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Exploring health beliefs and care-seeking behaviors of older USA-dwelling Mexicans and Mexican-AmericansAnissa T. Rogers aa Department of Social and Behavioral Sciences , University ofPortland , 5000 N. Willamette Blvd, Portland, OR, 97203, USAPublished online: 06 Aug 2010.

To cite this article: Anissa T. Rogers (2010) Exploring health beliefs and care-seeking behaviorsof older USA-dwelling Mexicans and Mexican-Americans, Ethnicity & Health, 15:6, 581-599, DOI:10.1080/13557858.2010.500018

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Exploring health beliefs and care-seeking behaviors of olderUSA-dwelling Mexicans and Mexican-Americans

Anissa T. Rogers*

Department of Social and Behavioral Sciences, University of Portland, 5000 N. Willamette Blvd.,Portland, OR 97203, USA

(Received 21 January 2010; final version received 7 June 2010)

Objective. This study explored health beliefs and healthcare-seeking behaviors ofolder USA-dwelling Mexicans and Mexican-Americans using the Theory ofPlanned Behavior (TPB) as a conceptual guide.Design. A mixed-method cross-sectional design was utilized using semi-structuredinterviews to obtain detailed descriptions of 31 older (50�) participants’behavioral, normative, and control beliefs about health and healthcare utilization.An interview schedule consisting of open-ended and demographic questions andone standardized tool, the Bidimensional Acculturation Scale (BAS) forHispanics, was used to collect data.Results. Several themes emerged for each belief area. Behavioral belief themesreflect participants’ faith in, comfort with, and knowledge of traditional methodsof care (e.g., herbs, teas, and use of curanderas) as well as their faith in theeffectiveness of conventional care (e.g., medicine, technology, and use ofphysicians). Normative belief themes indicate that participants perceive thatfamily and community contacts support participants’ use of traditional methodsand that family supports use of conventional methods. Control belief themessuggest that traditional methods are accessible and affordable but that conven-tional methods are not. BAS scored indicated that most (90.3%) participantsadhered to Hispanic culture. Two (6.5%) participants adhered to non-Hispanicculture and one (3.2%) scored as bi-cultural.Conclusions. Themes from the data suggest that beliefs about healthcare impactthe types of care utilized and the ways in which they are utilized. Clinicians andresearchers striving to reduce health disparities and develop more culturallycompetent healthcare services for ethnic minority groups should work toward abetter understanding of minority groups’ belief systems about healthcare and itsutilization. Utilization of the TPB allows for empirical model development thatcan better predict healthcare utilization behavior, further augmenting efforts toprovide services that will help reduce health disparities for older Mexicans andMexican-Americans and other populations.

Keywords: Latino/a; health; immigrants; cultural competence practice; disparities(health, racial)

Introduction

As a group, Latinos in the USA suffer from poorer health outcomes than their non-

Hispanic White counterparts (Smedley et al. 2003, Nielsen-Bohlman et al. 2004,

Kaiser Family Foundation 2005a). Factors contributing to health disparities include

*Email: rogers@up.edu

Ethnicity & Health

Vol. 15, No. 6, December 2010, 581�599

ISSN 1355-7858 print/ISSN 1465-3419 online

# 2010 Taylor & Francis

DOI: 10.1080/13557858.2010.500018

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advancing age, language barriers, and poor health literacy (U.S. Department of

Health and Human Services 2004). While various socioeconomic characteristics are

associated with health disparities, these characteristics only partially explain why

Latino people in general, and older Latino people in particular, have highermorbidity and mortality rates and poorer access to healthcare services than non-

Latino Whites. Indeed, health disparities experienced by Latino groups are thought

to be the result of complex interactions between and among cultural, socioeconomic,

and environmental variables (U.S. Department of Health and Human Services 2000).

While constructs such as health beliefs, health practices, and cultural norms about

health are likely to contribute to health disparities, little is known about how these

factors influence perceptions about health, which in turn influence health-related

behaviors.Because of the complexity of grouping diverse Latino cultures under the rubric of

‘Hispanic’ or ‘Latino,’ methodological shortfalls in capturing cultural subtleties

between and within Latino groups, and health issues specific to older Latinos,

particularly as they age in place in the USA, there is a need for more qualitative

approaches that investigate individual beliefs related to health behaviors and better

articulate relationships between various constructs (such as cultural norms and

perceived control over health) and behaviors that lead to poor health outcomes.

Further, more research is needed to determine how to organize constructs in a modelthat can be tested, replicated, and explain how these constructs interact to determine

specific health outcomes (National Academies Press 2003, Kaiser Family Founda-

tion 2005b). Thus, the aim of this study was to explore the health beliefs of a specific

group of Latinos, older Mexicans, and Mexican-Americans living in the USA, using

the Theory of Planned Behavior (TPB) (Ajzen 1991) as a conceptual guide. By

understanding health-related beliefs, it is possible to better articulate the processes

that influence people’s actions in health-related situations, leading to more accessible,

effective, and culturally competent approaches to health services that will reducehealth disparities for underserved populations.

