored to this group.
Popular narratives tend to describe men as generally avoidant of topics related to their health. Research with Latino men suggests that this avoidance is a mix of machismo and familismo; that culturally the role of maintaining family health is the role of women (Caballero, 2011; Hunter et al., 2007; Sobralske, 2006). This is often, but not always, interpreted as Latino men being unwilling to engage in discussions about health as a threat to their masculinity (Hawkins et al., 2017; Suennen, 2011). However, an interaction we observed during the community forum may add a wrinkle to this interpretation. When the audience was asked to comment or ask questions, the first person to stand up was a woman that attempted to invalidate the men’s perspectives by stating that their poor health is caused by their stubbornness. In a previous study, several of our research interns observed women taking over the coversations of men talking to presenters about cancer prevention. This may indicate that Latino men are also interested in making decisions about health, but gender roles may make acting on their own somewhat difficult (Courtenay, 2000). Further studies should be conducted to examine how to better engage Latino men in health decisions, within family units, and in broader community efforts. In addition, more in-depth exploration of the interactions between overall perceptions of men’s role in their health and gendered health roles, in general, needs to be performed.
Finally, the lack of connectedness that participants underscored is an important consideration. A lack of male social groups, coupled with the struggle to maintain their male roles of family provider and family protector, may lead to increased risk of mental health issues and unhealthy coping mechanisms, such as alcohol use among Latino men (Ornelas et al., 2016). As this project was ending, several offline conversations focused on alcohol abuse in the community. The lack of male-oriented social groups that serve the Latino community may contribute to health risks associated with social isolation and increased work- and family-related stress. Further efforts in developing local organizations to serve rural Latinos in general, and addressing Latino men’s health in particular, are important next steps in addressing the health of Latino men and their families.
Implication for This Study Looking Into the Pandemic
This study was conducted several years prior to the pandemic in a micropolitan in Iowa. One of the defining characteristics of this town is the reliance on a pork-processing plant that employed a large number of residents, providing for a large number of families, mostly immigrant and Latinx. First, sacrificing for family and protecting and providing for family are major motivators for the men in this study, as it is for many Latino men, especially those that move specifically to the Midwest for work. Thus, we can likely predict that this motivation makes them particularly vulnerable to pressure from employers to come to work despite perceived dangers of COVID. Indeed, Latinx throughout the rural U.S. were specifically vulnerable to COVID mortality and morbidity (Lundberg et al., 2022; Waltenburg et al., 2020). A significant proportion of Latinx worked in meat processing plants, data analyzed by the Economic Policy Institite, shows that about 35% of meat processing workers are Latinx (Stuesse & Dollar, 2020) and Latinx were significantly overrepresented in covid cases among food manufacturing and agricultural workers (Waltenburg et al., 2021). In essence, the drive of men to keep working and the country’s drive to keep meat production open very likely resulted in increased case and death rates among men in this situation. Our ties to several Latinx communities around Iowa provided some anecdotal data that suggested that many if not all Latinx families in Iowa experienced COVID-related deaths. The longterm impact on the health of the men, their families, and the next several generations is likely to exacerbate over the years.
Final Conclusion
Overall, this study shows that the physical and mental health of Latino men living in rural U.S. is complex and intersects with their immigration history and paths, ideas and perception of their origin countries, and the drive to provide a healthy and happy environment for their families. Constructions of masculinity, machismo, familismo, and caballerismo influence the strength of men’s desires to protect and provide for their families at the sacrifice of their mental and physical health. These factors are exacerbated by isolation from social bonding opportunities with other men, reduing their feeling of empowerment over their own health.
Footnotes
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 publication was supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) as a part of a Cooperative Agreement Number (U48 DP006389). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS or the U.S. Government.
