Community-based strategies to improve the health of Mexican American men.

This article focuses on the barriers that dissuade Mexican American men from seeking health care using a focused ethnography of Mexican American men living in the Northwest United States. Also highlighted are community-based strategies that can be employed to improve the likelihood that Mexican American men will access the health care system and become more aware of their health status in general.

Keywords: men, Mexican American culture, community-based health strategies, machismo

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Latinos constitute the fastest-growing minority population in the United States. In fact, one of every eight Americans is Latino, accounting for over 37 million people or 13% of the population. Of this segment, almost 70% are of Mexican ancestry (Ramirez & de la Cruz, 2003). Demographers predict that by 2010, Latinos will be the largest ethnic group in the United States. Because of the growing numbers and the racial and ethnic disparities, the health status among the Mexican American community is a major concern (Hatcher, 2002; Smedley, Stith, & Nelson, 2002).

Numerous factors influence minority men's health status (Forrester, 2000), for instance, the lack of social support, environmental stressors, lack of knowledge of everyday health habits, a paucity of health care resources, and cultural and religious beliefs and practices. Although researchers have paid attention to health issues of Mexican American women and children, few have focused solely on Mexican American men's health. Of particular interest is how the concept of masculinity and its influence can affect a man's health status (Galdas, Cheater, & Marshall, 2005; Kimmel & Messner, 2001). For instance, men's higher mortality rates have been linked to their masculine identity, gender roles, and patterns of socialization (Waldron, 1995). Forrester (2000) and Waldron (1995) argued that men's higher mortality rates are associated with various gender-related behaviors as well as inequities experienced by minority men in employment settings and their exposure to occupational hazards. Men, it seems, are more likely to engage in a variety of high risk-taking behaviors like drinking and driving, participation in extreme sports, and use of firearms (Chavez, Becker, Wiggins, Key, & Samet, 1993; Marin, Posner, & Kenyon, 1993; Sabo & Gordon, 1995).

CULTURE AND HEALTH

The notion that culture and health are linked can be supported by examining how various people from different cultures respond to stress, bodily aches and pains, and various illnesses (Leininger & McFarland, 2006). The fact is that health and illness are culturally defined and encompass much more then physical symptoms and medical conditions.

How a man defines illness forms the basis of his decision about when to seek health care (Kanu Dunn, 1987). An understanding of what motivates Mexican American men to seek help for illnesses, how they make decisions to seek health care, and what they view as important in defining their health are only a few of the issues that health care professionals must ask if they are going to assist Mexican American men to achieve better health care.

MASCULINITY AND HEALTH

Gender identity can be expressed as either masculine or feminine and is defined as the sense that one belongs to a particular gender ("I'm a woman" or "I'm a man") (Sobralske, 2005). Most gender scholars accept the idea that a person's gender identity is largely shaped by a culture's male and female gender role definitions (Stillion, 1995). As most men strive to prove their manhood and masculinity to others by shows of strength, virility, stamina, and fortitude, these very behaviors and their related values and attitudes may lead to men's high mortality rates (Hoga, Alcantana, & De Lima, 2001; Murphy, 1990; Sabo & Gordon, 1995).

For instance, Vicki Helgeson (1995) found that men who hold less traditional beliefs about their masculinity adjust more successfully to illness and subsequently have faster recoveries. Seemingly, men who espouse less traditional beliefs (i.e., less macho) about their masculinity are more amenable to health education messages than are men with more traditional beliefs about their masculinity.

ACCULTURATION

Acculturation is the process whereby a person adopts or adapts to a culture different than the one he or she was raised in (Spector, 2003; Suarez & Ramirez, 1999). For instance, an immigrant to the United States is considered as evidencing acculturation by showing a preference for and fluency in English and a preference for American foods (Randall-David, 1989; Villarruel, 1993).

Many Mexican Americans, however, retain a sense of their heritage and original culture (Cuellar, Arnold, & Maldonado, 1995; Leek, vande Kamp, & Kinne, 1991). They prefer to speak Spanish, although becoming proficient in English to some degree (Arcia, Skinner, Bailey, & Correa, 2001; Balcazar, Castro, & Krull, 1995). Several authors (Adams, Briones, & Rentfro, 1992; de Paula, Lagana, & Gonzalez-Ramirez, 1996; Randall-David, 1989) suggest that rural Mexican Americans are less acculturated than those in urban areas and that those who live in barrios, or segregated neighborhoods, retain their original cultural ways more so than those who live in integrated communities.

