519155 research-article2014

HPQ0010.1177/1359105313519155Journal of Health PsychologyTodorova et al.

Article

Gratitude and longing: Meanings of health in aging for Puerto Rican adults in the mainland

Journal of Health Psychology 2015, Vol. 20(12) 1602­–1612 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105313519155 hpq.sagepub.com

Irina LG Todorova1, Mariana T Guzzardo1, Wallis E Adams1 and Luis M Falcón2

Abstract Puerto Rican adults in the United States mainland live with socioeconomic and health disparities. To understand their contextual experience of aging, we interviewed participants in the Boston Puerto Rican Health Study. Through a Thematic Analysis we identify themes and tensions: normalization and acceptance of aging; gratitude; the importance of aging within social networks; longing to return to Puerto Rico at older age. We address the tensions between ‘acceptance’ and fatalismo as a cultural belief, and a function of structural barriers. The experience of aging is discussed in the context of Puerto Rico’s history and continued dependence on the United States.

Keywords age, critical health psychology, ethnicity, illness, qualitative methods

Introduction Recent work has illustrated the relevance of sociocultural context (Clarke and Korotchenko, 2011), socioeconomic disadvantage (Breheny and Stephens, 2010), and cultural values and discourses (Ebrahimi et al., 2012; Lai and Surood, 2009; Paulson and Willig, 2008; Pond et al., 2010; Tan et al., 2010) for the experience and expectations of aging. As the proportion of older adults in the world population increases, health psychology can have an increasing role in understanding these processes and contributing to sustaining well-being and prevention of disease (Stephens and Flick, 2010). Its contributions can be in multiple directions, one of which is the exploration of the diversity of lived experiences and meanings of aging, and

the accompanying changes in health and the body for different groups aging in different contexts. One such group for which it is important to have an understanding of the experiences of aging in a specific context is the Puerto Rican

1Department

of Health Sciences, Northeastern University, USA 2University of Massachusetts, Lowell, USA Corresponding author: Irina LG Todorova, Department of Health Sciences, Northeastern University, 360 Huntington Ave. 208 Robinson Hall, Boston, MA 02115, USA. Email: [email protected]

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Todorova et al. adults living on the US mainland. Puerto Ricans live with clear socioeconomic and health disparities, including serious chronic conditions, such as hypertension, arthritis, diabetes, and depressive symptoms (Tucker et al., 2010). Among those 65 years old or older, Puerto Ricans experience a high poverty rate (over 25%) compared to other Hispanic1 subgroups in the United States (US Census Bureau, 2007). The historical context of the relationships between Puerto Rico and the United States is relevant for understanding the lived experiences in relation to aging for Puerto Ricans on the island, as well as those that currently live on the mainland or move back and forth. The island of Puerto Rico was seized by US troops in 1898, and since then, it has undergone a number of political transitions, yet it remains dependent on the United States in political and economic aspects. In 1952, the island was granted “Commonwealth” status which gives the Puerto Rican people self-governance as they have their own constitution and administrative autonomy over internal affairs (Picó, 2006). This status provides a voice but no voting rights in the US congress and precludes formal electoral participation within the US political process (Duany, 2011). Puerto Ricans have been US citizens since 1917, which allows them benefits afforded to US citizens, as well as the capacity to move freely between the island and the mainland (Duany, 2011). Currently, Puerto Ricans are the second largest Latino subgroup in the United States (Ennis et al., 2011), and those who live on the mainland usually maintain strong multidimensional connections with the island. This particular history and current situation is related to the strong and distinctive cultural identity of Puerto Ricans both on the island and particularly on the mainland, and some authors (Duany, 2011) argue that it is stronger than that of other ethnic groups in the United States. Past research on the meaning of aging for Latinos is limited, particularly for Puerto Ricans, but existing studies coincide on several themes. An important theme in the existing literature is the idea that elders are

