Keywords

Latinxs in the United States

Latinxs make up 17.7% of the US population, and this percentage is projected to increase to 23% by 2035 [1]. The rapid growth of the Latinx population in the US highlights the need to understand the lifestyle practices associated with the burden of chronic diseases like cancer. An estimated 18% of cancer cases in the United States are related to physical inactivity, poor nutrition, alcohol consumption, and adiposity [2]. Despite having lower socioeconomic status (SES) compared to other racial/ethnic groups, many chronic diseases are observed to be lower in Latinxs, a pattern often referred to as the Hispanic Paradox [1, 3,4,5]. As Latinxs acculturate to US culture, their risk for chronic disease increases [6]. As such, understanding the cultural and behavioral patterns of recent immigrants may shed light on the protective behavioral practices that may explain the better-than-expected health outcomes in this community. This chapter highlights the core cultural values among Latinx populations that may buffer the impact of low SES on lifestyle behaviors like physical activity and diet. These values include personalismo (e.g., formal friendliness), familismo (e.g., strong family values), collectivism, and aspects of acculturation. The following sections describe the potential buffering effects of these cultural factors on health outcomes in Latinx communities.

Bidimensional Aspects of Acculturation and Their Influence on Health

Acculturation is the change in an individual’s attitudes, behaviors, and values from the culture of origin to the dominant or host culture; acculturation can influence disease risk through stress-induced exposures and the adoption of unhealthy behaviors [7, 8]. Some behaviors related to acculturation, such as increased physical activity during leisure time, can also decrease the risk of disease [9]. The process of acculturation is multi-faceted and can occur at the physical, biological, political, economic, and societal levels [10]. Some argue that acculturation is not a linear process and that individuals can maintain elements of their own culture while simultaneously adopting elements of the dominant culture (e.g., biculturalism) [11]. Other bidimensional aspects of acculturation include assimilation into the dominant culture, maintenance of the traditional culture, and marginalization (e.g., rejection of both the traditional and dominant culture). These processes of cultural acquisition and other cultural aspects of the Latinx heritage can contextualize the health practices of Latinxs to inform interventions.

Reframing Latinx Health Using a Strength-Based Approach

Strength-based research posits that individuals, groups, and organizations have strengths, and researchers could use this information to inform the development of health programs that aim to protect communities from chronic diseases [12]. Strength-based research is a counterpoint to the more traditional approach where intervention/prevention strategies are informed by the deficits of participants (e.g., low education) or communities [13]. The advantage of strength-based research is that it can enhance individuals’ agency and empower communities to achieve and maintain recommended health practices [14]. Originally implemented in the field of social work, strength-based approaches have been used with greater frequency in psychology and public health. Using a strength-based framework to inform intervention research can empower individuals and re-affirm their cultural identity. Cultural identity, which often includes an individual’s racial/ethnic or geographic origins, is also hypothesized to be associated with health-protective behaviors [15].

Latinx culture has many positive aspects that promote health and serve as protective factors. Cultural elements such as collectivism, personalismo, and familismo can be considered strengths as opposed to deficits or risks to health. When cultural strengths are recognized, they can be leveraged to increase the relevancy for individuals to engage in research and health programs. The incorporation of Latinx cultural practices and values into patient care and public health interventions may also increase health management behaviors. For example, the inclusion of cultural components such as language, values, and beliefs can influence medical mistrust, patient-provider communication, and adherence behaviors for Latinxs [16].

Latinx Cultural Strengths

Collectivism

Latinxs living in the United States are a heterogeneous group, with diverse attitudes, values, and beliefs. Within the context of the overall group, Latinx populations are collectivistic and prioritize the welfare of the group over the well-being of individuals within the group. Distinguishing features of collectivism include interdependence within members of the group and fostering social relationships that establish reciprocal obligations [17]. Social organization within collectivism is typically hierarchical, with all members of the group fulfilling roles that support the goals of the group. Health programs that build on collectivism and are group based have demonstrated positive outcomes in Latinx communities [18, 19].

Familismo

Within the overarching system of collectivism is familismo, which stresses the importance of social cohesion among the family unit and is one of the core cultural values for Latinxs [20, 21]. Familismo, as it is referred to in Latinx culture, is a multidimensional system of beliefs and values that emphasizes the connection to family, group harmony, respect (respeto), and obedience. The family unit is considered the primary “in-group” and can include the nuclear and extended family. Familismo encompasses social cohesion behaviors and structural values including frequent socialization and consultation with members of the family. For Latinxs, familismo is hypothesized to be a protective factor that minimizes risks related to physical health and could help explain some of the positive health outcomes between foreign-born and US-born Latinxs [22]. Health programs can build on this cultural aspect by engaging family members when addressing an individual’s health to increase support and reinforcement of health guidelines and recommendations.

