Introduction
Latinos represent the largest and fastest growing ethnic minority population in the United States (U.S. Bureau of the Census
2010). Although the incidence of many cancers is lower among Latinos compared to non-Latino whites, Latino men and women are less likely to survive most cancers, even after accounting for differences in age (American Cancer Society
2009). Lower rates of survival likely reflect diminished access to early detection, diagnostic, and treatment services. Many Latinos face financial, structural, and sociocultural barriers to health care and are therefore less likely to seek and receive healthcare services (American Cancer Society
2008; Balluz et al.
2004). Latinos have lower rates of screening for breast, cervical, and colorectal cancer compared to non-Latino whites (American Cancer Society
2008). Persistent cancer disparities suggest the need for new approaches to reach this population.
Faith-based organizations (FBOs) are a promising avenue to reach Latinos. Ninety percent of Latinos report membership in a religious group (Cadge and Ecklund
2007; Espinoza et al.
2003). Moreover, religious institutions play a prominent role in Latino communities, shaping numerous behaviors from political decisions to daily family life (Pew Hispanic Center and Pew Forum on Religion and Public Life
2007). Qualitative research suggests that Latinas, in particular, view religiousness/spirituality as an important dimension of overall health (Jurkowski et al.
2010).
Religiousness is a multidimensional construct that reflects the shared beliefs and practices of a faith-based, social organization (Miller and Thoresen
2003). A sizeable body of literature documents relationships between religiousness and health outcomes (Chatters et al.
1998; Koenig et al.
2001; Powell et al.
2003). Recent research has focused on the link between different dimensions of religiousness and preventive health behaviors (e.g., Benjamins et al.
2011; Holt et al.
2009a). However, little is known about the specific religious factors that may impact preventive health behaviors among Latinos (Benjamins
2007).
Religious coping theory (Pargament
1997) and social support theory (Israel
1990) suggest several possible avenues through which religious factors may influence use of preventive health services, including cancer screening behaviors. First,
church
participation, generally defined as frequency of attendance at religious services or other church-related events (Idler
1999), may influence exposure to church norms (e.g., no smoking and moderation of alcohol). Second, increased access to
religious support, defined as instrumental, informational, or emotional assistance exchanged within a religious community, may buffer stressful life events, thereby providing increased ability to cope with negative events (e.g., abnormal screening results) (Krause
1999; Pérez et al.
2011; Strawbridge et al.
1997; van Olphen et al.
2003). Third, one’s relationship with a higher power may affect perceived control over health behaviors and outcomes (Thoresen and Harris
2002). For instance, a collaborative relationship with a higher power in the management of one’s health, known as an
active
spiritual health locus of control, may empower people to engage in behaviors beneficial for their own health. Alternatively, a
passive spiritual health locus of control may lead people to rely solely on God to determine their health (Holt et al.
2003,
2007), akin to what has been described as
fatalismo (fatalism)—a sense that one’s life outcomes are beyond one’s control (Abraído-Lanza et al.
2007; Añez et al.
2005). Finally, religion may impact health behaviors through
religious coping, a construct that reflects how people utilize religion to understand and deal with stressors (Pargament
1997; Pargament et al.
2000).
Positive religious coping reflects benevolent religious methods of understanding and managing life stressors, whereas
negative religious coping reflects religious struggles in coping (Pargament et al.
1998). An association between religious coping and health suggests the presence of stressors in a population. In the current sample of participants, factors such as low socioeconomic status, racism, language barriers, undocumented immigration status, and lack of access to health care were expected to be stressors.
A better understanding of the specific dimensions of religiousness associated with health behaviors (in this case, cancer screening) among Latinas could enable the development of effective, religiously tailored interventions to promote cancer early detection with the ultimate goal of reducing health disparities. Studies conducted with African-American populations suggest that incorporation of religious themes into health interventions may enhance their relevance, improve program participation, and, ultimately, boost intervention efficacy (Campbell et al.
2007; Holt et al.
2009b; Voorhees et al.
1996; Yanek et al.
2001). Church-based interventions have been used to promote cancer education and cancer screening among low-income Latinas (e.g., Duan et al.
2000; Fox et al.
1998b; Lopez and Castro
2006). However, to our knowledge, none of these programs have integrated religious content into their health promotion messages. Therefore, we sought to understand the relationship between varied dimensions of religiousness and cancer screening practices among Latinas in order to inform such interventions. Specifically, we explored the association between cancer screening practices and four dimensions of religiousness: (1) church participation, (2) perceived religious support, (3) spiritual health locus of control, and (4) religious coping.
Discussion
We sought to identify possible relationships between dimensions of religiousness—church participation, religious support, spiritual health locus of control, and religious coping—and adherence to cancer screening recommendations. The most noteworthy finding was a strong association between positive religious coping and adherence to all age-appropriate screening, even after controlling for relevant covariates. For every one-point increase on the positive religious coping scale, the odds of having completed all cancer screenings were increased by a factor of 5.3. Positive religious coping involves actively seeking spiritual support and working in partnership with God to solve problems (Pargament
1999). Such actions may reduce anxiety about getting screened or receiving positive test result. Cancer screening may be perceived as a “risky” behavior among some Latinos; one risks discovering that one has cancer through screening, which is often linked to
muerte (death) in the Latino community (Fernandez et al.