respected in the community (Beyene et al., 2002; Romo et al., 2013; Zsembik and Bonilla, 2000). Studies with Puerto Rican older adults also identify the cultural belief that older adults should be respected by younger family members (Zsembik and Bonilla, 2000), and that adult children and grandchildren should provide support due in part to that respect. Several studies discuss the importance of religion in adjusting to aging (Beyene et al., 2002; Hilton et al., 2012; Laditka et al., 2009; Romo et al., 2013). A third theme present in the literature on the perception of aging for Latinos is the importance of family support (Beyene et al., 2002; Hilton et al., 2012) or of being involved with family, spending time together and receiving care and love (Hilton et al., 2012). The importance of family is related to the concept of familism, comprising filial piety and intergenerational reciprocity when it comes to the care of elder family members (Ramos, 2007). In summary, while past research has begun to provide an understanding of the meaning of aging for Latinos, there is a clear gap in the literature on older Puerto Rican’s cultural meaning of old age and health in aging. The material disadvantages that they experience, as well as strong Puerto Rican cultural identity, make this an important area of inquiry.

Methodology Study and sample Data are drawn from the Boston Puerto Rican Health Study (BPRHS), a National Institutes of Health (NIH)–funded longitudinal cohort study of a total of 1500 participants (Tucker et al., 2010). The study has been approved by the Internal Review Board of the University. The BPRHS aims to explore the high incidence of health problems experienced by Puerto Ricans in the US mainland. Inclusion criteria consist of the following characteristics: Puerto Rican adults, aged 45–75 years at time of entry into the study, who reside in the greater Boston area. A total of 50 participants

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from the longitudinal cohort study were randomly selected to participate in the qualitative project. Individuals in this subsample were interviewed through semi-structured interviews lasting 1 to 4 hours. Some of the topics addressed included reasons for migration, the experience of aging in the United States, illness and well-being, social support, acculturation, discrimination, and comparisons between Puerto Rico and Boston. Trained interviewers of Latino origin conducted the interviews in Spanish at the participants’ homes. The interviews were digitally recorded, and subsequently transcribed verbatim. Of the 50 interviews, 20 were translated from Spanish into English so that more members of our team could participate in the analysis and discussions, and our findings reflect an analysis of these 20 interviews. Not all interviews were translated due to limitation of resources for translation, and those that were selected reflect a diversity of gender (10 men and 10 women) depressive symptoms (high, medium, and low) and educational attainment (less than high school, high school, and some college). At the time of the interviews, participants’ ages ranged from 49 to 75 years, with an average of 60 years of age. The participants had lived in the US mainland for a significant amount of time, averaging over 40 years of residency, with residency in Massachusetts averaging 28 years. Eight of the interview participants were currently married and living with their spouse; more than half (n = 13) had less than a ninth-grade education.

Analysis We followed a Thematic Analysis process, informed by a phenomenological perspective (Braun and Clarke, 2006) in order to identify and analyze patterns and themes in the qualitative data. Analysis was conducted with the qualitative research software ATLAS.ti. Three of the authors completed initial coding of the 20 interviews. The thematic analysis was iterative, with the authors meeting frequently to discuss interpretations based on the rereading and

coding of each interview. For the analysis, we used both the Spanish and English versions of the transcripts for coding and interpretation, since two of the authors are bilingual and bicultural. Through these meetings, themes were first identified, then reviewed, defined, and finalized in agreement among the coauthors (Braun and Clarke, 2006).

Results Our analysis identified several overarching themes related to the meanings and experiences of aging for the Puerto Rican adults in our study. These included normalization and acceptance of aging and health problems in age, gratitude for the health one has, aging as a socially connected process, and the experience of aging within time and place.

Normalization of aging and symptoms of illness and disability Participants in the interviews talked about the process of getting old and old age as an inevitable part of life. For most of them, the process was natural and life flowed surely into old age, as well as into the aches and pains also normally associated with getting older. One’s life path was to move from being young to getting old since, as Francisco2 (age 73 years) says, “In this life we are born to die.” As part of this process, changes in the body and the appearance of symptoms were also normalized and accepted. The appearance of aches and pains of aging, viejitis,3 is seen as inevitable, and generally their attitude was one of minimizing these problems and to a large extent tolerating them. Sofia (age 57 years) has several health problems, but overall she says that her health is good, “especially for my age.” She states calmly, “I don’t have pains that are killing me” and though “It is not easy to get older, you have to accept things.” María (age 67 years) also talks about the inevitability of health problems: “It all comes out when you get old,” a process that cannot be changed and thus “At my age I have to accept whatever comes.”