Being Mexican American requires a balance between two cultures, which takes incredible patience, insight, effort, and diplomacy (Balcazar, Castro, & Krull, 1995; Ramos-Sanchez, 2000). Most Mexican Americans see the need for adopting more Anglo lifestyles. For example, whereas Mexican American women are often required to take a more active role in providing for their families' well-being, many Mexican American men have had to take on more family roles like cooking and child care, behaviors more traditionally assigned to women.

METHODOLOGY

The ethnographic approach (Germain, 2001) employed in this study began with participant observation in the community. The study specifically focused on men's health care-seeking beliefs and behaviors within communities where Mexican Americans constitute a majority or a large minority of the total population (Sobralske, 2004). As the study progressed, the focus narrowed to a selected portion of the population.

RESEARCH SETTING

The Northwest United States was chosen as the research setting because Mexican culture plays a significant role in this geographic area. Spanish-speaking radio stations and music, Spanish language billboards, Mexican restaurants, and brownskinned people all stand out in contrast to the dominant white population/culture of the area.

Previous studies have used the allopathic health care system as their point of entry to study the Mexican American population. This approach is problematic, however, because many Mexican American men never use allopathic health care and may choose to seek out a folk healer or a lay person in the community for help. To determine where men seek help, research participants were met through contacts in the communities where they lived and, therefore, outside of the standard health care system.

Entry into the research setting was a gradual process. Data collection started with visits to local museums, historical societies, libraries, and art exhibits to discover the local and regional history of Mexican Americans. Small talk with store proprietors, employees, and their customers, both Mexican American and non-Mexican Americans, was insightful. Research participants were met while attending community activities, at public schools, and at churches. One female participant was encountered at a Mexican drug store, a yerbero. She was a friend of the proprietor and helped translate for non-Spanish-speaking customers. She assisted in purchasing amulets and explained their meaning to patrons and members of our research team. Visiting places where Mexican Americans congregated, such as local parks on a Sunday afternoon and Mexican restaurants and bakeries patronized by Mexican Americans, provided access to the population under study.

PARTICIPANT OBSERVATION

Participant observation is one way to understand the behavior, values, and customs of a group of people (Nanda & Warms, 2004). It is the nature of ethnography to meet research participants by first observing them and then engaging them in the community (Roper & Shapira, 2000). Although contacts from allopathic health care facilities were not targeted, several research participants were part of the health care system. They were interested in the study and wanted to contribute in some way.

Observing men in the community and participating in activities that allowed interaction with them and their families, friends, co-workers, and other community members added to understanding men's masculine identity and how it influenced their decisions about seeking health care. From these interactions, the researchers were able to identify many of the barriers blocking men's health care activities.

RESEARCH PARTICIPANTS

The Mexican American community with its social network of loosely connected members provided access to the eventual research participants. A snowball technique (Creswell, 1998) was used to select participants who fit a selection criteria outlined by Gilchrist (1992).

Two types of research participants were selected: primary and secondary. Adult Mexican American men who were (a) well informed and accessible, (b) willing and able to participate by being interviewed in-depth, (c) stable residents (not migratory workers), (d) identified themselves as similar to other Mexican American men they knew in their community, and (e) capable of providing insights about health care-seeking activities made up the primary research participants.

The secondary research participants were similar to the primary research group's characteristics, but differed in that this group was composed of adult men and women who provided insights about health care-seeking beliefs and behaviors of Mexican American men, could contribute to the social and cultural context of the study, and could confirm, validate, and add to the data collected from the primary research participants. The focus of interviews with secondary research participants was mainly to confirm the data provided by the primary research participants as well as to add to the data collected. These men and women (i.e., the secondary group) were interested in, working with, or somehow related to Mexican American men. Of 24 secondary research participants, nine women and four men were formally interviewed and audio-taped.

The primary research participants and several secondary participants were interviewed in their homes or at a place of their choice that allowed for privacy; for example, a room in a church hall or a private booth in a restaurant. Interview questions identified and explored the health care-seeking beliefs and behaviors of Mexican American men. The questions were based on selected concepts from Chrisman's (1977) health-seeking process and Kleinman's (1980) ideas on symptom interpretation. Sociodemographic and ethnographic information provided a basis for determining the primary research participants' level of acculturation.

