Commentary: Fatalismo Reconsidered: A Cautionary Note for Health-Related Research and Practice with Latino Populations

Abstract

Over recent years, interest has grown in studying whether fatalismo (fatalism) deters Latinos from engaging in various health promotion and disease detection behaviors, especially with regard to cancer screening. This commentary presents problematic issues posed by the concept of fatalism, focusing on research on Latinos and cancer screening. We discuss key findings in the literature, analyze methodologic and conceptual problems, and highlight structural contexts and other barriers to health care as critical to the fatalism concept. Although the need to better understand the role of fatalistic beliefs on health is great, we discuss the public health implications of reaching premature conclusions concerning the effect of fatalism on Latinos’ cancer screening behaviors.

Introduction

Latinos, who now constitute the largest ethnic minority group in the United States,¹ experience numerous disparities in health relative to non-Latino Whites.² In recent years, an increasing amount of research has been undertaken to study these disparities. These efforts include studies that assess whether Latino cultural beliefs and values present barriers to health-related behaviors. Such research endeavors hold the promise of generating findings for developing culturally appropriate public health campaigns and programs to improve the health of the most disadvantaged. Little consensus, however, exists on how to identify, measure, and assess Latino cultural beliefs, values, and attitudes that pertain to health promotion and disease prevention behaviors. Fatalismo (fatalism), in particular, is cited as a dominant cultural belief that deters Latinos from engaging in various early detection and other health preventive behaviors, such as cancer screening and diabetes and HIV testing and prevention.^3–6

Fatalism refers to a general belief that the course of fate cannot be changed and that life events are beyond one’s control. In the health literature, fatalism usually is conceptualized as a set of pessimistic and negative beliefs and attitudes regarding health-seeking behaviors, screening practices, and illness.^5–8 Particular emphasis has been placed on cancer fatalism, defined as the belief that cancer is unavoidable regardless of personal actions or that death is certain when cancer appears.^7,8 Because it presents a potential barrier to early detection, much of the health-related literature on cancer fatalism focuses on cancer screening. Cancer fatalism, studied mostly on African Americans and Latinos, is of special public health interest, given disparities in early detection and other cancer-related health indicators among these groups.^2,9,10

Although some parallels exist in the literature on cancer fatalism among African Americans and Latinos, several reasons warrant a specific focus on Latinos. First, no consensus exists on the precise definition of cancer fatalism among African Americans, Latinos, or other populations. A closer inspection of cancer fatalism among Latinos –a specific ethnic group – would allow for a refinement and better understanding of the construct. Second, no consistent, explicit theoretical framework exists to guide research on cancer fatalism.⁸ Contexts that are hypothesized to give rise to cancer fatalism among African Americans include powerlessness as a function of poverty and other historical, cultural, and social circumstances (eg, racism, discrimination, unemployment) that are specific to this population.⁸ Because some of these experiences may be unique to African Americans (eg, racism and discrimination rooted in the historical context of slavery), we must identify sociopolitical, historical, and other structural factors associated with cancer fatalism among Latinos and explore areas of overlap. Finally, a critical analysis of cancer fatalism among Latinos would be useful not only for obtaining a better understanding of fatalism in Latinos vs other groups but also for crafting culturally relevant public health interventions to address beliefs about cancer and screening.

This commentary outlines some problematic issues and challenges posed by conceptualizing fatalism as a cultural trait that influences cancer screening practices among Latinos. We provide an overview of key findings concerning cancer screening and fatalism among Latinos. We examine inconsistent evidence, and analyze methodologic issues and conceptual shortcomings. Using examples of other groups and conditions as appropriate (eg, working-class non-Latino Whites, African Americans, HIV-positive persons), we postulate that structural contexts (eg, institutional racism, barriers to health care) are fundamental to the fatalism concept. Finally, we discuss the public health implications of reaching premature conclusions concerning the effect of fatalism on Latinos’ health behaviors.

Fatalism and Cancer Screening: General Findings

Our review of the literature focused on three main questions. First, to what extent does the current state of the literature support the hypothesis that fatalism is a prominent worldview among Latinos? Second, is there evidence that fatalism is a culturally based belief system (eg, are Latinos more fatalistic than non-Latino Whites, is greater acculturation associated with less fatalism)? Finally, does fatalism deter Latinos from receiving cancer screening?