Health disparities and care-seeking behaviors among older Mexicansand Mexican-Americans

Many researchers and healthcare professionals agree that the key to decreasing

health disparities is to improve the quality of and access to healthcare, particularly

for older patients. Research indicates that health disparities can be accounted for, inpart, by problems in communication, poor ‘cultural matches’ between patients and

providers, and specific behaviors of patients and providers (Kaiser Family Founda-

tion 2005b). However, many other factors contribute to health disparities for older

Mexicans and Mexican-Americans. Social context, which includes culture, is

important to consider when examining health outcomes, yet it is poorly understood

(Kaiser Family Foundation 2005a). Culture, or the norms, beliefs, values, and

traditions that influence people’s world views (Helman 1994), gives meaning to

health, health information, and perceptions about appropriate health-relatedbehaviors. It determines the type and quality of communication between individuals,

families, communities, and providers about health, illness, and healthcare-seeking

behaviors. The experience of culture also is not static. Often as people age, move, and

gain experiences, their perceptions change as they adapt to new situations and

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environments. Acculturation, then, as part of culture, impacts how people think

about health and interact with various healthcare systems (Nielsen-Bohlman et al.

2004).

Individual characteristics also interact with cultural characteristics to furtherinfluence a person’s perceptions and behaviors. Personal beliefs and attitudes about

health, illness, what should be done in case of illness, and perceived access to desired

care all influence individual health behaviors. Further, age, income, education,

transportation, legal status, health literacy, language ability, familial patterns,

geographic location, community support and resources, and ability to navigate

healthcare systems are only a few of the factors that, combined with cultural factors,

affect care-seeking behaviors and the perceived control people feel they have over

accessing care (National Academies Press 2002, Kaiser Family Foundation 2005a,Rogers and Gallegos 2007).

Institutional and other barriers also contribute to disparate health outcomes. For

example, health jargon, language barriers, and competing and conflicting health

messages and sources of information can create insurmountable barriers to care

(Nielsen-Bohlman et al. 2004). Geographical and physical barriers to facilities,

negative interactions with healthcare systems, and a lack of knowledge about how to

utilize systems can create problems for patients, particularly older patients. Time

constraints and biases or uncertainties about how to work with older minoritypatients may create problems for providers (Smedley et al. 2003). Age and race

discrimination are even larger, more entrenched institutional issues that contribute to

health disparities and create barriers for older minority individuals in receiving

equitable effective care (National Academies Press 2003).

Theoretical background and conceptualization

To conceptualize and explore how individual and cultural factors influence healthbehaviors, the TPB (Ajzen 1991) was used to guide and organize constructs in this

study. According to the TPB, behavioral beliefs are personal beliefs that underlie

people’s attitudes about particular behaviors. Normative beliefs are beliefs that people

perceive are held by individuals or groups within one’s culture or environment about

behaviors, and these beliefs underlie people’s subjective norms about particular

behaviors. Control beliefs are beliefs that people perceive either hinder or help to

facilitate behaviors, and they underlie people’s perceived behavioral controls. This

theory posits that ‘salient’ beliefs, or the most important beliefs about behaviors, arethe determinants of behavioral intentions (Ajzen and Fishbein 1980, 2000, Ajzen

1988, 1991). Figure 1 offers a visual display of the theoretical concepts and how they

function to influence behavior.

This theory emphasizes the importance of beliefs about healthcare-seeking

behaviors, which is an important step to understanding the complex interplay

between cultural and individual factors that influence people’s care-seeking

behaviors. Using the TPB, this study explores beliefs of older Mexicans and

Mexican-Americans regarding use of various types of healthcare. Because of thecomplexity of problems related to health disparities, a better understanding of

cultural and individual beliefs that affect health-related attitudes, norms, and

perceived control over health is needed to better articulate how these factors impact

decision-making processes about healthcare. This enhanced understanding will assist

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in developing and implementing more effective, accessible, comprehensive, and

culturally appropriate healthcare services that will help to permanently reduce health

disparities among older Mexicans and Mexican-Americans and other ethnic

minority groups (National Academies Press 2003, Kaiser Family Foundation 2005b).

Methods

This study employed a non-experimental, mixed-method (Morse 1994, Creswell

2003), cross-sectional design to explore participants’ behavioral, normative, and

control beliefs regarding use of traditional (e.g., herbs, sweat lodges, and providers of

care, such as curanderos and yerberos) and conventional (e.g., medications,

technology, providers of care such as nurses and physicians) healthcare using one-

on-one in-depth interviews. Researchers argue that qualitative approaches are the

best methods to use to study health disparities because of the complex factors related

to the issue (Smedley et al. 2003). When guided by a theoretical framework,qualitative methods offer a better understanding of individual perceptions than can

be gained through quantitative means alone. Further, qualitative methods allow for

theory development by allowing for exploration of the meaning of constructs and

interrelationships between them that may not have been identified in previous

research (Creswell 1998). Thus, in-depth explorations of concepts related to health

expand our knowledge of these issues and assist in developing more effective

culturally competent solutions to health disparities.

To assist with the project, a research team was formed that included leaders in theLatino community, bilingual/bicultural interviewers, and community-based advisory

committee members. This team informed the development and implementation of

the project and assisted in identifying community targets that could benefit from

dissemination of results. Before the study began, research ethics approval was

secured through the author’s home institution and the governmental entity

overseeing the agencies from which participants were recruited.