Secondary research participants were interviewed about men's health care-seeking behaviors as they were known to occur within their families or in the Mexican American community in general. We asked how family members, co-workers, and friends helped in decisions about men's health care seeking, how men are involved in the decision-making process in seeking health care within their families, what influences family members and friends have on a man's decision to seek health care, and how family members and friends help men who are ill.

A total of 36 men and women participated in the study. Eight men were chosen as primary research participants (see Table 1). Their average age was 47.5 years (ranging from 24 to 73 years of age). Their level of education ranged from completion of second grade to post-graduate education. The average grade completed was twelfth grade or its equivalent. These men held a variety of occupations, and some men had more than one occupation at a time. All had lived and worked in the Northwest for different lengths of time.

Determining the level of acculturation of the primary research participants was based on ideas drawn from acculturation rating scales that already existed and are well established in research with Mexican Americans (Cuellar, Harris, & Jasso, 1980; Matin, Sabogal, VanOss Matin, Otero-Sabogal, & Perez-Stable, 1987; Ramos-Sanchez, 2000). Congruent with ethnographic methodology, the participants were asked about their level of educational attainment or years of formal education, age, religious affiliation, occupation, birthplace of participants and their parents, the amount of time they had lived in the United States if born in Mexico, and the length of time they had lived in the Northwest United States.

Acculturation data included:

Language(s) spoken and written (Spanish, English) and which language was commonly spoken at home

Country where the participant's childhood had been spent (Mexico, the United States, or both)

Personal history

Current circle of friends (Mexican American, Hispanic, or non-Hispanic)

Sense of pride in having a Mexican background or heritage

Sense of ethnic loyalty, pride, affiliation, and identification

Commitment to and involvement in cultural customs and rituals

Sense of family cohesiveness

Sense of acculturative stress and coping strategies used to deal with this

Social support from community members

Perceived discrimination (if any)

Table 1 includes an indication of the overall level of acculturation of the participants based on these factors.

Determining the level of acculturation also included observations used to assess the general living environment, the use of technology in the home, the kinds of food eaten and clothes worn, and physical appearance (Leininger, 2001).

ETHNOGRAPHIC DATA ANALYSIS

Analysis progressed from lower to higher levels of abstraction, moving from collection of raw data to identifying common patterns and then formulating major cultural themes (Leininger & McFarland, 2006). Taped interviews were transcribed verbatim and converted into word-processed transcripts. Transcribed data and fieldnotes were entered using the Ethnograph 5.0 computer program (Seidel, Friese, & Leonard, 2002).

Recurrent patterns of meaning, expression, interpretation, and explanation of relevant data were discovered. This involved comparing, contrasting, and sorting data using a determinate number of categories (Fetterman, 1989). Synthesis and configuration analysis, interpretation of findings, and the creation of formulations led to our conclusions. Pattern analysis identified consistent and recurrent patterns across data sources, leading to the emergence and discovery of four major cultural themes, which will be described below.

RESULTS

The men varied in their level of acculturation and the number of years they had lived in the targeted area. Most lived in or near towns or small cities that are neither rural nor urban. Mexican Americans were not living in insulated, self-contained communities segregated from mainstream society. Although small neighborhoods contained many Mexican American families, the communities were more or less integrated. Participants' lives were firmly established in both cultures--their Mexican heritage and the dominant culture of the United States. Most were bilingual and spoke both English and Spanish at home and in the workplace.

Four cultural themes emerged from data analysis. A thorough explanation of the analysis and formulation of these themes has been presented in a prior publication that focused on the health care--seeking process of Mexican American men (Sobralske, 2006).

Theme 1: The identity of manhood in Mexican American culture dictates health care--seeking behavior.

Theme 2: Good health means being able to be a man.

Theme 3: Illness means not being able to be a man.

Theme 4: Men seek health care when their sense of masculinity (manhood) is threatened or impaired.

Discovering these cultural themes enabled health care providers to decipher what is important to Mexican American men in order to devise strategies to promote their health. Since this paper focuses on these strategies, the findings that are most relevant to that effort are presented. The participants' words with the researchers' reflections support and substantiate the findings.

WHAT IS IMPORTANT TO MEXICAN AMERICAN MEN?