Personalismo

Personalismo refers to the value of personal relationships with an emphasis on friendliness and trust [22, 23]. Valuing interpersonal relationships may be one of many reasons why the promotora model has been successful in influencing behavioral outcomes in Latinx communities. Because promotoras are integrated and trusted members of their community, they can motivate individuals to engage in behavioral change based on cultural understanding and social support [24]. Promotoras can facilitate the cultural currency needed to achieve desired results or health outcomes of an intervention.

Health Practices Evident in Recent Immigrants

The following sections describe the hypothesized protective role of cultural strengths on health practices for behaviors related to diet and physical activity.

Dietary Intake

Healthy dietary patterns are linked to reduced cancer risk [25, 26]. Among the three most common forms of cancer (breast, colorectal, and prostate), diets rich in fruits, vegetables, whole grains, fiber, and fish can reduce cancer incidence and increase survival [25]. The nutritional value of foods consumed by recent Latinx immigrants declines with acculturation to US culture [27,28,29,30]. Specifically, studies show that less acculturated Latinxs consume more fruits, vegetables, whole grains, seafood, and plant proteins, and less sodium than more acculturated Latinxs [31, 32]. These findings are consistent with those of a systematic review of the dietary intake of Latinxs showing that less acculturated Latinxs consumed fewer sugary foods and sugar-sweetened beverages; and more fruits, rice, and beans compared to their acculturated counterparts [30]. Described below are family-related behaviors that may contribute to healthier nutritional intake among less acculturated Latinxs, who exhibit an array of protective dietary behaviors that contribute to the quality of foods consumed, including the frequency of consuming away-from-home foods, home-cooked meals, grocery shopping, and meal sharing.

Away-from-Home Foods

Away-from-home eating includes consuming foods purchased at fast food and full-service restaurants, pre-prepared foods from grocery stores, and foods obtained from friends or relatives [33]. Among Latinxs, consuming away-from-home foods less frequently is associated with higher diet quality [34]. More acculturated Latinxs also tend to consume more fast food than less acculturated Latinxs [30].

Home-Cooked Meals

One potential reason for lower away-from-home food consumption among less acculturated Latinxs is their emphasis on cooking meals at home. In the time-use study by Sliwa et al., over 90% of first-generation Latina mothers prepared foods at home in the previous 24 hours, compared to approximately 75% of third-generation mothers [35, 36]. Increased time spent preparing a meal may indicate greater cooking skill and less reliance on ready-to-eat foods, both of which are related to healthier food intake [37,38,39].

Grocery Shopping

Grocery shopping is also an important indicator of cooking at home, which is associated with lower consumption of daily calories, fat, and sugar [40]. Using language as a proxy for acculturation, findings from the National Health Nutrition Examination Survey (NHANES) study show that purchases at grocery stores over 30 days were higher among Spanish-only speakers ($450) versus English-only speakers ($369) [36]. These studies suggest greater grocery shopping behaviors among Latinxs who are less acculturated to the United States.

Sharing Meals

Sharing meals as a family is a dietary practice evident in less acculturated Latinos [41]. This behavioral practice acts as a protective factor as family meals versus individual meals are more likely to be healthier (e.g., include a variety of fruits and vegetables), provide for emotional connection among family members, and enable parents to model healthy eating behaviors [42].

Gender and Family Influences on Dietary Practices

The role Latinas play in planning, purchasing, and preparing meals may be a key reason why less acculturated Latinx families eat healthier [43,44,45]. Many Latina immigrant mothers preserve their traditional dietary patterns after immigrating to the United States where they incorporate fresh produce into their meals [46]. As such, Latina mothers’ healthy food practices can positively influence their children’s eating and food preferences [35, 45, 47, 48]. Latinx children can also influence the dietary practices of family members. For example, Latino mothers who have a bicultural versus an assimilated child are more likely to eat vegetables and are less likely to consume sugary beverages and eat away-from-home meals [49]. These findings suggest that children can influence the dietary practices of their parents and the type of influence may be dependent on the acculturation status of children.

Culture and Physical Activity

Physical Activity

Physical inactivity has been linked to bladder, colon, esophageal, kidney (renal cell), and stomach (gastric) cancers [50]. Physical activity is a modifiable factor that can help to decrease the risk of obesity and other related comorbid diseases. Active individuals may experience a 10–25% reduction in relative cancer risk in comparison to minimally active individuals [51, 52].

