Reducing Cancer Health Disparities among U.S. Latinos: A Freireian Approach

Abstract

Purpose –

This paper applies Paulo Freire’s writings from Pedagogy of the Oppressed to critique current efforts to reduce cancer health disparities (CHDs) among Latinos in the U.S.

Design/methodology/approach –

Freire’s writings on oppression, critical consciousness, praxis and dialogical education are applied to recent efforts to reduce CHDs among Latinos in the U.S. through the use of promotores.

Findings –

Freireian teachings can provide insight on ways to engage Latino communities in culturally sensitive conversations that respect deeply rooted beliefs, and address the political and socioeconomic inequities many continue to face. Programs must revisit Freire’s political and transformative roots to ensure efforts to reduce CHDs also promote health equity and community empowerment.

Practical implications –

Public health initiatives should incorporate Freireian principles of dialogical education and critical consciousness in the development of cancer prevention and screening programs tailored to Latinos in the U.S. to ensure program longevity and success.

Societal implications –

Approaching conversations and interactions dialogically can foster critical engagement and empower collective action among Latino communities in efforts to improve their environments and reduce health disparities.

Originality/value –

This is a multi-layered analysis of different social and structural factors influencing CHDs among Latinos in the U.S., and is coupled with a historical overview of colonialism and oppression in Latin America. It culminates in suggestions on ways to improve future public health efforts that embrace Freireian approaches and promote health equity.

Classification –

Conceptual paper

Introduction

Reducing health disparities in the United States (U.S.) has been an important public health goal for over two decades. In 2008, the U.S. Department of Health and Human Services (HHS) released the third version of the Healthy People initiative, a comprehensive set of national public health objectives that envision “a society in which all people live long, healthy lives” (HHS, 2008). Known as Healthy People 2020, these revised guidelines highlight the need to not only eliminate disparities, but also achieve health equity and improve the health of all citizens. Additionally acknowledged are the complex dynamics that influence health disparities among underserved and disadvantaged populations. Among these groups are Latinos, who represent the largest minority group in the U.S. (U.S. Census Bureau, 2018).

In 2016, 55.2 million Latinos lived in the U.S., accounting for 17.3% of the total population (U.S. Census Bureau, 2018). Although commonly agglomerated under one ethnic group, U.S. Latinos stem from a myriad of backgrounds. The majority of Latinos are of Mexican origin (64%), followed by Puerto Ricans (9.5%), Cubans (3.7%), Salvadorans (3.7%) and Dominicans (3.3%); the remaining 14.3% represent all other Spanish-speaking countries from Central and South America (Stepler and Brown, 2013). Documentation status also differs by country of origin: in 2012, it was estimated that 5.8 million Mexicans, 675,000 Salvadorans, 525,000 Guatemalans, 350,000 Hondurans, 170,000 Dominicans, 150,000 Colombians, 130,000 Ecuadorans and 120,000 Peruvians were undocumented (Passel and Cohn, 2014). Meanwhile, although Puerto Rican migratory patterns are not affected by documentation status due to their U.S. citizenship, its recent economic recession led a 7% decline in its total population between 2010 and 2015 – accounting for approximately 250,500 individuals, the majority migrating stateside (Krogstad, 2016). These numbers have rapidly grown after Hurricane María hit the island on September 20, 2017, with some estimating up to 200,000 moving to Florida a mere two months after the storm (Sesin, 2017).

In addition to sub-ethnic diversity, differences in healthcare access, socioeconomic status, acculturation, and preferred language each uniquely contribute to the health disparities and political and socioeconomic inequities U.S. Latinos face. Having a thorough understanding of these factors is particularly important in chronic diseases such as cancer, the leading cause of death among Latinos (Murphy et al., 2016). As such, the following essay applies Paulo Freire’s contributions to critical pedagogy to reflect on and problematize current efforts to reduce cancer health disparities among Latinos in the U.S. It will first describe how cancer impacts Latinos, taking into account how different factors influence disparities and inequalities among U.S. Latinos. This will be followed by a brief historical overview of colonialism in Latin America, leading to a discussion of Freire’s writings on oppression, critical consciousness, praxis and dialogical education. His approaches will then be applied to efforts to reduce cancer health disparities among U.S. Latinos, discussing the strengths and weaknesses in current public health initiatives. It will conclude by suggesting ways to improve programs and interventions tailored to reducing cancer health disparities among Latinos, elaborating on programmatic successes and applying Freireian concepts to these approaches.

