Psychological thriving among Latinas with chronic illness - Thriving: Broadening the Paradigm Beyond Illness to Health

Arthritis is clearly a women's health concern (Callahan, 1996), occurring about twice as frequently in women as men (U.S. Department of Health and Human Services [HHS], 1993a). Because the most common types of arthritis involve severe pain, joint swelling, and functional limitations, arthritis is the leading cause of disability among women in the United States (HHS, 1993a). There is, however, a lack of adequate data on arthritis (and other chronic conditions) among Latino populations in the United States (HHS, 1993b). The limited available national data, based on self-reported chronic conditions, indicate an arthritis prevalence rate of 6.5% among Latinos, compared with 16.0% among non-Latino Whites (Padilla & Perez, 1995). Care must be taken in comparing these rates, however, as Latinos are less likely than non-Latino Whites to have health insurance (Flack et al., 1995), and this limited health care may result in fewer diagnoses and referrals to rheumatologists (Padilla & Perez).

Latinas coping with arthritis may also confront added stressors related to social class. As a group, Latinos are poorer and have less education than non-Latino Whites (Flack et al., 1995). Hispanic female-headed families are disproportionately represented among the poor (Schmittroth, 1991). Lower social class contributes to greater psychological distress (Belle, 1990) and to mortality and morbidity of many diseases, including osteoarthritis (Adler et al., 1994) and rheumatoid arthritis (Callahan & Pincus, 1995). Adversity related to lower social class, therefore, presents an added burden for Latinas coping with chronic illness.

Despite these multiple hardships, Latinos have better health than their social class profiles would predict (Vega & Amaro, 1994). There is growing evidence that male and female Latinos have a lower all-cause mortality rate than non-Latino Whites (e.g., Sorlie, Backlund, Johnson, & Rogot, 1993) - a finding cited as an epidemiologic paradox (Markides & Coreil, 1986). The mechanisms underlying these health differentials have not been adequately uncovered. Recent analyses (Abraido-Lanza, Dohrenwend, Ng-Mak, & Turner, 1998), however, suggest that the differences are not artifacts of migratory processes (e.g., the "healthy migrant effect"). Instead, they may reflect cultural influences on health behaviors and other psychosocial factors. Yet there is a paucity of research on cultural protective factors and adaptive behaviors among Latinos and other ethnic minorities (Abraido-Lanza, 1997a).

Applying a thriving paradigm (O'Leary & Ickovics, 1995) may help uncover the cultural strengths that promote positive adjustment and thriving among Latinas confronting both chronic illness and limited social class resources. Although chronic illness does not necessarily present a traumatic, acute event, dealing with an ongoing illness can promote psychological thriving. Both types of events involve similar processes. For example, both traumatic events and chronic illness threaten and change the self-concept, both require mobilization of social support and coping processes, and both may entail a number of other psychosocial adaptive tasks. Thus, chronic illness presents an important context in which to study thriving.

The available literature has only begun to identify cultural, psychological, social, and behavioral processes that foster health and well-being among Hispanics. Although a review of this literature would extend beyond the scope of this article, several potential cultural protective factors have been identified (see Abraido-Lanza, 1997a). These include (among others) familism, that is, valuing family relationships, and viewing the family as a source of support, strength and inspiration; religion and spirituality; and an active coping stance when faced with problems. Cultural values also involve acceptance of destino. As Saucedo (1996) noted, deficit models of Latino adjustment sometimes refer to this cultural value as fatalism, with a negative connotation of passive acceptance. Destino, however, more accurately reflects adaptive acceptance of insurmountable difficulties.

If these resources serve as cultural protective factors, then acculturation (e.g., espousing more American values and less Latino cultural cohesion) should have adverse effects on well-being. Several studies have, in fact found that greater acculturation is related to poorer outcomes among Latinos (Vega & Amaro, 1994). The mechanisms accounting for this finding are not clear, but may include loss of protective cultural health beliefs, behavioral practices, identity and values, and responses to continued discrimination.

Theories of adjustment to chronic illness (e.g., Moos, 1982; Taylor, 1983) suggest other psychological mechanisms that may promote thriving. Several theories maintain that a sense of competence - specifically, self-efficacy, mastery, and self-esteem - are critical determinants of psychological well-being for people with chronic illness. Supporting these theories, studies of non-Latinos with arthritis indicate that feelings of self-efficacy over the illness play important roles in adjustment (O'Leary, Shoor, Lorig, & Holman, 1988; Schiaffino & Revenson, 1992; Tennen, Affleck, Urrows, Higgins, & Mendola, 1992). A sense of competence mediates the relationship between illness stressors (e.g., pain) and psychological well-being (Smith, Dobbins, & Wallston, 1991). A recent cross-sectional study of Latinas with arthritis reported similar findings (Abraido-Lanza, 1997b).