Participants

A convenience sample of 31 older community-dwelling Mexican and Mexican-

American adults living in a northwest metropolitan area in the USA were recruited

through several non-health-related community agencies. Members of the research

team identified community agencies known to serve large numbers of older Latinos

Behavioral

Beliefs

Normative

Beliefs

Control

Beliefs

Perceived

Behavioral

Control

Subjective

Norm

Attitude

Intention Behavior

Figure 1. The Theory of Planned Behavior.

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and contacted staff of these agencies to recruit participants for the study. Staff of

these agencies discussed the purpose of the study with clients meeting eligibility

requirements and referred participants to the project’s research assistant, who set up

appointments between interviewers and participants. Clients were deemed eligible to

participate if they were aged 50�, identified Mexico as their country of origin

(whether first or subsequent generation), and showed no cognitive impairments that

would hinder the interview. Participants received $15.00 compensation for their time.

Selected demographic information was collected on individuals who chose not to

participate (N�3); analyses on these data indicated no significant differences on

demographic characteristics between participants and non-participants.

The age range of the participants was 54�85 (M�68) and most were female

(87%). On average, participants reported suffering from two illnesses, primarily

diabetes and high blood pressure. Participants reported, on average, taking two

medications for their ailments. They also reported, on average, turning to teas and

vitamins to help manage their physical symptoms and health. Table 1 displays

demographic characteristics of the sample.

Age 50 was selected as the minimum age for study inclusion for two reasons.

First, the Latino population in general is young; the median age is approximately 25

(Bureau of the Census 2000). Further, Latinos as a group suffer from dispropor-

tionate rates of disability and mortality at young ages from chronic illnesses

compared to other ethnic groups (National Institutes of Health 2000), which

underscores the need to consider aging from a functional (versus chronological)

standpoint to ensure adequate sample size.

An attempt was made to recruit equal numbers of women and men and select

individuals with varying demographic characteristics (e.g., income and education

levels; time living in the USA) to reflect a wide range of experiences. Given the

diverse cultural, political, economical, historical, and geographical experiences

captured by the term ‘Latino,’ participants were limited to a subgroup of ‘Latino’

defined as individuals who identify Mexico as their country of origin to allow for

comparison of beliefs within the sample. Immigrant or first, second, or third

generation Mexican-Americans were recruited to account for levels of acculturation.

Though care was taken to oversample men to obtain equal numbers of men and

women, only a few men were recruited. This may be a function of few men utilizing

services in the targeted agencies. Further, authors of the TBP (Fishbein and Ajzen

1975, Ajzen and Fishbein 1980, 2000, Ajzen 1988, 1991) and other researchers

(Godin and Kok 1996) recommend a sample size of 25 for eliciting beliefs. Thus, 31

participants were interviewed to ensure that at least 25 valid interviews were realized.

Data collection

An interview schedule consisting of open-ended and demographic questions and one

standardized tool was used. Three sets of qualitative questions were developed using

guidelines from the TPB (Francis et al. 2004) and community partner input. One set

explored participants’ behavioral beliefs or perceived advantages and disadvantages

of using traditional and conventional methods of care; another set explored

participants’ normative beliefs or participants’ perceptions of what significant others

think about participants using traditional and conventional types of care; and the

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Table 1. Participant demographics (N�31).

Variable N %

Gender

Female 27 87.1

Male 4 12.9

Marital status

Married 9 29.0

Divorced 2 6.5

Widowed 12 38.7

Single 7 22.6

Separated 1 3.2

Income

$0�$10,000 26 83.9

$10,001�$20,000 1 3.2

$20,001�$30,000 3 9.7

$30,001�$40,000 0 0.0

$40,001�$50,000 1 3.2

Educationa

Primary school completed 16 51.6

Secondary school completed 9 29.0

Professional school completed 6 19.4

University education completed 2 6.5

Graduate school completed 0 0.0

Religion

Catholic 27 87.1

Adventist 2 6.5

Jehovah’s witness 1 3.2

Other (‘Christian’) 1 3.2

Employment history

Domestic labor 5 16.1

Teaching 1 3.2

Vending/sales 5 16.1

Agriculture 1 3.2

Skilled labor 6 19.4

Unskilled labor 5 16.1

Formal caregiving 2 6.5

Professional work 2 6.5

Religious work 3 9.7

No work history 1 3.2

Geographic area of origin

USA

Montana 1 3.2

Texas 1 3.2

Mexico

Chihuahua 1 3.2

Distrito Federal 4 12.8

Durango 1 3.2

Guanajuato 2 6.5

Guerrero 1 3.2

Jalisco 5 16.1

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third set explored participants’ control beliefs or participants’ beliefs about the

extent to which they were able to use traditional and conventional types of care.

Participants also responded to the Bidimensional Acculturation Scale (BAS) for

Hispanics (Marın and Gamba 1996), which is a 24-item Likert-type scale consisting

of three subscales measuring language use, linguistic proficiency, and electronic

media use, where 4�‘very well/almost always’ and 1�‘very poorly/almost never.’