Cancer Health Disparities among U.S. Latinos

Latinos in the U.S. face many cancer health disparities. Although Latinos have lower incidence and mortality rates than Whites for breast, lung, colorectal and prostate cancers, they are more likely to be diagnosed with advanced stages of disease (National Cancer Institute [NCI], 2012). However, due to difficulties in maintaining accurate records of cancer deaths among migrating Latino populations, survival rates may be inflated (American Cancer Society [ACS], 2015). Latinos also have disproportionately higher incidence and mortality rates of cancers caused by infectious diseases, such as cervical, stomach and liver cancers (ACS, 2015). Additionally, because Latinos are younger than the general population in the U.S., a larger proportion of cancer diagnoses occur in younger age groups – 25% of cancer diagnoses among Latinos occur in persons less than 50 years old, while only 12% occur in non-Hispanic Whites (ACS, 2015).

Research highlights multiple factors that influence cancer health disparities among U.S. Latinos. Among these is language, which has been perceived as a barrier to accessing cancer information among predominantly Spanish-speaking Latinos (Díaz et al., 2013). While 89% of U.S.-born Latinos report speaking only English or doing so very well, only 34% of those born outside the U.S. do so (Stepler and Brown, 2013). These differences can affect access to and understanding of cancer information: one study found that Spanish-speaking Latinos were 63% more likely to find it difficult to understand sought cancer information than English-speaking Latinos (Vanderpool et al., 2009). They were also 65% more likely to report it taking a lot of effort to search for cancer information. Language has also been documented to affect patient-provider communication and contribute to poor cancer screening rates (Díaz et al., 2013; Becerra et al., 2015).

Healthcare access also impacts cancer prevention, screening and treatment service utilization (ACS, 2015). Yet, in 2015, 16% of Latinos reported having no health insurance during the previous 12 months; another 19% went without health insurance at some point during the year (Latino Decisions, 2015). Comparisons between U.S. and foreign-born Latinos highlight additional disparities: only 78% of foreign-born Latinos had health insurance in 2015 compared to 87% of those born in the U.S. (Latino Decisions, 2015). Furthermore, 12% of those with health insurance coverage are on Medicaid, while another 19% are on Medicare, which may impact the type of care received. Undocumented Latinos face further barriers to healthcare access, as they are ineligible for Medicare and health insurance through the Affordable Care Act, while Medicaid access is limited to certain emergency services (U.S. Centers for Medicare and Medicaid Services, 2014). As such, many are limited to receiving care at low-cost and free clinics. Also important in cancer rates among Latinos is acculturation – the process by which immigrants adopt the customs, attitudes, beliefs and behaviors of a new culture (Abraído Lanza et al., 2005). Although acculturation has been seen to improve access to healthcare services, cancer screenings and HPV vaccine uptake, it has also been reported to increased uptake of behaviors linked to cancer, such as smoking, poor dietary behaviors and increased alcohol consumption (Lara et al., 2005).

Notwithstanding these important distinctions, the vestiges of Latin America’s shared colonial history have influenced overarching cultural values present in many Latin American communities, such as machismo – male gender-role identities influenced by the interaction of sociocultural and behavioral components (Torres, 1998) – and fatalismo – beliefs that events are predetermined or externally caused and cannot be prevented or changed (Flórez et al., 2009). Although these values do not always lead to negative health outcomes (Torres, 1998; Flórez et al., 2009; Erwin et al., 2010), they have been documented to impact Latino cancer health disparities (Goldman et al., 2009; Otero-Sabogal et al., 2003). For example, a qualitative study exploring stigma and misperceptions about colorectal cancer risk and screening among Puerto Rican and Dominican men in the U.S. highlighted machismo as an influential barrier to getting screened (Goldman et al., 2009). Similarly, fatalismo has been associated with decreased breast and cervical cancer screenings (Otero-Sabogal et al., 2003). The following section provides a brief historical overview on Latin American colonialism and oppression, describing how these have influenced values such as machismo and fatalismo. This historical and political overview also serves to contextualize the emergence of critical thinkers and community organizers in Latin America post World War II, such as Brazilian educator Paulo Freire, whose teachings may provide insight on ways to improve the socioeconomic and political inequalities U.S. Latinos continue to face today.