2008). In this context, positive religious coping may help individuals overcome fear that may act as a barrier to screening.
While passive spiritual locus of control was negatively associated with all age-appropriate cancer screening, it did not achieve statistical significance. Notably, few in our sample expressed a highly passive spiritual health locus of control. Levels of active spiritual locus of control—a collaborative relationship with God—were much higher. This finding is consistent with qualitative work by Flórez et al. (
2009), showing that breast cancer screening behaviors among Dominican women were influenced by a combination of internal (personal agency) and external (e.g., based on God’s will) forces. It was also consistent with qualitative work among healthy Latina women, showing that an active relationship with God in maintaining one’s health was much more common than a passive relationship where God alone is responsible for one’s health (Jurkowski et al.
2010). Taken together, these findings suggest that simplistic conceptions of
fatalismo may not accurately reflect the predominant health locus of control about cancer screening and prevention among Latinas (Abraído-Lanza et al.
2007).
Overall, we found low rates of adherence to all screening tests for which one was eligible; nearly half of respondents needed one or more of the recommended examinations. However, adherence to individual cancer screening tests in our predominantly female sample was similar to Massachusetts screening rates among Hispanic women (Massachusetts Department of Public Health
2009). For example, 88 % of women aged 18 and older in our sample reported having had a Pap test within the past 3 years, compared to 86 % in a Massachusetts sample (Massachusetts Department of Public Health
2009). Mammography in the past 2 years for women aged 50+ was 83 % in our sample, compared to 89 % for women aged 40+ in Massachusetts (Massachusetts Department of Public Health
2009).
Not surprisingly, we found high levels of church participation among our church-based sample; the majority of respondents were at the church on a daily or weekly basis. Although respondents frequently attended church and reported high levels of positive religious support, neither of these variables was associated with cancer screening practices. Prior studies of these relationships have been mixed, with some finding no association (Fox et al.
1998a; Katz et al.
2008) and others finding positive associations (Benjamins
2006) between church attendance, self-rated religiousness, and breast cancer screening. In our sample, there was very little variability in these measures (i.e., ceiling effects), which may partially account for the lack of associations.
Before discussing implications, there are a number of study limitations that must be noted. First, data were collected from a small, purposive sample of low-income, Spanish-speaking Latinas primarily from Central and South America. Although the focus on an underserved, minority sample is a strength of the study, generalizability of this data is limited. Second, participants self-reported both cancer screening behaviors and religiousness, which leaves open the possibility of recall and social desirability biases. To minimize the potential for this, we assessed the religious measures after the cancer screening items to minimize order effects. Third, the negative religious coping and negative religious support variables had very low interitem reliability and, therefore, could not be included in the analyses. This may be due to a floor effect, as very few participants in this highly religious sample endorsed these items. Finally, we used a cross-sectional design, which limits our ability to explore temporal or cause-effect relationships. Accordingly, relationships between religiousness and screening utilization may be explained by additional unknown, unmeasured factors. For example, an underlying personality trait, such as optimism, could have influenced both religious coping and cancer screening behaviors (Koenig, et al.
2001).
Nevertheless, we believe this to be one of the few studies to employ multidimensional measures of religious/spiritual constructs that assess distal aspects of religion (e.g., church attendance) and proximal aspects of religion (e.g., religious coping) that may influence cancer screening behaviors in a Latina population. If proximal religious predictors of cancer screening behaviors can be identified, they should be examined as potential mechanisms in church-based interventions. Understanding these underlying mechanisms could enhance the efficacy of cancer control interventions.
Churches provide access to a large segment of the Latino population—including people of diverse ages, socioeconomic levels, and ethnic groups (Pew Hispanic Center & Pew Forum on Religion and Public Life
2007), and provide existing infrastructures, communication networks, and facilities that are useful for health promotion activities. As such, they represent a promising venue for the dissemination of health interventions. Understanding the aspects of religion that can support health behaviors will be helpful in designing interventions that resonate with a church-based audience. If replicated in a larger, more representative sample, our findings suggest that religious coping can play an important role in motivating cancer screening. Such investigations are warranted given the health disparities among Latinos.
Acknowledgments
This study was supported by a grant from the National Institutes of Health (U56 CA118641); Dr. Pischke was supported by R25 CA057713-05. We gratefully acknowledge the leadership and support of Drs. Karen Emmons and Adán Colón-Carmona. We also thank the following for their participation and support: Milagros Abreu, Erick Alcantata, Esteban Barreto, Lois Biener, Karen Burns White, Katia Canenguez, Magnolia Contreras, Ana Gáleas, Maria De Jesus, Ericka Gonzalez, David Hurtado, Thelma Juarez, Bryan Leyva Vengoechea, Yolanda Martins, Yudy Muneton, Leyla Pérez-Gualdrón, Maria Nieves Sesma, Max Stewart, and Jamielle Walker.