Subscales yield scores for both Hispanic and non-Hispanic acculturation. High

scores on both indicate bi-culturality. The BAS provides effective bidimensional

acculturation measurement (i.e., bidirectional changes in behavior accounting for

acculturation to a new culture and identification to the culture of origin). Concurrent

validity and reliability coefficients range from 0.31 to 0.88, indicating that the

subscales show strong validity and reliability in measuring acculturation (Marın and

Gamba 1996). Examples of questions include, ‘How often do you speak English?’

and ‘How often do you watch television programs in English?’ The BAS has been

translated into Spanish and validated for use with Latino populations. Items from

this scale were used to inform and augment participants’ responses to open-ended

items. Finally, demographic items were included in the interview schedule to describe

the sample and to inform and enhance the meaning gained through qualitative data.

To develop items in the interview schedule, several best-practice guidelines were

followed (e.g., Marın and Marın 1991, Guillemin et al. 1993, Chang et al. 1999, Skaff

et al. 2002, Maneesriwongul and Dixon 2004). The research team met to develop,

translate, and review questions. The open-ended and demographic questions were

reviewed and revised several times to ensure cultural sensitivity and relevancy for the

study population. Items in the interview schedule were then back-translated by the

research team, and pilot-tested to revise and clarify the meaning of questions.

Interviews were conducted by two bilingual/bicultural interviewers trained on

qualitative research methods, cultural issues in interviewing, and administering the

interview schedule. Training also included methods reported to improve reliability

and validity of qualitative studies by decreasing researcher effects (e.g., not ‘inflating’

the problem under study; maintaining a not knowing stance, conducting interviews

in locations comfortable for participants; using probing questions to enhance

meaning; conducting interviews in the participants’ language of choice; and keeping

field notes) (Miles and Huberman 1994). Pilot tests were conducted to establish

Table 1 (Continued )

Variable N %

Michoacan 2 6.5

Mexico 2 6.5

Morelos 3 9.7

Nayarit 2 6.5

Oaxaca 2 6.5

Puebla 2 6.5

Sinaloa 1 3.2

Zacatecas 1 3.2

M Range

Age of migration to the USA 39 5�71

aTotal does not equal 100% since respondents could complete more than one level of education.

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inter-rater reliability for administering the BAS, which yielded strong correlations

(0.80) between raters, and to ensure conformity between interviewers with regard to

following interview protocol, particularly around asking qualitative questions in

identical ways with identical prompts. On average, interviews took about one and ahalf hours to complete. Most interviews were conducted in Spanish and took place at

the recruiting agency or in participants’ homes.

Analyses

Data from interviews were transcribed and, when needed, translated by a trained

bilingual transcriptionist. Qualitative data were analyzed by the primary investigator

on textual, conceptual, and organizational levels using ATLAS-ti (ATLAS.ti, Berlin,Germany). An interpretive�phenomenological methodwas employed to emphasize the

importance of the social context in which participants experience their world and the

ways in which their world impacts their experiences of health and illness (Benner 1994).

Following guidelines from the TPB (Francis et al. 2004), textual data were coded and

analyzed to find themes, or ‘salient beliefs,’ in each belief area. To increase reliability

and internal and external validity of the study, several procedures were employed

throughout the analysis process. First, coded themes were cross-checked for meaning

by a group of Latino leaders who were part of the research team (Miles and Huberman1994, Ryan and Bernard 2003). Second, ‘extreme’ cases were identified and analyzed to

check for representativeness; thus, two cases that scored as ‘acculturated’ on

the BAS were examined to determine that their beliefs did not differ significantly

from the other cases. Third, datawere examined for ‘negative cases’ or those caseswhere

content or themes did not fit the model, disconfirmed patterns, or refuted emerging

constructs; none were found (Miles and Huberman 1994).

Descriptive statistics were generated on demographic and acculturation variables.

Relationships between these variables and open-ended responses were explored todetermine whether any individual differences existed for health beliefs based on

demographic characteristics (e.g., age, income, education level, or acculturation

level). Specifically, different levels of demographic characteristics (e.g., higher income

versus lower income; older age versus younger age) were compared to corresponding

open-ended responses to ascertain whether different demographic characteristics

were correlated to particular open-ended responses. All results were examined for

outlying or extreme cases, ‘surprising’ responses from participants, or responses that

‘disconfirmed’ themes or that refuted a theoretical construct (Miles and Huberman1994).

Results

Table 2 offers a summary of the themes that emerged from the qualitative questions

for each belief area.

Behavioral beliefs

According to themes that emerged from participants’ responses in this belief area,

there were many advantages to using traditional and conventional care. With regard

to traditional care, participants turned to these methods because they were part of a

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long cultural tradition, were familiar with these methods, had knowledge about how

to use them, and were comfortable using them. Traditional methods evoked a sense

of familiarity. Quotes from participants exemplify this idea:

And [the methods have] just been passed on, so a lot of traditional things are just passedon down through the families.

I just think from your tradition it is . . . it’s what you’ve been raised with. It’s part of yourculture for healthcare.