Colonial Oppression, Freire and Critical Consciousness

Between the late 1400s and 1800s, the vast majority of Latin American countries remained under Spanish or Portuguese colonial rule. These patriarchal Catholic monarchies maintained their power through cultural hegemony, described by Chasteen (2001, p.69) as “a form of political power [that] is resilient and does devastating damage to people at the bottom. When they accept their inferiority and [...] ‘know their place,’ they accept their own subjugation.” This patriarchal structure is still present in Latin America’s cultural fabric and is manifested through familial, religious, educational and other social structures. Within many of these structures, male superiority continues to take a leading role, contributing to the perpetuation of machismo (Quiñones Mayo and Resnick, 1996).

As these countries sought independence in the 1800s, ensuing conflicts pitted liberal and conservative ideologies against each other, perpetuating a subordinate identity to U.S. and European countries and maintaining hierarchical race and class relations as they were (Chasteen, 2001). Although most Latin American countries achieved their independence (with the exception of the U.S. Commonwealth of Puerto Rico), colonial influences still contribute to the internalization of oppression among many Latin Americans and prolong a sense of deference and silencing among the marginalized (Lacerda Jr., 2014). In regards to fatalismo as a ramification of internalized oppression, Paulo Freire writes (1970, p.43):

“Fatalism in the guise of docility is the fruit of a historical and sociological situation, not an essential characteristic of a people’s behavior. It almost always is related to the power of destiny or fate or fortune – inevitable forces – or to a distorted view of God.”

During Latin America’s neocolonial period in the late 1800s and early 1900s, U.S. presence in Latin America grew through policies like the Monroe Doctrine and the Roosevelt Corollary. These policies, coupled with the Great Depression and subsequent world wars, contributed to a growing a sense of nationalism in Latin America that embraced transculturation and mixed racial identities (Chasteen, 2001). However, nationalism did not erase internalized racism that, alongside the expansion of industrial jobs across Latin American countries, contributed to the growth of shantytowns around the continent. As industrialization lost momentum post World War II and the Cold War began, Latin American countries – many U.S. allies during the war – failed to receive economic aid upon the enactment of the U.S. Marshall Plan. Many of these factors influenced a period of revolution in the 1950s and 60s, led by a number of revolutionaries influenced by Marxist ideologies and liberation theology. During this time, many religious and political leaders took inspiration from Paulo Freire’s work to empower peasants in northeastern Brazil.

Freire, arguably the most influential contributor to critical pedagogy, explored the process of achieving critical consciousness through his writings while in political exile in Chile. At the core of his groundbreaking work is the importance of mobilizing communities without a voice by helping them recognize their oppressive realities and consequently enact change (Freire, 1970). While a substantial part of Freire’s work consisted of teaching Brazilian and other Latin American peasants to become literate through raising their critical consciousness, a cursory view of his work can lead to a limited interpretation of what this process entailed.

Freire’s work was written in a time of political revolution. His desire to educate as a form of liberation stems from the oppression many of his Brazilian countrymen had faced for decades. Freire was instrumental in Brazil’s 1950s mass educational movement (“Movimento de Cultura Popular”), which aimed to motivate peasants and the illiterate to become aware of their democratic rights and consciously partake in the voting process (Mies, 1973). Within the span of 45 days in 1962, he and his team taught 300 peasants and workers to read and write. However, his methods did not stop at alphabetization: Freire’s method of awakening critical consciousness enabled the illiterate to become agents capable of changing their current state of oppression. By 1964, 90,000 newly literate, eligible voters understood power structures and started organizing themselves (Mies, 1973). This mass mobilization contributed to his arrest in 1964 during Brazil’s coup d’etat, escaping prison and fleeing to Chile 70 days later.

It is not surprising, then, that Freire denounced a “state of oppression that gratifies the oppressor” in the preface of Pedagogy of the Oppressed (1970, p. 19). His work emphasizes the duality of the oppressed: oppression that stems from colonization and other social inequities present in Latin America, and internalized oppression that contributes to fatalistic beliefs that reality is “the way it must be”. Thus, his denunciation of oppression radicalizes by generating critical consciousness and embracing transformation, leading to a liberation of the self and others. According to Freire, praxis – the process of critically reflecting and acting upon the world – is transformative, enabling self-affirmation and promoting a sense of freedom that creates action (Freire, 1970). As such, Freire argues that the oppressed must want to change their reality in order for oppression to end and to evoke change. The educator’s role is to facilitate praxis: to facilitate the process of turning thought and education into action that enacts change.