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Todorova et al. Participants, generally, minimized existing health problems and attempted to go on with their lives in spite of them. Roberto (age 64 years) states that he has “a little diabetes” but he does not see that as a health problem, since he has energy and can continue to be active and mobile. When Rafaela (age 52 years) is asked how she feels about her health, she says that she is in good health (in spite of the multiple conditions which she has) and can do what needs to be done “… I can [be active] although a little slow, but I can do it.” Thus, often health was defined through being able to be productive as well as through comparison with others. In the comparisons with others, participants are also able to construct themselves as relatively healthy and to normalize any symptoms they have as part of aging. When asked how she sees her health Carmen states “it is very poor … poor, because I take medicines, like nine different types. My health is very poor but I feel good.” Thus, poor health is not a barrier to feeling good. The narrative of acceptance was prevalent throughout our interviews, but is also entwined with different proactive positions. Many participants start their reflections on aging and health problems with an attitude of acceptance of the negative developments with time, and then move on to examples of taking control of their physical or mental health. César (age 53 years), for example, says that the pains he has are acceptable and thanks God for being able to tolerate them “I accept it the way it comes.” However, he also states that he first tries to solve problems, but “If I can’t resolve the problem, I let it go.” A bit later in the interview he says that if you want to, you can always fix your life. This ostensibly individualistic position is later elaborated as being a relational one, as he says that the purpose of this would be to help others: I’m the kind of person who … when the moment comes I try to resolve it [the problem]. If I cannot resolve it, and if the [solution] is not within my reach, I let it go. Because I’m not going to die because of that. […] You fix your life when you

decide to fix your life. […] [You have to say] I’m going to fix my life first, so I can help my kids. Because they need me. Then you will fix yourself first. And so you will go forward. (César, age 53 years)

Participants talked about ways of sustaining health in old age through taking responsibility for prevention of health problems. Sebastián (age 58 years) says that when looking toward old age, one has to take responsibility for health and prevention, prepare, and approach it thoughtfully: That’s right. I am responsible for myself. For my quality of life. I am very responsible for my quality of life. Looking out for my old age. I mean … I don’t feel old, but I have to prepare for old age. (Sebastián, age 58 years)

Thus, there is a prevailing sense that one accepts what happens in older age to the changing body and abilities, yet one can also affect what will happen later in life by choices made now or especially in youth. The men in the study more evidently spoke of risk behaviors in their youth, or the need to avoid “the vices” (e.g. smoking, drinking alcohol, and/or using hard drugs) in order to be able to prevent health problems in older age. In these narratives some of the participants shift to individualistic positions about “taking care of oneself” and frame it as one’s own responsibility to eat healthy, not give into vices, and value their own lives and health: Well I always try to take care of myself, I always try because if you let yourself go, you die. I keep active all the time. I try to … or I try to at least. I’ve always played sports. Eating well also. Because that affects you also. Resting also. And trying to avoid “the vice.” Because “the vice” is also something that goes on killing you. Taking care of oneself, that is the most important. If you don’t take care of yourself, who will do it for you? (Juan, age 62 years)

The narratives of acceptance can be heard from older people who normalize the changes in health and see them as a part of the flow of life