Men in the study generally regarded themselves as hard working. They achieved as much as they could, given the opportunities available to them. Many of the men talked about finding a balance between the "old and new ways." They appreciated the "old ways," defined as the desirable values and beliefs of their parents, including a strong work ethic, providing for their families, and following religious teachings and rituals. They respected their ancestors' fortitude and ability to look to the future and give their children more than they had had in their own lives. For example, Eduardo (aged 30) talked about how his parents "worked hard so he and his brothers and sisters could get an education."

Our participants also recognized the "new ways," namely, the values that the dominant society holds. Ruben (aged 54), for example, was proud of his ability to speak and read English and Spanish equally well. "If Mexican Americans are bilingual, they have many job opportunities helping other Spanish-speaking individuals." Ruben had friends from a variety of ethnic backgrounds and liked working with people from "all walks of life. Many Mexican Americans in this country face the decision about whether they should adopt the language and culture of the U.S. so that they can be more successful. A balance of both seems to be the solution for now." He believed that his community is "a good place for Mexican Americans to live. I feel like I fit in here and I've heard that from many people."

The "new ways" also meant getting a good education and being employed in a secure occupation. Receiving an education themselves and providing an education for their children was highly valued. Men's pride in academic achievement was a recurring finding. Several men proudly explained that they acquired a GED (General Equivalency Degree) later in life because they did not have the opportunity to receive a high school diploma when they were young. The men were earning a living in stable employment. A high school diploma was not necessary because they had proven themselves to their employers, but they wanted to earn a diploma to set a good example for their children and to enhance their own ability to pursue additional employment opportunities. For example, Roberto, the oldest primary research participant at age 73, proudly described how, "after acquiring my GED when I was in my 50s, I marched in the local high school graduation ceremony with my 18-year-old son who was also graduating." Roberto mentioned that his granddaughter had recently been accepted by several colleges. He was very proud when he introduced her.

MALE IDENTITY, MACHISMO, AND HEALTH

Although the eight men had varying backgrounds and life experiences, they described common patterns of connection between masculinity and health. A man's identity in the Mexican American culture has a marked influence on his health care--seeking beliefs and behaviors (Sobralske, 2004). The culture has definite expectations about the role men should play and how they should think and act. Men appeared to feel a need to explain what being a man means to them and how this affects the meaning of health, illness, and whether or not they seek health care.

Understanding the meaning of manhood is critical. Although traditional cultural values of Mexican American men may be changing as they adapt to mainstream society, inevitable changes in values do not necessarily alter the basic meaning of being a man. Machismo, the Spanish word describing a set of attitudes and the identity associated with the Mexican concept of masculinity and manliness (Urrabazo, 1985), continues to be an important value in the Mexican American culture. A Mexican American man's self-worth is based on being able to fulfill the cultural expectations of being a husband, lover, father, son, brother, and worker. It means being able to earn a living and provide for and protect the welfare of his family. The participants explained what it is like to be a Mexican American man and how they would behave when ill and needing help. "Men don't complain about things because a man is supposed to be a man. Men are not supposed to complain about things like aches and pain" (Lavita, aged 52). "When I was growing up and got injured, I would just keep working because that was expected of men and older boys" (Chique, aged 55).

Mexican men often put the welfare of their family above their own needs. When they become ill enough to see that it is a threat to their manhood and impedes fulfilling their cultural obligations, they will then seek health care. Rather than attributing the level of acculturation, socioeconomic status, and educational background as predictors of health care-seeking behaviors, the best predictor is when men experience their manhood as having been compromised (Sobralske, 2004). Illness disrupts a man's family life, work, and ability to earn a living, as well as interrupting his social and community activities. The psychological costs, such as the stigma attached to a man who needs help and the humiliation he experiences if other men perceive him as being weak, were apparent in our research findings. The reasons why they seek or do not seek health care were often linked to their gender identity within their culture (Sobralske, 2006).

Severe pain and disability are major motivating factors in seeking health care. Some men seek care only when they have enough pain to keep them from working and performing activities of daily living. Mateo, a 47-year-old male Mexican American health care professional employed in a clinic that serviced a large population of Mexican Americans, offered that, if a man's pain is not responding to the "usual stuff, like Tylenol and ibuprofen, or if the pain is not alleviated by applying home remedies, like rubbing alcohol or putting grilled tomatoes on the painful area," he will seek care.