Freire also emphasizes the dual nature of praxis: both action and reflection must co-exist. Action alone leads to activism, which fails to be in partnership with the oppressed, while reflection alone leads to verbalism: empty words that fail to transform (Freire, 1970). Furthermore, he highlights the importance of humility among the oppressors who align with the oppressed; one cannot impose change or determine how the oppressed work as a community. In allowing people to critically assess their realities without imposing solutions, barriers can be overcome creatively and in unison.

Per Freire, praxis cannot be achieved through traditional teaching methods, which he refers to as the banking concept of education, where information is presented as a discourse and meets the educator’s goals. Instead, Freire promotes dialogical education, where the educator engages with individuals in a dialogue that is reflexive and acknowledging of their truths (Freire, 1970). This dialogical approach sees education as a form of liberation, as it allows the oppressed to vocalize their realities and work collectively to critically reflect and act upon it. On the differences in these concepts, Freire (1970, p.77) states:

“We must never merely discourse on the present situation, must never provide the people with programs which have little or nothing to do with their own preoccupations, doubts, hopes and fears – programs which at times in fact increase the fears of the oppressed consciousness. It is not our role to speak to the people about our own view of the world, nor to attempt to impose that view on them, but rather to dialogue with the people about their view and ours. We must realize that their view of the world, manifested variously in their action, reflects their situation in the world. Educational and political action which is not critically aware of this situation runs the risk either of ‘banking’ or preaching to the desert.”

Critiquing Current U.S. Latino Cancer Programs through a Freireian Lens

Freire’s educational philosophy has inspired work in many fields (Spencer et al., 2010; Minkler and Cox, 1980), including efforts to reduce health disparities among U.S. Latinos through the use of promotores. Promotores, also known as community health workers or health advocates, are typically community members trained to provide health education and prevention in culturally and linguistically appropriate manners (Office of Minority Health [OMH], 2015). They play important roles in connecting local residents with necessary health and social services, empowering communities through leadership and capacity-building (Spencer et al., 2010). Promotores are instrumental in efforts to support access to health insurance programs (OMH, 2015). Their importance in Latino health initiatives has also been recognized by HHS, calling for the Promotores de Salud/Community Health Workers Initiative to help achieve Healthy People 2020 goals (OMH, 2015).

Promotores have been very successful at educating underserved Latino communities about cancer health disparities. The majority of these programs have been tailored to serve Latinas in the U.S., with some promoting messages to increase knowledge and attitudes for breast, cervical and colorectal cancers (Molokwu et al., 2015; Scheel et al., 2015; Fernández et al., 2009), while others focus on increasing preventive and screening services for the aforementioned cancers (Mojica et al., 2016; Parra Medina et al., 2015; Thompson et al., 2014; O’Brien et al., 2010; Erwin et al., 2010; Moralez et al., 2012; Larkey et al., 2012; Byrd et al., 2013; Sauaia et al., 2007). A successful example of using promotores is AMIGAS, a bilingual, multi-site cervical cancer screening educational intervention available through the U.S. Centers for Disease Control and Prevention (Byrd et al., 2013). This program saw statistically significant increases in Pap smears among participants randomized to receive cervical cancer screening education by a promotora (Byrd et al., 2013).

However, one cannot forget Freire argues empowerment comes from praxis. As the use of promotores in Latino communities has been introduced in the medical services model, their role tends to be compartmentalized to educating about a specific disease. Initiatives described in the literature primarily focus on either educating about cancer prevention and specific types of cancer screenings, or helping individuals navigate the medical system to access services. Only one study was found to measure the impact of social engagement and knowledge as a way to improve mammography intentions among predominantly Mexican American women in Yakima Valley, Washington (Scheel et al., 2015). Although the role of promotores has undoubtedly assisted thousands of Latinos in accessing necessary healthcare and increasing knowledge and attitudes about screening and prevention efforts, many times it stops at service provision or patient navigation. This approach, which is often disease-specific and biomedically focused, limits the ability of communities to empower themselves in relation to the structural constraints that lie at the root cause of health disparities (Spencer et al., 2010).