Participants also believed that traditional methods are safer and more effective than

conventional methods. Many participants talked about traditional methods offering

relief without dangerous side effects and working much better or faster than

conventional methods. For example, one participant who suffered from chronic

headaches talked about how conventional medications did nothing to relieve the

pain. Indeed, she talked about how medications could damage the body. She went on

to state that traditional methods

. . . do not harm us as much as [conventional] medicines do. Even though the perceptionof [conventional] medicine is that it’s perfect, it also has some bad things that can affectone. It heals the pain, but for example it damages the liver and things like that. So yes,I have resorted to regular medicine, but only if there is no other possibility. I try to gofirst for the things that do not harm us as much.

Table 2. Qualitative responses about beliefs.

TPB belief areas Traditional health care Conventional health care

Behavioral beliefs Advantages Disadvantages Advantages Disadvantages

Knowledge

and tradition

of methods

Methods don’t

always work,

particularly with

severe illness

Methods are

superior

Methods cause

problems and

prolong suffering

Methods are

effective

Methods can be

accessed

quickly

Trust and faith

in methods

Trust and faith

in methods

Normative beliefs Approve Disapprove Approve Disapprove

Family Nobody Family Nobody

Community

Control beliefs Enabling

factors

Non-enabling

factors

Enabling

factors

Non-enabling

factors

Methods are

accessible and

affordable

Methods

sometimes are not

accessible or

affordable

Methods

sometimes are

accessible and

affordable

Methods are not

accessible or

affordable

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Another participant stated that traditional methods ‘are more comfortable and less

dangerous because they don’t poison. And [conventional] medicine � if you take too

much, it poisons you.’

Related to cultural tradition and beliefs in effectiveness, participants also

expressed a great deal of faith in traditional methods. Participants trusted these

methods because they had been established and they were simple, pure, and not

fabricated. Talking about traditional methods, one participant stated:

The advantages are that the plants are more original than medicine because there aremany medicines that are very harmful to some people because we all have differentbodies.

Many participants also talked about the advantages to using conventional methods

of care. One theme that emerged was that conventional methods are superior to

traditional methods with regard to the science behind them and the advances in

knowledge and technology that have taken place in recent decades. Participants often

referred to this superiority in relation to how conventional methods were better at

curing ‘serious’ illness and diagnosing problems more effectively. For example,

several participants stated:

When it’s a serious or advanced condition, there is no natural medicine, no acupuncture,no homeopathic therapy that solves it. Traditional medicine is not a magical cure.

The advantage of using [conventional] methods, when curing something, is thetechnology � it finds and detects your illness. For example, if it is an infection orcancer . . ., and if you receive treatment in time, it can save you. That is one of thegreatest advantages that modern medicine has . . . that it can quickly detect your illnessand save you from a grave illness.

But now everything is advanced, and there are things that are really good and haveserved to make us well, to cure us. In these advanced days, we don’t use [traditionalmethods] because now there are other things more advanced that we know of � pills,medicines are better, no?

Participants also believed that conventional methods allowed for people to get care

more quickly, leading to faster cures of diseases. For example, one participant stated:

It’s important to go to the doctor. You can get more ill and then pass the time that youshould be at the doctor’s so they can give you the medicine you need.

Participants expressed trust in conventional care providers. Participants had faith in

the way that conventional care providers often offered direct advice such as writing

out directions for medications and care plans. For example, two participants stated:

Well the truth is when they examine you, you feel that everything is better. Thateverything is okay.

Here the doctors tell you what you should be eating. That’s to say, pure, healthythings . . .

According to participants, the main disadvantage to using traditional methods was

related to the idea that traditional methods were not as effective as conventional

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methods in diagnosing and curing serious illnesses. Many participants also expressed

beliefs that traditional methods are not always effective in relieving symptoms even

in cases of mild illness. However, one theme that emerged with regard to

disadvantages of conventional methods was that these methods often cause

problems and prolong suffering, such as the example given earlier about how

medications can sometimes damage the body. Other examples of these beliefs are as

follows:

If I am very ill they should give me something for the pain yes, but they should not putme on machines, no, those things no. I don’t want that. Prolonging life no.

[The doctors] leave [children] too long in the hospitals. The children suffer so much inthe hospitals. That’s why I never visit the hospitals because they give me so much pain.I feel the pain in my person.

With drugs, they give you your medicine to cure one illness, and it leads to anotherillness.

Normative beliefs

We also examined participants’ beliefs about how others perceived participants’ use

of traditional and conventional care. Several themes emerged in this belief area. The

main theme that emerged with regard to others disapproving of participants’ use of

traditional and conventional methods was that participants believed that no one �not family, friends, church leaders, or community members � disapproved of use of

either type of care.

However, several themes emerged with regard to participants’ beliefs about the

approval of others regarding the use of traditional and conventional methods of care.

Participants believed that family and community groups with whom participants

associate approved of participants’ use of traditional methods. For example, various

participants stated:

A lot of the community groups that I hang out with, they would approve of thetraditional.

I use all the sage and stuff, but my friends are always trying to get me to go to sweatlodges.

We are from Mexico, and yes, people still have that belief. Yes, they have it. People fromMexico, yes, they believe.

My son [believes] the more natural the better and he is an adult now too.

With regard to the use of conventional methods, the theme of family members

emerged as an important group approving of this type of care. Participants talked

about family members, particularly children, growing up in a community

where conventional methods were the norm and readily available, so children were

especially likely to put pressure on the older participants to use conventional care.