Active Transportation

Levels of physical activity among Latinxs will vary by acculturation status [53]. Among less acculturated Latinxs, exposure to US culture may decrease behaviors that were commonly practiced in the country of origin [54]. Behaviors such as completing errands by foot and the use of public transportation are often replaced by increased automobile use through the process of acculturation. Dependency on a vehicle may also be associated with neighborhoods that have limited infrastructure and are less walkable or safe to engage in physical activity [55]. Given the benefits of physical activity against cancer risk, public health programs may want to consider active transport (e.g., walking school buses) as an appealing and viable intervention option for diverse communities [56, 57].

Interventions That Build on the Strengths of Latinx Culture

Figure 15.1 outlines the ways in which behavioral interventions can integrate Latinx cultural factors.

Fig. 15.1
An illustration depicts cultural factors of behavioural interventions. It includes collectivism, familismo, personalismo, cultural elements, intervention approaches, and short, and long-term outcomes.

Latinx cultural elements, intervention approaches, and outcomes. The first segment depicts a three-tiered socioecological model with ascending nested levels of personalismo, familismo, and collectivism. The second segment describes Latinx cultural elements at each level and their hypothesized protective factors. The third segment introduces intervention approaches for implementing the values into practice, and the fourth segment describes potential short- and long-term outcomes of Latinx practices

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Harnessing the Positive Aspects of Familismo

Although stressors from work and education may impact the division of responsibilities among family members, familismo may increase support for engaging in healthy behaviors. Research indicates that family support improves Latinx women’s self-management of diabetes care, including increased physical activity and healthy dietary behaviors [55]. Several obesity-prevention programs that draw on familismo and engage family members have been successful. For example, Active and Healthy Families (Familias Activas y Saludables) recruited parent-child dyads to participate in 10 weekly 2-hour-long group sessions that addressed culturally relevant topics including parenting practices, dietary behaviors, immigration, and stress [55]. Another successful program that harnessed family relationships was Entre Familia [58]. This intervention was delivered by promotoras (community health workers) via home visits and telephone calls and was successful in increasing children’s reported intake of a variety of vegetables and mothers’ diet quality [58, 59]. Finding common ground through communication and shared experiences to engage family members in healthy practices may ultimately lead to increased familial bonds promoting family health.

Health Programs Embracing Collectivism and Personalismo

Studies that incorporate culturally specific values and beliefs, such as collectivism, may be more effective for their intended populations [60]. For Latinxs, the promotion of physical activity through group-based programs led by promotores in community settings has resulted in increased physical activity among Latinxs [61, 62]. The successes of these programs are, in large part, due to the promotores’ ability to engage and interact with community members and participants receiving social support from and feeling connected to other group members.

Challenges, Opportunities, and Future Directions

Current challenges to advancing the science for Latinx individuals include access to care and financial constraints, which have been further exacerbated by the COVID-19 pandemic disproportionately impacting communities of color [63]. Many Latinx individuals have experienced increased risk and occupational exposure due to the nature of service-related jobs [61]. There has also been an increase in loss of employment and associated benefits, such as health insurance. For these reasons, recruitment for intervention studies may be especially challenging, as individuals are prioritizing more critical needs for the survival and prosperity of their family. Public health practice and research will also experience challenges due to the current political climate and social upheaval in our society related to the targeting and mistreatment of individuals of color [64]. This may contribute to health disparities already present among those with limited resources. Considering the challenges in front of us, it is essential that we connect with community groups to enforce the infrastructure and relationships that existed before the pandemic and to encourage their continued partnerships in health with providers, researchers, and healthcare systems.

Creating Future Opportunities Using Cultural Strengths to Advance the Science

To advance the health of Latinxs, health interventions need to build on the protective factors associated with Latinx health while recognizing the nuances specific to risk within the culture. The cultural aspects of familismo, collectivism, personalismo, and other shared values should be integrated into the design and practical application of research because they may serve as potential mechanisms of action related to health prevention, risk, and management behaviors. Community-based interventions that are implemented in churches, non-profit organizations, neighborhood clinics, and other community-endorsed establishments are effective because they are trusted sites for participants which align with the value of personalismo. With recruitment and participant engagement being the most challenging aspects of cancer prevention and treatment studies, community-based studies can be a key component to the advancement of health among Latinxs, especially now. Knowledge and understanding of the local community will also aid in the dissemination of information and the advancement of prevention efforts.