Freire also argues that knowledge not only empowers, but creates a space for critical consciousness to grow. Knowledge, then, becomes a resource in efforts to eliminate social conditions as fundamental causes of disease (Link and Phelan, 1995). According to Link and Phelan, avoiding or minimizing disease risk requires access to resources such as knowledge, power, money, and social networks; without these, the association between disease and inequities persists. These resources are crucial because they are transportable – they allow for individuals to critically assess their environments and reduce their risk for multiple diseases. Again, efforts to educate Latinos about cancer that limit knowledge acquisition to cancer control and prevention facts fail to engage participants in critical assessments of the realities perpetuating these disparities. Without the ability to critically assess and raise ones critical consciousness, there is no praxis, which leads to a limited ability in reducing health disparities and improving health equity.

This inability to raise critical consciousness is coupled with structural barriers that continue to oppress by not empowering people to change their social, economical and political realities (Minkler and Cox, 1980; Link and Phelan, 1995). In the case of cancer, current structures continue to oppress Latinos lacking the transportation or health insurance to seek access to care, or those who cannot communicate with their provider because of language barriers, low education levels, or fear of questioning authority – a remnant of patriarchy and machismo. Existing structures also make it difficult for underserved Latinos who participate in cancer screening programs, but cannot afford subsequent surgery or treatment and do not know where to go – thus perpetuating a fatalistic view of cancer. These structures also impede the adoption of prevention efforts in neighborhoods that lack infrastructures promoting physical activity. In the words of Freire (1970, p.55):

“Indeed, the interests of the oppressors lie in ‘changing the consciousness of the oppressed, not the situation which oppresses them.’ […] The oppressed are regarded as the pathology of the healthy society, which must therefore adjust these ‘incompetent and lazy’ folk to its own patterns by changing their mentality. These marginals need to be ‘integrated,’ ‘incorporated’ into the healthy society they have ‘forsaken.’ The truth is, however, that the oppressed are not ‘marginals,’ are not people living ‘outside’ society. They have always been ‘inside’ – inside the structure which made them ‘beings for others.’ The solution is not to ‘integrate’ them into the structure of oppression, but to transform that structure so that they can become ‘beings for themselves.’”

Oppressive power dynamics are also present in anti-immigration policies and messages of racial intolerance. In 2015, 36% of Latinos reported having been treated unfairly because of their ethnicity, while another 48% reported being Latino as the main reason they were treated unfairly at a healthcare setting, job, store, restaurant and/or by law enforcement (Latino Decisions, 2015). These dynamics are also likely to contribute to silencing among many Latinos: only 13% indicated they were extremely or very likely to vote in the next election; 16% to attend a meeting to talk about political or social concerns; and 15% to participate in a rally march, demonstration or protest (Latino Decisions, 2015). As long as these structures and beliefs continue to exist, Freireian approaches can provide insight to ways to address them. However, this approach requires that public health efforts move beyond disease treatment and prevention to include social justice and mobilization as core pieces of interventions targeting Latinos. By serving as facilitators in the process of raising critical consciousness, researchers and practitioners can assist Latino communities in finding their voice and increasing their visibility. This, in turn, can enable communities to embrace a liberating sense of collective action that promotes social activism. This is particularly important for organizations seeking visibility and active community support to provide cancer screenings and other health services to undocumented and marginalized Latinos.

It would be incorrect to attribute these structural barriers to the many programs directed at improving cancer health disparities among Latino communities, as these frequently work within the confines of time-bound funding mechanisms targeting specific types of cancers and screening efforts (Spencer et al., 2010). Koskan et al. (2013) discuss issues pertaining to the sustainability of initiatives using promotores, citing funding as the most influential barrier to program longevity. They also highlight the importance of ensuring that long-term sustainability is discussed at the design phase of programs using promotores, particularly if these are linked to short-term grant-funded research initiatives. Therefore, it would be beneficial for public health researchers and practitioners invested in using promotores as a vehicle to reduce cancer health disparities to embrace community-based participatory research (CBPR) approaches and engage in conversations with communities before implementing these programs, a dialogical approach that is at the core of Freire’s work (Quiñones Mayo and Resnick, 1996).

The intent in highlighting the limitations of current public health approaches to reduce cancer health disparities among Latinos is not to deter these programs or initiatives, but to build on ways to improve them. Public health programs and interventions wanting to reduce cancer health disparities and improve health equity should heed to Freire’s message that being in praxis goes beyond verbalizing or rationalizing disparities: it requires communities to critique their realities and enact change to achieve equity. This is echoed in a review of public health programs using Freireian popular education and empowerment to promote health outcomes, where the author concludes that these approaches are paramount to community solidarity and self-belief, “which are essential pre-requisites to group action to address basic inequities” (Wiggins, 2011).