For example:

Well family, they were born in a place where it was easier for one to go to a doctor andget cured.

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My daughter-in-law . . . she always thinks I should go to the doctor for certain thingsthat I don’t think I should.

My daughters all say, ‘mom, go to the doctor.’ They ask me ‘why haven’t you gone to thedoctor?’

Control beliefs

Finally, we examined participants’ beliefs about factors that might hinder orfacilitate their use of traditional and conventional care. Several themes emerged in

this belief area, all of which related to access and cost. Participants perceived that

traditional methods were largely accessible and affordable, while conventional

methods largely inaccessible and unaffordable. With regard to traditional methods,

participants believed that these methods were easy to find, easy to use, easy to ‘stock

up on,’ and easily affordable. Examples of these beliefs include:

I know of some people who can get me the herbs that I need.

They are not too expensive. They are always within reach.

It definitely is a lot cheaper. And it’s something that you can do in the comfort of yourhome. The access to the herbal healers or whatever you want to use is good. And I thinkas you get older, you probably have a good supply of them because you stock up.

If you’re going to go to Mexico, or you know someone who is going to Mexico, you say‘hey can you get me this?’ or, if you deal with a pharmaceutical company in Mexico, youcan get a lot of the herbs.

Conversely, participants viewed conventional methods as largely out of reach.

Participants believed that expense, lack of insurance, lack of ‘legal papers,’ language

barriers, and a lack of knowledge of available resources (e.g., transportation and

interpreters) made conventional care inaccessible. Participants described how antici-

pation of not being helped, understood, or respected would be enough to keep them

from seeking conventional care. Two participants described their beliefs in this way:

People don’t have insurance. So they do wait until the last minute, because they can’tafford it. And then if you give them prescriptions, that’s really expensive and a lot ofthem don’t get the prescriptions. So, it’s just out of their reach. It’s not accessible.

I think that some in the medical community are really rude to people who do not speakEnglish and who they feel are low income. People don’t know that they’re going to havesomeone who can consult with them in Spanish.

Well the disadvantage is not knowing the language. Because a lot of times I don’tunderstand or know what they are saying. So for this, yes, it is necessary that theytranslate truthfully � to be able to ask the questions one wants to ask. For instance withmy daughter, whenever I go to the doctor I tell her to go and ask certain questions, buteven like this it is very hard. One feels frighten for not knowing the language. One thinksthings like, I would not be able to answer what I am being asked, or I would not be ableto explain exactly what is it that I am feeling or the symptoms, or even why it is that I amcoming to the hospital. It is very difficult the language barrier that exists, even startingin the registration process at hospitals.

Participants also described beliefs about traditional care being inaccessible at times.

Much of this inaccessibility centered on lack of knowledge of where to find

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traditional care or on traditions not being passed down to subsequent generations, so

knowledge of traditional practices is being lost. Some participants even stated that

traditional methods are more expensive than conventional methods. Many partici-

pants expressed problems with finding the exact traditional methods they were used

to finding in Mexico (e.g., names of herbs were not translated the same; teas were

made differently). Two participants stated:

It’s impossible to use traditional if you haven’t access to some of the oils or ingredientsyou need for a salve or for a paste or something. Or as tradition . . . people aren’tcarrying on the traditions. I think there’s less and less people that are caring about thetraditional. So I think that a lot of people growing up don’t know much about this asthey did in the past. I don’t think it’s because conventional is so accessible, I just don’tthink people . . . it was passed on in the families like the Curandera passing on toanother . . . or somebody taking up [the practice]. . . I think every household might havesomeone that does a little bit with the herbs. But I don’t think it’s as prevalent as it usedto be.

One of the disadvantages in the United States is that they change the names. The people,in this case Hispanics, know them by one name. But here sometimes they have othernames. For example zabila here is called ‘aloe vera.’ The manzanilla tea here is called‘chamomile.’

Other participants described conventional methods sometimes being accessible and

affordable. Participants talked about having insurance, family members who could

help with finding resources, or knowing how to access resources, such as free care,

medications, transportation, interpreters, or other programs that can help pay for

care. Participants described their beliefs in these ways:

There is good help for all of us people who do not have a lot of money for a gooddoctor. The advantage is that there are programs, they help a lot.

I call a driver and the driver takes me . . . and he returns to pick me up. He takes me backhome.

Here we see social workers, and they give us an application to fill out and they don’tcharge us. And she herself takes us to the office where we can get emergency medicalservice. We didn’t have insurance or money so my wife stopped taking her diabetesmedicine. But what we didn’t know was that we were ignorant, we didn’t have money formedical insurance. We didn’t know that here, in two or three months, they would give usmedical assistance up to a certain point if it was an emergency.

Acculturation

According to participants’ responses on the BAS, most (90.3%) participants adhered

to Hispanic culture. Two (6.5%) participants adhered to non-Hispanic culture and

one (3.2%) scored as bi-cultural. An analysis of these three cases with regard to their

responses on qualitative questions suggested that they did not differ from the other

participants on their beliefs. However, responses from these three participants did

indicate that they held more cautious views on both traditional and conventional

methods of care; they expressed more directly the pros and cons of both methods of

care, but their beliefs were still congruent with those of other participants. These

three participants also seemed to be more knowledgeable about resources that

allowed them access to both types of care.