In general, the literature provides mixed evidence on the extent and ubiquity of fatalistic beliefs among Latinos. One qualitative study of Latina women revealed that most participants did not believe that fate caused breast cancer.¹¹ A second qualitative study replicated this finding in that very few (2 out of 94) Latinas mentioned fate as a risk factor for cervical cancer; however, in closed-ended statements, foreign-born (but not US-born) Latinas frequently endorsed fatalistic perspectives.⁷ Another study also provided mixed evidence: approximately half (54%) of women believed they had no control over getting breast cancer, and most did not express fatalistic attitudes concerning the chances of surviving cancer of the breast, uterus, or cervix.¹² Other studies report levels of fatalism among Latinas that are, on average, only low to moderate.¹³

One of the studies most frequently cited as supporting the fatalistic nature of Latinos was a California-based telephone survey that reported that, controlling for sociodemographic factors, Latinos are more likely than Whites to endorse statements that little can be done to prevent cancer and that cancer is “like a death sentence.”³ Other studies find that Latinos are more likely than Whites to agree that fate is a cause of breast and cervical cancer^14,15 and that health is a matter of luck.^16,17 In some studies,^14,17 but not others,¹⁶ these differences disappear after controlling for potential confounders (eg, age and socioeconomic status [SES]). In addition, more Latinas than non-Latinas would prefer not to know if they had breast or cervical cancer.^3,14,15

These general patterns – that Latinos relative to Whites report higher rates of fateful and pessimistic attitudes concerning cancer – are interpreted as evidence of fatalism among Latinos. That lower acculturation (controlling for SES and other confounders) is associated with fatalistic beliefs about cancer^{3,13–15,18–20} further supports the hypothesis that fatalism is a culturally based construct. Some evidence, however, runs counter to the fatalism hypothesis: Latinos do not differ from Whites in optimistic attitudes about early detection and treatment. For example, Latinas are as likely as Whites to agree that if breast or cervical cancer were found early, it could be cured^14–16 and that they would be willing to undergo painful and unpleasant treatment if it would improve the chances of living longer.^14–15 Latinos also hold positive beliefs about the efficacy and importance of screening.^11,21 Thus, Latinos exhibit fatalism as well as other, “positive” attitudes about cancer. The former, however, tends to be highlighted in the fatalism literature on screening.

Although Latinos’ fatalistic beliefs about cancer are assumed to create a deterrence to screening, few studies test this supposition. Again, the literature provides inconclusive evidence on this issue. In one study, a measure that combined cancer fear and fatalism was inversely associated with recent Pap smear but not recent mammography. The inclusion of fear items in the scale, however, precludes the conclusion that fatalism accounts for decreased screening. Furthermore, analyses did not adjust for various sociodemographic characteristics that were associated with the fear/fatalism measure and with screening.¹⁹ In general, few published studies have investigated the extent to which fatalism acts as a barrier to cancer screening after controlling for potential confounders. Studies that employ these methods yield mixed evidence. Three studies indicate that fatalism is associated with decreased screening. A fear/fatalism measure predicted a lower likelihood of recent cervical cancer screening in a large study of Latinas recruited from churches in Phoenix.¹³ In two California-based telephone surveys, fatalistic beliefs decreased the likelihood of recent screening for cervical cancer¹⁵ and maintenance of regular mammography and Pap test screening.²⁰ Four other studies, however, found no effect of fatalism measures on cervical or breast cancer screening.^22–25 Finally, a sixth study reported that fatalism decreased the likelihood of screening for colorectal cancer with the fecal occult blood test, but the effect was very weak.²⁶ In conclusion, despite the popularity of the proposition that fatalism among Latinos poses a barrier to screening, evidence to support it is inconclusive.

Methodologic Problems and Conceptual Pitfalls

In some studies on fatalism and cancer screening, Latinos hold fatalistic beliefs, but the definition of fatalism varies greatly across studies. Overall, research on fatalism among Latinos is hampered by numerous methodologic and conceptual problems. These center on four broad limitations: 1) reliance on single-item measures; 2) a lack of established and reliable scales; 3) limited evidence of the validity of existing measures; and 4) use of scales that may tap distinct fatalism constructs.