Men may develop medical conditions such as hypertension and diabetes and fail to see the benefit of early detection and treatment. Jose (aged 39), a Mexican American medical interpreter working with Spanish-speaking patients in several health care facilities, explained that severe problems like "bad circulation of the blood" and obvious conditions like "their feet turning purple" will prompt Mexican American men to seek care eventually.

Not knowing what is going on with the body "scares the living heck" out of Eduardo. In responding to a probe, he admitted that it is the unknown that prevents him from seeking health care. Eduardo admitted that when his "testicles hurt and hurt and it wouldn't go away, and I had a lump in my groin," he was afraid to tell his wife at first, but two days later he decided to tell her about the pain. She told him, "It's time to go," and they went to see his doctor together. "If a health problem is severe in a man's mind, it is difficult to ignore." Ruben sought care because he had red blood in his urine once. Seeing the "source of life coming out of my manhood" made him afraid that something was "gravely" wrong. Both men and women said that men have a lot of pride. Lavita explained, "Men do not just go to the doctor for nothing. Men have to be really sick to go to the doctor. It's viewed as a sign of weakness if men go to the doctor without being really sick." Men sometimes seek health care when everything else fails, including over-the-counter medications and home remedies. Some men only go to a doctor if it is the "last resort," "there is excruciating pain," "the pain is not going away," and "they can't stand it anymore." "This macho attitude was typical in my family and extended family; my uncles, grandfather, and father" (Carlos, aged 32).

WOMEN'S ROLE IN MEN'S HEALTH

Many men in this study did not seek health care readily on their own. When men were ill, the power in the family often shifted from the husband to the wife. Most men relied on their wives for health care advice and assistance and their input about seeking health care. They depended on their wives to be caretakers of their health status. Wives often encouraged men to seek care from their doctors. They used a variety of ways to get their husbands to seek help. Some, including Gloria (aged 26), said they ignored their husbands or withheld sex until the men agreed to get help. "Women have the weapons to make men get help. I get angry with my husband. I don't acknowledge him at home, in bed, any place. I ignore him [laughs]." When asked how long she would do that before she gives up, Gloria laughed and answered, "When I have achieved what I want."

Rosita, an elder Mexican American mother, said she would not let her son visit her until he went to the doctor to get treated when he was sick. When men do access health care they are often accompanied by their wife or someone else. They often will not go by themselves. For men who were not married, the person from whom they most commonly asked for advice was their mother. Men saw their mothers as the traditional caretakers in the family as they were growing up. Jose agrees

   that it's the woman who sees her husband not getting
   up out of bed. Then she thinks you need to go to the
   doctor because things aren't getting any better. First
   she calls the aunts ... try this, try that ... quite a
   few people try to use up all their resources whether
   it is their neighbor or somebody like that, before they
   make it to the doctor.

MENTAL HEALTH CARE

Ruben and Tomas (aged 57 and 60, respectively) reported that men often drink alcohol infrequently but drink large quantities of alcohol when they do drink. "Mexican American men use alcohol to cope with mental health disorders like depression and anxiety" (Tomas). As men learn about what mental health care can offer, however, they are more likely to seek it out and use it.

Mexican American men are taught to tough it out when they have problems, not just physical pain, but also psychological disturbances. The researchers often saw depression among Hispanic men; for example, alcohol addictions due to depression that is not diagnosed. Men are brought up to think they have to know everything because they are men. In the community studied, the local police department recommends mental health services to men who often get into trouble with the law (Ramiro, aged 40).

Mexican American men may avoid seeking help for mental health problems even if they recognize that there is a problem. Factors that influence their perceptions of mental health care include cultural beliefs and the stigma associated with being mentally ill, lack of education, social isolation, language barriers, unfamiliarity with the health care system in general, bureaucratic barriers, and unavailability of service compatible with their cultural needs. Lavita, a Mexican American mental health care specialist, observed that, if the mental health care workers are not Mexican American, men will not seek care. They will not turn to "strangers."

BARRIERS TO HEALTH CARE

Patty (aged 45) pointed out that "men have difficulty identifying and describing their symptoms. Problems are often not recognized until they become obvious to men." According to Lavita, Mateo, and Sandra, language was a perceived barrier to health care access. Lavita explained that men will spend hours in the waiting room before they even tell anyone they are there to be seen. According to Patty, a health care administrator in a small clinic, a man's presenting reason for being there is commonly "my wife (or my employer) told me I had to come." She reported that men needed to be reassured that it was all right to seek help for their health problems. Some men had lived in the United States for many years but still did not speak English, and this inhibited them from seeking health care. In general, men who were less acculturated needed special consideration regarding the unfamiliarity of the health care setting.