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Discussion

This study expands on and enhances prior research on health disparities in several

ways. First, it offers insights into the health beliefs of older Mexicans and Mexican-

Americans, which according to the TPB, can help to predict healthcare-seeking

behaviors. A better understanding of beliefs and behaviors can inform the

development of services that are more culturally appropriate and congruent with

the needs of the older adults they serve, thereby helping to reduce health disparities.

Second, because the TPB is useful for predicting health-related behaviors, this

study provides a foundation on which additional research can be conducted to fully

explore and better understand issues driving healthcare disparities for older

Mexicans and Mexican-Americans. Predictive models focused on how healthcare

beliefs impact behaviors can offer insights into how services can be developed to

improve health outcomes. Related to this, the methods utilized in this study can be

easily replicated and generalized to other populations to provide a more systematic

comprehensive approach to investigation on health disparities.

Using health beliefs to improve service provision

People’s perceptions of health and illness and the ways in which these perceptions

interact with cultural context impact the ways in which people think about, access,

and utilize care (Rogers and Gallegos 2007, Felicity 2010, van Andel and Westers

2010, Waldstein 2010). However, a great deal of the research on health disparities has

been fragmented, focusing on just a few of the factors or barriers thought to be

related to disparities, excluding the context in which these factors exist. Further,

much of this research focuses mainly on assumed barriers � not on what people

actually perceive as barriers. For example, much attention has been given to the role

of health literacy as it relates to health disparities; this is an assumed barrier to care.

Indeed, health literacy, or the extent to which people are able to understand health

information and make health decisions based on that information (U.S. Department

of Health and Human Services 2000), is a particularly pressing problem among the

elderly (because of physical and cognitive ailments) and individuals with English

proficiency limitations (Beers et al. 2003, U.S. Department of Health and Human

Services 2004). While low health literacy contributes to health disparities, prior work

has primarily looked at health disparities from the perspective of a westernized belief

and healthcare system such as how health literacy (as it is narrowly defined) among

certain populations can be improved and how access to care can be facilitated.

However, a limited conceptualization of health behaviors is at risk of failing to

capture the complexity of individual thought processes within social contexts that

influence how individuals receive and process health-related communication (e.g.,

Helman 1994, Kaiser Family Foundation 2005a).While steps have been taken to improve health services (e.g., focusing on health

literacy issues), these efforts have not been successful in eliminating health

disparities; they have taken us a step further in advancing our understanding of

the causes of health disparities and how to make meaningful change in patient and

provider behaviors and communication patterns that lead to health equality, but

there is much more work to be done (Smedley et al. 2003, Kaiser Family Foundation

2005b). Much of these efforts have been focused on specific strategies that are

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applied after patients have accessed care, mostly in an attempt to improve patients’

compliance with westernized conventional care. However, these efforts neither have

considered patients’ health beliefs nor have they been couched in patients’ cultural

contexts. For example, responses from participants in this study reflected a need for a

better connection with the healthcare community (e.g., knowing that resources exist,

trusting that they would be met with respect and understanding should they access

care) � not a need for more clarification of technical healthcare jargon. Further,participants’ responses indicated that beliefs about illness and whether or not family

members would support care-seeking behaviors were influential on whether or not

participants would attempt to access conventional care. Understanding the nature of

these beliefs and their impact on care-seeking behaviors could contribute a great deal

to our understanding and implementation of healthcare improvement efforts such as

literacy campaigns (e.g., perhaps efforts are wasted if they are used in care facilities

that people won’t access in the first place).

These implications have been articulated in both national and international

studies examining healthcare beliefs and utilization among various immigrant groups.

For example, studies of immigrant groups from low-income countries in Spain and

Belgium suggest that immigrants’ perceptions that health-related services and

resources do not exist create significant barriers with regard to healthcare access.

Investing in efforts to increase culturally sensitive, community-based education

campaigns may assist to change these perceptions and offer immigrants concrete

information about available services and how to access them (Rue et al. 2008,Manirankunda et al. 2009). Additionally, studies examining the effects of immigrant

patient�care provider relationships on immigrants’ healthcare service utilization in

the Netherlands and Israel suggest that limited awareness of immigrant patients’

cultural beliefs and practices on the part of care providers hinders immigrants’ use of

services. Specifically, limited cultural awareness can lead care providers to make

assumptions about immigrant patients’ level of acculturation, knowledge of

resources, adherence to different beliefs systems around illness and wellness, and

willingness to comply with treatment protocols; these assumptions not only can

impact the care immigrants receive (or do not receive), but they can damage the trust

in the patient�care provider relationship. Thus, increasing care providers’ awareness

around immigrant populations’ health-related beliefs, traditions, and practices could

greatly facilitate patient�care provider relationships that are more responsive to

immigrants’ healthcare needs (Benyamini et al. 2008, Harmsen et al. 2008).