Many studies use a variety of individual items to assess fatalism, including beliefs about bad luck, cancer as a death sentence, and the preference not to know if one has cancer.^{3,12,14,15,24} The reliability of these single-item measures, however, has not been established. Furthermore, the face validity of some of these items is questionable. For example, it is not clear whether fatalism underlies the preference not to know if one has cancer, or whether psychological (eg, blunting or denial styles of coping) or other cultural value systems better account for such beliefs. Furthermore, Latinos’ endorsement of “death sentence” and other pessimistic “chances of survival” items are interpreted as evidence of fatalism.^3,12 As some authors note,²⁷ however, these statements may accurately describe certain types of cancer that have a poor prognosis and survival rate.

Other studies^{16,17,22,23,26} use multiple-item measures developed on non-Latino populations, including the Health Locus of Control scales²⁸ and an inventory validated on African Americans.²⁹ The psychometric properties of such measures among Latino populations are not established, and some studies report poor reliabilities.^16–17 Because the meaning of items in these scales may differ across diverse cultural beliefs and practices, and fatalistic notions may vary across populations, standard instruments may not be applicable across different groups. Moreover, indexes and scales tend to sacrifice contextual and cultural dimensions where fatalistic beliefs and attitudes are produced. Few studies assess fatalism with scales developed on Latino samples.^20,25 The reliability of these measures also ranges from poor to modest.^20,30

Fatalism measurement also suffers from a high degree of conceptual confusion, raising further questions about the construct validity of some measures. Some scales combine fear^13,19 and numerous other items presumed to tap fatalistic beliefs, including ideas about chance or fate, cancer as “fatal,” self-efficacy regarding screening, and religious attributions.^20,31 These various indicators of fatalism could differentially predict screening. For example, unlike believing that cancer is fatal, believing in fate (eg, that cancer is predetermined or occurs by chance or bad luck) may not influence screening at all, and evidence exists that these different features of fatalism differentially predict screening.^22,23 The Powe Fatalism Inventory,²⁹ developed among African Americans, also contains various types of distinct items. Although the scale has had limited use in cancer screening research on Latinos,²⁶ it is not clear whether several of the items in the inventory tap fatalism or lack of confidence in or knowledge of the efficacy of cancer treatments. Finally, the interconnection between fatalism and spiritual attributions^{7,11,20,31,33} also warrants closer inspection, given evidence that such beliefs may serve a beneficial purpose.^11,31,32 If these finer conceptual and measurement distinctions were more thoroughly explored, better strides could be made in the study of fatalism. Overall, little research demonstrates the construct validity of various scales that presumably measure fatalism.

In summary, little consensus exists on what fatalism is and how to measure it. Perhaps as a result of the conceptual confusion inherent in the literature, fatalism instruments suffer from poor construct validity and other inadequate psychometric properties. Measurement and conceptual pitfalls may account for the inconsistent and mixed findings that typify the fatalism literature. We turn next to a more in-depth critique and discussion about what fatalism is (or could be) and how it may be misinterpreted.

Beyond Fatalism: Uncovering Its Social Determinants Among Latinos

Some scholars challenge the portrayal of Latinos and Latinas as passive and fatalistic by showing the pervasive effects of prejudice and institutional racism on Latinos’ ability to empower themselves (eg, to voice their concerns and need for adequate, culturally meaningful, and satisfactory health care).^34–37 Research on these structural factors underscores the importance of viewing fatalism “not just as a cultural characteristic… but also as a meaningful cognitive construction that emerges from specific experiences of social disempowerment.”³⁴ As other research notes, structural factors may also play a role in producing cancer fatalism in African Americans, a socially disadvantaged group.⁸ Similarly, in inner city communities, where Latinos are faced with poverty and exposed to everyday physical and symbolic violence, fatalistic statements may be the result of a cumulative chain of past negative events.