Lack of financial resources was also a barrier to care for some men. Lack of health insurance or money to pay for gas to drive to a health care facility, or being unable to pay for a babysitter, were some of the barriers cited. Even if people had health insurance, however, they still had to meet the co-payment, which some men could not afford.

On the other hand, men who had health insurance and/or access to health services did not necessarily seek help when they had problems. Alonso, a 36-year-old Mexican American male community outreach worker, believed that "if women cannot pay or lacked health insurance, they would still seek care and worry about the bill later." Ruben's opinion was that "some men use the lack of the ability to pay as an excuse to not seek care."

Sandra (aged 50) talked about how she grew up with grandparents who were not born in the United States. She realized that in "their generation, they were not out actively looking for medical help." Her father finally sought health care when he was 70 years old when he "got into a dentist's chair, and the dentist told him he could not work on his teeth because his blood pressure was so high." After that, her father began to see a doctor. "He is more informed now and is interested in his health. He asks the doctor questions, something he never would have done when he was younger."

Lorena's (aged 46) elderly grandfather was recently diagnosed with diabetes and some other health problems. "My grandfather had no experience taking medication, so he was taking all of his medications at one time--in the morning. He did not know that he needed to spread them out over the day. Without any experience taking medications, a man cannot draw on prior knowledge."

Patty admitted that in her experience working with Mexican American men for over 15 years she had witnessed many men wait a long time before going to a health care provider when they were ill. Some men were very sick and still did not access health care. "I believe that in men's minds, they are confident they will get better." In the ambulatory clinic where she works, her staff tracks patients who fail to keep their appointments. Men often do this, and they represented the greatest number of people who walked out of the clinic before they were seen by a health care professional.

   If men have to wait to be seen for a length of
   time that exceeds their expectations, they leave
   the clinic. If a man brings his son, and his son
   witnesses this behavior, he models his behavior
   on his father's behavior.

Several men mentioned that they did not want to admit they believed they had a folk illness like empacho. Empacho is a condition that can be explained as a ball of food getting stuck in the stomach or a feeling of indigestion. This condition usually occurs when a man is under stress during or immediately after eating or from eating improperly cooked food (Marsh & Hentges, 1988). A folk healer or a knowledgeable family member treats the person by pulling the skin on his back, massaging his back and stomach, or by administering cooking oil by mouth. While touching the patient, the folk practitioner recites religious prayers. For men, admitting they have empacho means taking a risk that a health care professional may laugh at them. They were embarrassed about this belief, and this kept them from seeking health care.

Gloria mentioned that her husband was embarrassed when he had a cyst removed from his foot.

   I insisted he go and have it removed. And I was
   serious about it. He had a shot in his back that
   numbed him from the waist down [spinal anesthesia].
   He complained that when he woke up he was naked. He
   doesn't like anyone to see him. The nurse [female] saw
   everything. He blames it on me. It was my fault
   because I made him go. I think it's the machismo
   thing. His friends find out and they tease him.

Mexican Americans prefer health care congruent with the cultural expectation of personalismo, or personalized attention. Personalismo denotes an emphasis on warm, intimate, interpersonal relationships (Purnell, 2003). Having a personal bond with the health care provider is important in building an atmosphere of trust (Caudle, 1993). Lack of personalismo is perhaps the major source of dissatisfaction with health care. In a busy health care facility, men feel they are being treated as a thing to be processed rather than as people. Cultural expectations of personalismo are ignored, dismissed, and not valued. These feelings increased the chances Mexican American men would not seek care for health problems.

Medical technology also acted as a barrier between the patient and the health care system if too much emphasis was placed on medical equipment and not enough on the patient. Chique complained that his family members were asked to leave the hospital during several recent hospitalizations. "As soon as visiting hours were over they kicked my wife and kids out, even if they were helping me eat or taking care of me. Why can't they just let them stay with me?" His wife offered that "the staff probably gets tired of all the Mexican American families hanging around the hospital all the time."

SUMMARY

Zoucha and Purnell (2003) claim that good health for many Mexican Americans means to be free of pain, to be able to work, and to have a general feeling of wellbeing. Villarruel and Ortiz de Montellano (1992) found that Mexican Americans endure illness and pain as a sign of showing strength, and they do not seek help until pain or the condition become unbearable. Sabo and Gordon (1995) have pointed out that gender socialization predicts how males adopt masculine behaviors from observing what is happening around them.