Taking patients’ beliefs into consideration often means deconstructing thinking

about westernized care. For example, a few cities in Mexico and the USA have

established traditional medicine clinics alongside conventional hospitals. Thisapproach allows patients to decide when, where, and in what context they will

access care, depending on their particular beliefs about their situation. Participants

in our study indicated that they would likely pursue traditional methods in cases

where they did not perceive their health situation to be serious. So, with this service

configuration, an older adult suffering from pre-diabetic symptoms could access

traditional care; if and when her illness is perceived to be more serious, she could

access conventional services next door, where she could enjoy a continuity of service

and trust that is congruent with her beliefs. Ideas such as these that are based in

patients’ cultural beliefs can lead to greater healthcare utilization, decreasing the

health disparities for the groups who utilize them. Ultimately, looking at beliefs from

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the patient’s point of view and cultural context might be a more effective approach to

redesigning healthcare environments and means of services. This may be particularly

important for young migrants who age in place in the USA but who continue to hold

beliefs congruent with those from their countries of origin, as was seemingly the casefor participants in this study.

Building a model to predict healthcare behaviors

Several healthcare utilization models exist that can help researchers and healthcare

professionals better understand the complex issues affecting health beliefs and

service use for minority and other populations. These models draw from learning

theory, socio-cognitive perspectives, and other theoretical foundations to helporganize and explain key factors that influence people’s perceptions of health and

illness, intentions to seek care, and systems that impact people’s healthcare use. In

addition to the TPB, other models such as the Self-Regulation Model (Leventhal

et al. 1984), the Health Belief Model (Rosenstock 1966, 1974), Andersen’s (1995)

Sociobehavioral Model, Pescosolido’s (1992) Network Episode Model, and Cramer’s

(1999) Help Seeking Model all attempt to describe the ways in which psychosocial

and cultural factors impact people’s healthcare decision-making and utilization.

While these models contribute to our understanding of healthcare access and use, theTBP pays particular attention to the ways in which beliefs impact people’s intentions

to follow through with certain behaviors; understanding belief systems is critical to

understanding how cultural context impacts people’s actions (Ajzen 1988). Conse-

quently, the TPB can play an important role in better understanding health

disparities among older Mexicans and Mexican-Americans. Using the theory and

its concepts, healthcare-seeking behavioral beliefs, attitudes, norms, and perceived

behavioral controls among this older population can be explored, ultimately

predicting their intentions to act on certain behaviors, in turn predicting their actualhealthcare-seeking behaviors. For example, the salient beliefs or themes identified in

this study can be developed into quantifiable questionnaire items that can measure

the strength of beliefs in each area, which can be tested through advanced statistical

techniques (e.g., structural equation modeling), providing a model through which

health-related behaviors can be predicted (Ajzen 1991, Francis et al. 2004). Given the

complexity of issues underlying people’s healthcare behaviors, it is improbable that

the TBP alone can explain the multitude of factors influencing these behaviors.

However, the TPB does offer a conceptual framework within which other modelscould be incorporated to more comprehensively address the factors involved in

healthcare use. A more comprehensive approach to thinking about healthcare use

may be what is ultimately needed if health disparities are to be reduced. Models such

as these, when combined, can be used to inform the development of improved

healthcare services and generalized to different populations to improve healthcare

access and utilization.

This study has several limitations, particularly with regard to sampling. This

study interviewed participants who were utilizing community services; thus, we donot know anything about the beliefs of people not using services. However,

interviews with this group of participants still yielded rich information about what

people viewed as barriers to healthcare, as many of the participants were not able to

access it even though they were able to access other types of services. Further, while

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attempts were made to oversample male participants, we were unable to do so. It may

be that the health beliefs of men and women differ and they have different

experiences in attempting to access care. Thus, future studies should attempt to

explore whether these differences exist.Because cultural context is so important in understanding belief systems, future

studies should attempt within- and between-group comparisons of participants’

beliefs and experiences. While this sample included people from a wide variety of

Mexican states, the sample size of people from each state was small, making

comparisons difficult, and case study analyses for these types of comparisons were

beyond the scope of this paper. Further, while our study included three people who

did not adhere to Hispanic culture, more study is needed to ascertain to what degree

acculturation impacts healthcare beliefs and behaviors. Results from this studysuggested that acculturation might not significantly influence people’s beliefs, but it

may influence people’s level of knowledge (and skepticism) about existing resources

and healthcare systems.

Conclusions

This study explored the health beliefs of older USA-dwelling Mexicans and Mexican-Americans from the context of the TPB (Ajzen 1991) to better understand how

beliefs translate into health-related behaviors. Because health disparities are the

result of a complex interaction of cultural, socioeconomic, and other variables, the

results of this study offer insights into how beliefs contribute to health-related

outcomes. Results of this study also provide a foundation for future research that

better predicts health-related behaviors, leading to the development of more

accessible, effective, and culturally competent approaches to health services that

will reduce health disparities for underserved populations.

Acknowledgements

This work was supported by a grant from the Hartford Foundation. The author wishes tothank Dr. Peter Maramaldi for his mentorship on the project, the Hartford Foundation whofunded this project, the interviewers (Jeannie Toscano and Denise Garcia), research assistants(Ben Welch and Jo Corder), and community members, including Dr Joseph Gallegos, whoprovided feedback on various portions of the project.

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