Structural barriers may underlay Latinos’ feelings of pessimism and fatalism that are reinforced by the inaccessibility of and discrimination in the healthcare system. Compared with non-Latino Whites, Latinos are less likely to have health insurance and to have a regular healthcare provider.³⁸ Both of these factors are strong predictors of breast and cervical cancer screening.^39–44 In studies reporting an effect of fatalism on screening, health insurance has a much stronger effect.^15,20 Latinas cite lack of physician recommendation as the major reason for not obtaining cancer screening tests^11,45,46 and receive limited or no information concerning the importance of screening.⁴⁷ Such findings lead some researchers to conclude that health service factors (eg, health insurance, access to free care, and interactions with physicians) –not ethnicity or culturally-based attitudes about cancer – are the most important predictors of screening.²³

Latinos also report negative experiences in healthcare settings,^21,47 which may foster mistrust of physicians and medical institutions.³⁸ Furthermore, Latinos may internalize these experiences as discrimination by the physician and the medical system.³⁸ As one article notes, “Fatalistic beliefs may be part of the Latino culture but may also reflect a rational adaptation to the obstacles to medical care experienced by Latinas in the United States.”¹⁵ To fully understand Latinos’ notions of fatalism, therefore, structural barriers, including access to healthcare factors, must be considered.

The Public Health Implications of Fatalism

Some caution should be exercised in reaching conclusions concerning the health ramifications of fatalistic beliefs, especially when developing health-related messages, programs, and interventions. A common conclusion in the literature on fatalism and cancer screening among Latinos is that health education and other public health programs must consider the effects of fatalism. The current state of the literature, however, suggests that reaching such conclusions may be premature. While some Latinos may, in fact, espouse fatalistic notions, the behavioral consequences of such beliefs (eg, that fatalism poses a significant barrier to screening) are not adequately established.

From a public health perspective, the focus on fatalism – without fully capturing the cultural nuances of this concept or recognizing the structural and other social constraints on the health and behaviors of Latinos – could be problematic. Research on cancer and heart disease fatalism in working-class communities illustrates the danger of de-contextualizing fatalism.^48,49 This work demonstrates that the tendency of health educators to emphasize lifestyle changes – while ignoring broader environmental and social risk factors – can elicit resentment among community residents and lead to inappropriate interventions targeting attitudes rather than more fundamental social problems. Health interventions geared toward changing Latinos’ “fatalistic” beliefs are at similar risk of being misguided. As detailed in this commentary, evidence is insufficient to conclude that Latinos’ beliefs concerning fatalism interfere with cancer screening behaviors. Therefore, public health messages such as those found in the literature should be reconsidered. Particular care should be taken to avoid portraying fatalism as a negative Latino cultural worldview or counterproductive cultural trait upon which public health must take action. The passive manner in which fatalism is sometimes portrayed in the literature may be influenced by embedded notions of culture as an innate obstacle to health. In light of the inconclusive evidence of the negative health effects of fatalism, health-related messages must integrate a deeper understanding of how disease risk is developed and experienced in a given social context. Doing so is of particular importance given the great need for and criticisms of cultural competency in research and in practice.^20,32

In conclusion, it is possible that the concept of “fatalism” is valid, as some Latinos may believe that little can be done to change their fate. In this commentary, however, we challenge the assumption that “fatalism” is a cultural trait among Latinos and that fatalism is a passive response that deters them from engaging in screening behaviors. Rather than advocating for the rejection of research on fatalism, we propose a more thorough examination of different concepts cloaked under the notion of fatalism; the development of more complex, valid, and reliable measures to assess its effects; and a closer analysis of how socioeconomic and other factors (eg, oppression, racism, and limited access to health care) may be masked as “fatalism.” Although our commentary focuses on Latinos, the literature on cancer fatalism among African Americans and other groups also suffers from many of the problems outlined in this commentary (eg, a paucity of evidence of the effects of fatalism on cancer screening, methodologic and conceptual limitations).^8,50 Even if Latinos (and other socially disadvantaged groups, such as African Americans) espouse views that could be interpreted as fatalistic, more research is needed to demonstrate that these beliefs deter individuals from engaging in health-promoting and early detection behaviors.

Thus, the concept of fatalism, especially among ethnic minorities who have been the major focus of this research, would benefit ultimately from further study and “unbundling.”