If men do not seek health care until they can no longer work and provide for their families, chronic diseases will have progressed far enough to produce bothersome symptoms. Late detection and treatment of life-threatening diseases can, however, shorten a man's life (Sabo & Gordon, 1995). Chavez et al. (1993), Marin, Posner, and Kenyon (1993), and Neff and Hoppe (1992) note that consuming large quantities of alcohol and a high rate of alcoholism contribute to mental health problems in Mexican American men. Health care providers need to routinely assess patients' participation in health promoting behavior and encourage them to make changes in their health habits (Hulme et al., 2003).

The goal of health care is to provide effective, appropriate interventions that are mutually agreed upon by the patient and the health care provider (Kavanaugh, 1995). The inability of patients to speak English and the lack of health care providers who speak Spanish have been identified as significant barriers to health care access (Torres, 1996). Elders can use culture brokers to coach, protect, and navigate patients through the allopathic health care system and to help assure greater adherence to recommended health treatments. Such brokers act as bridges, links, and mediators between health care professionals, patients, and their families so that language and cultural barriers can be overcome (Chalanda, 1995).

The literature attests to the fact that lack of financial resources to pay for health care is a barrier to seeking care (Ell & Castaneda, 1998; Spector, 2003). Mexican Americans often do not have health insurance; therefore, they do not have access and financial support to use health services (Perry, Kannel, & Castillo; 2000). Those who are uninsured are less likely to have a regular source of health care and rate their health status as excellent or very good (Trevino, Moyer, Valdez, & Stroup-Benham, 1991). For example, according to the National Center for Health Statistics (2002), 51% of Latinos in the United States aged 18 to 64 years old said they had not seen a dentist in the past year.

A lack of personalismo permeates the American health care system, where relationships between health care providers and their patients may be impersonal and distant (Delgado, 1995). Mexican Americans have a preference for health care encounters that emphasize the patient's relationship with health care providers in an atmosphere of trust and intimacy (Warda, 2000). Health care providers should therefore learn as much as possible about the Mexican American culture, ideally directly from the people under their care (Urrabazo, 1985). Feelings about lack of personalismo increase the chances Mexican American men will not seek care for health problems and make it imperative that health care professionals understand and engage in culturally competent practice. Medical technology itself also adds to barriers between people of different cultures (Leininger, 2001).

Norcross, Ramirez, and Palinkas (1996) found that men were 2.7 times more likely than women to be influenced to seek health care by a member of the opposite sex. They concluded that women exert a significant influence on men's decisions to seek health care and from whom to seek it, regardless of ethnicity. Women, especially wives, acted as health care brokers for men. Heusinkveld (1993) and Zoucha (1997) support the idea of engaging women as advocates for men's health. Specifically, Gleason (2006) found that women force Latino men to seek health care.

Averill (1997) found that the family plays an important role in solving problems, making decisions, and providing support. When Mexican Americans are being treated for health problems, there is usually a family member involved with the care (Berry, 2002). Families make health care decisions together, and in most cases it is not an individual patient's decision (Warda, 2000).

RECOMMENDATIONS FOR COMMUNITY-BASED HEALTH STRATEGIES

Several community-based strategies can be employed to improve the health of Mexican American men. First, men need to become more knowledgeable about health issues, recognize when they have a problem, and know what to do if there is a problem. Mexican Americans have more access to information through television and radio than ever before. Therefore marketing health promotion and care to Mexican American men through various media is important. Community leaders can assist in marketing strategies that are successful in the Mexican American community.

Manuel (aged 49), Ruben, Tomas, Carlos, and Roberto all agreed that Mexican Americans in their communities got most of their news by listening to the radio, especially Spanish radio. They frequently watch Univision (2006), a Spanish television station. According to many research participants, the most effective way news travels within the Mexican American community is by "word of mouth as it moves through the grapevine." Delgado (1995) emphasized that health promotion programs should target the specific communities where Mexican Americans seek health care.