While limited, there are some cancer programs tailored to Latinos that exemplify how to understanding Freire’s concepts of praxis and dialogical education can influence programmatic design. Two programs were found to integrate Freireian principles through the PEN-3 model in the development of breast and cervical cancer programs tailored to Latinas (Scarinci, Bandura, Hidalgo & Cherrington, 2012; Erwin et al., 2010). The PEN-3 model centralizes the importance of culture in explaining health outcomes in three domains, one of which contains factors that influence cultural empowerment (Airhihenbuwa, 1989; 1992; 2004). Both programs acknowledged the importance of embedding health and social issues unrelated to cancer in their programmatic design. For example, Scarinci and colleagues (2012) implemented educational sessions on building self-esteem, goalsetting and personal responsibility into their cervical cancer program for Latina immigrants. Meanwhile, Erwin et al. (2015) emphasize not to isolate conversations about cancer from global health conversations, acknowledging that Latinas suffering from cancer disparities face multiple structural barriers to improving their health.

Freire’s dialogical approach towards educating and empowering communities also requires a full understanding of a group’s social and environmental contexts, as well as their perceptions of these contexts. Erwin and colleagues’ work with Latinas in Kansas and New York City also highlights that a successful intervention will avoid conceptualizing cultural values as innately positive or negative, instead working with communities dialogically to embrace their beliefs and use these to design interactive lessons (Erwin et al., 2015). For example, they utilize focus group discussions to explore the positive, negative and neutral influences of cultural values like machismo in the lives of the Latinas they served, using these in messages of empowerment. Instead of focusing on the negative aspects of machismo, they bolstered ideas that support the inclusion of men in conversations about the importance of breast and cervical cancer screenings.

It is also possible to develop programs that promote social justice as a way to improve health outcomes – which is at the core of praxis. In a review of the literature, Wiggins (2011) identified programs with an emphasis on empowerment that also measured an impact on health outcomes. Among these programs was “Poder es Salud”, where community health workers were essential in achieving the primary goal of increasing social capital among Latino and African American communities in Portland, Oregon (Farquhar et al., 2008). The program used Freireian techniques to educate community health workers on leadership, advocacy, community organizing and other social initiatives. Findings demonstrated increases in social support (p<0.003) and self-reported physical health (p<0.004), as well as decreases in depressive symptoms (p<0.003) among participating community members (Michael et al., 2008). This CBPR project was led by the county health department in collaboration with local universities and community organizations, emphasizing the importance of communities working together to tackle health disparities.

Revisiting Freireian Efforts to Address Cancer Health Disparities among Latinos in the U.S.: Implications and Recommendations

Although the use of promotores to reduce health disparities stems from a Freireian philosophy, the implementation of this approach has slowly been stripped away from its transformative roots. Freire’s writings on oppression and the facilitative role of the researcher bring back the transformative nature of these programs by taking a holistic approach to reducing cancer health disparities. Furthermore, because it was developed in response to oppressive systems and patriarchal values embedded in Latin America, Freire’s work truly captures the tensions some Latin Americans face when critically assessing their environments. Understanding and revisiting these arguments is paramount in applying a Freireian lens to programs and interventions designed to reduce cancer health disparities among Latinos in the U.S. Doing so opens doors to research that can empower Latino communities to not only partake in cancer prevention and screening behaviors, but also to critically assess the realities surrounding social and structural barriers to care. This, in turn, can provide an opportunity for further community organizing that influences change.