Addressing the objectives from Healthy People 2010 (United States Department of Health and Human Services, 2000), a national health promotion and disease prevention initiative, is important for the Mexican American population. Healthy People 2010 promotes health screening, health education, and learning about common health problems. Community leaders and health care professionals can create community-based initiatives, such as working in partnership with community organizations. For example, programs such as the Hispanic Academic Achievers Program (Columbia Basin School Districts, 2005) are avenues to interest children in their health early in life. The strong network of Mexican American families that often exists in a community can be used as an infrastructure for community-based health initiatives. Churches and the school system are stable sources for promoting health and health care. Children can learn about health and, in turn, can influence health decisions and actions taken by their parents and grandparents.

Community centers and churches can offer classes on techniques such as cardiopulmonary resuscitation and first aid, engaging community members in health initiative efforts. Family or community sports activities that usually appeal to men can be organized to promote healthy behaviors.

Juarbe (1996) maintained that a community-based paradigm is needed to promote cardiac health among Mexican American men and women. She suggests that schools, the workplace, women's organizations, and community-based organizations can effect change. Juarbe adds, however, that community-based programs will not be successful without state and local policy support.

The skills that health care professionals need in serving Mexican American men include bilingualism, objective listening skills, subjective caring, providing personal care, and knowing when to give advice. If health care providers keep an open mind and are nonjudgmental about cultural and religious beliefs a patient may hold, they will avoid embarrassing the patient and themselves. Health care professionals might consider building relationships with folk healers if a Mexican American population is utilizing their services.

Theresa, a 42-year-old Mexican American woman, lost her husband to an early death when he was 25 years old because he sought health care too late. She suggested that health care professionals "catch a man when you have him," meaning, convince him to be examined or screened for health problems when the opportunity arises if he does access the health care system or even if he happens to be in a health care facility with his children.

Community leadership is a significant factor in promoting effective transcultural health care. Community leaders can have great impact on health care policy and practice, improving and enhancing heath care organizational culture and serving as role models. It is wise to engage clergy and staff at churches where Mexican Americans are members to provide input and support for health programs.

If health promotion, disease prevention, and early detection strategies are not reaching Mexican American men, perhaps these could be directed toward women so that they can reach the men in their families and communities about health-related issues. How women, especially wives, influence Mexican American men's health status should be further explored. Women may help improve health-promotion awareness and action among the men in their lives. Health care professionals and community leaders might recruit women to become health care advocates to men, because often this is the traditional role of women in the culture. Women can learn how to be cultural brokers for the men in their lives.

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MARY C. SOBRALSKE

Shriners Hospitals for Children

Honolulu, Hawaii

Correspondence concerning this article should be directed to: Mary Sobralske, PhD, RN, Shriners Hospitals for Children Honolulu, 1310 Punahou Street, Honolulu, HI 96826. Electronic mail: msobralske@ shrinenet.org.

Table 1
Demographic Characteristics of Eight Primary
Research Participants (Pseudonyms)

                Felipe         Eduardo        Carlos

Age             24             30             32
Marital
  status        M              M              S
Religion        Apostolic      Catholic       Catholic
Present         Farm           Home           Community
  occupation      worker         visitor        outreach
Education
  (grade)       10             12             16
Nativity
  (self)        Mexico         Texas          Texas
Nativity
  (mother)      Mexico         Mexico         Texas
Nativity
  (father)      Mexico         Mexico         Mexico
Years
  in U.S.       5              22             32
Years in
  WA state      5              11             24
Acculturation
  level *       Low            Moderate       High

                Manuel         Chique         Ruben

Age             49             55             57
Marital
  status        M              M              D
Religion        Catholic       Catholic       Catholic
Present         Educator       Factory        State
  occupation                     worker         employee
Education
  (grade)       18+            2              14
Nativity
  (self)        Mexico         Mexico         Texas
Nativity
  (mother)      Mexico         Mexico         Texas
Nativity
  (father)      Unknown        Mexico         Mexico
Years
  in U.S.       30             33             57
Years in
  WA state      15             29             36
Acculturation
  level *       Low            Low            Moderate

                Tomas          Roberto

Age             60             73
Marital
  status        M              M
Religion        Catholic       Catholic
Present         Social         Construction
  occupation      services
Education
  (grade)       12+            10
Nativity
  (self)        Texas          Texas
Nativity
  (mother)      Texas          Mexico
Nativity
  (father)      Texas          Mexico
Years
  in U.S.       60             73
Years in
  WA state      13             55
Acculturation
  level *       High           Moderate

* Acculturation level is based on answers
to questions on acculturation.