Freire’s philosophical underpinnings can serve as a foundation to engage Latino communities in conversations that are culturally sensitive and cognizant of multifaceted structural barriers to healthcare. In encouraging communities to achieve praxis and enact change, Freire emphasized that researchers and leaders cannot unveil the world for the oppressed: the oppressed must do so for themselves and on their own time. As such, public health practitioners wishing to engage Latino communities should not impose the rejection of “oppressive” beliefs and adoption of “progressive” ones. Instead, they should engage in dialogical approaches – such as those presented in CBPR – that allow communities to better understand their realities and choose to transform them. This transformative perspective requires researchers to leave preconceived ideas aside and meet communities where they are. For example, although beliefs of machismo and fatalismo have been identified by some as cultural aspects among Latinos that limit the effectiveness of cancer screenings and treatment (Goldman et al., 2009; Otero-Sabogal et al., 2003), community members may fail to view these beliefs as negative. They may also choose to dispel the negative aspects of these values and embrace the positive ones, such as the role of men as respectful, dignified and honorable protectors of the family (Torres, 1998) or the belief that “God is in control” and that doctors are “instruments of God” (Leyva et al., 2014). Thus, adopting Freireian dialogical approaches can help avoid misconceptions in how public health should approach fatalismo and machismo in cancer control and prevention efforts, which may lead to inappropriate and culturally insensitive interventions (Erwin et al., 2010; Abraído Lanza et al., 2007). It can also help communities challenge their beliefs and decide on ways to transform them.

Freire’s writings also allow public health researchers and practitioners to acknowledge the diversity among Latinos in the U.S. His emphasis to work alongside communities to facilitate change enables dialogue that highlights the unique struggles a myriad of Latinos face. Because this communication is at the core of his approach, it discourages initiatives with blanket solutions that view all Latino communities as having the same disparities. Instead, it encourages interventions and systems that meet local needs, which may range from an English-language intervention focused on engaging acculturated families from El Salvador and Honduras in efforts to improve access to healthy foods and places to exercise, to a Spanish-language campaign informing recently relocated Puerto Ricans in Florida how to access preventive healthcare services and register to vote. Cancer programs wanting to engage in these transformative approaches should consider embedding CBPR communication modalities (Sullivan and Siqueira, 2009), intervention mapping (Bartholomew, Parcel and Kok, 1998) and other participatory mechanisms into their programs. Doing so promotes communication between the community and researchers that allows individuals to take ownership of their health and their specific needs.

Freire’s dialogical, participatory approach can also assist in the longevity of efforts to reduce cancer health disparities and improve health equity, as it ensures communities are invested in improving their realities once researchers and educators are no longer there. Echoing Koskan and colleagues (2013), Wiggins (2011) highlights that a major limitation in public health programs implementing Freireian principles to empower individuals is program longevity. Similarly, Erwin and colleagues (2015) state that linkages to services must be established through community partnerships prior to implementing outreach efforts; failing to do so limits how local level programs can impact policy level barriers to cancer care. Programs must thus work alongside communities and engage them in consciousness raising, not only educating them about ways to prevent and treat cancer, but also on how to critically assess the barriers impeding their access to quality care and prevention services. By doing so, knowledge can become a transferable resource that allows community members to engage in social change. Researchers and practitioners invested in these approaches should also leverage partnerships with local governments and community organizations as ways to facilitate sustainability and capacity building and foster dialogue.

Lastly, social media can also play an enormous role in Freireian efforts to raise critical consciousness, allowing those who have been historically oppressed to engage in conversations that will mobilize others and foment social and structural changes. Social movements have already been propelled on social media platforms (González Bailón and Wang, 2016), such as those seen during the Arab Spring, Black Live Matter and #MeToo. These platforms can also provide a space for users to engage in conversations about structural and social barriers to cancer and other important health disparities. Future public health researchers should explore ways to utilize Facebook, Instagram, Snapchat and similar dialogical platforms to promote messages linking reduced cancer health disparities to improved health equity and empowerment using Freireian approaches. This research can also be used to inform programs that integrate the use of promotores both in-person and on social media as a way to further empower and engage Latinos. In this way, promotores can reach a broader audience in ways that still encourage Latinos in the U.S. to take an active role in improving their health and wellbeing.

Conclusions

Cancer has the unique ability to act as a vehicle to unite and empower Latino communities. A myriad of U.S. organizations use empowering language when discussing cancer, evoking messages of unity and fighting back, such as the American Cancer Society’s® “fight against cancer” and the Breast Cancer Research Foundation’s “Cancer divides. We unite.” Efforts to reduce cancer health disparities among Latinos in the U.S. can thus create a sense of community that cultivates health equity and social justice by implementing the aforementioned Freireian approaches in public health programs and initiatives. Furthermore, these principles provide public health practitioners with a platform that prevents compartmentalizing issues within a specific disease, while serving as a blueprint for establishing sustainable, long-term community partnerships. Ultimately, these approaches ensure programs build strong, empowered community members who understand their world. In doing so, we may give credence to the saying that “knowledge is power.”