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(Clarke and Korotchenko, 2011), but has an additional nuance for groups living in conditions of limited resources (Breheny and Stephens, 2010). The above examples of prevailing attitudes of acceptance of aging and health limitations could be tied to Puerto Rican cultural values such as fatalism or destino (Flórez et al., 2009). On the other hand, we also see examples of accepting one’s problems, because they are due to insurmountable structural barriers (AbraídoLanza et al., 2007). Several people referred to poverty, limited resources, and food shortages with a tone of resignation. Inequalities are made livable by reframing the conditions that stem from them, and by resigning oneself. A phrase that is interspersed throughout the narratives is “I can’t complain.” César (age 52 years) shares that he often faces a shortage of food at the end of the month, but he always gets by because he can get along by eating white rice for a while: “You have to adapt to what there is […] Be satisfied with what you have. […] Things are not good, but we are not dying of hunger, I can’t complain.” Manuel (age 52 years) also illustrates a similar dimension of resignation: “We poor people have to stay where we are, what can we do? […] When you don’t have money, you have to conform to what there is.” Though not always directly related to aging, the above examples of acceptance and resignation to structural barriers and inequalities further illustrate participants’ philosophy regarding acceptance and control. On the other hand, the examples indicate that what is often interpreted as a Latino cultural value can also be a manifestation of having limited choices due to objective social and economic constraints, a point which we further address in the “Discussion” section.

was overwhelming in many of the narratives, and could include gratitude for one’s overall life situation, for one’s friends and family, and for one’s health, often independent of their actual health status. They identified what they are appreciative of, and were grateful for little comforts available to them, as they grew older. This gratefulness in some cases was general gratefulness to life and fate, while in others it had religious dimensions, and the paragraphs of many narratives were sprinkled with the phrase “thank God.” When María (age 67 years) is asked how her health is, her response is “As long as I can move around, I thank God.” Even in the light of multiple health symptoms, Rafaela (age 53 years) has a very positive definition of her overall health. The illness that she had to deal with led to inability to pay her rent, yet she identifies many things she is grateful for, and in many situations sees the positive aspects “thanks to God.” She is grateful to God for the fact that she is “here” at this point in her life, considering the many conditions that she has:

Being grateful for the health one has

Another dimension of the attitude of acceptance and gratefulness was also avoiding complaining, that is, avoiding the ay bendito.4 Some defined health as an absence of complaints (Diana), so that reducing complaining, even if problems were present, in itself is a way of having better health. Participants tended to be critical of others who did

Being grateful for what one has, including the health that one has, is a theme that is also prevalent and is tightly related to the first theme of acceptance. Acceptance was achieved through letting go (of attempts to control) and also by gratitude for what one has. The sense of gratitude

Well I have arthritis, I have the cholesterol high, I have diabetes, I have migraines, they are giving me … it’s eleven medicines, for the asthma, they are giving me the pump, another type of pump, for the nose they are giving me the spray because at night I almost lack the ability to breathe, because I cannot breathe either, so they are giving me the spray, they are giving me some drops for the eyes ’cause the eyes seem that … seems that with the diabetes or something I do not see very well and that my vision sort of fogs up. I have many illnesses on me, it is not only one, it’s too much too much, but here I am, thanks to God, I am under treatment for everything. (Rafaela, age 53 years)

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Todorova et al. complain. The ay bendito itself was seen as a health problem, a sickness. César (age 53 years) defines people with mental health problems as those who are complaining. Being an immigrant from the island of Puerto Rico to the mainland of the United States also gives reason to accept one’s circumstances and be grateful for what one has. Whatever circumstances they find themselves in, they focus on those that they see as being better than what would have been in Puerto Rico: I don’t complain about the way I am. Because I came to this country without anything, and I arrived, alone, alone. Without friends or anything. And I progressed. I’m not rich, but I don’t need to be rich. What I need is to live. And I am living, I have enough. (César, age 53 years)

Aging as a socially connected process Aging was experienced as balancing between independence and social connection. Many associated aging with a loss of control and independence “Aging means someone has to do things for you, take you places” (Dolores, age 61 years). They worried about health problems that limit their activities and independence. Thus, sustaining one’s independence in older age was highly important for many of the participants. However, the overwhelming emphasis was placed on aging in connection with others. This is the value and concern about aging, which is also identified in other work (Ramos, 2004, 2007) and which prevailed in all of our interviews. Rafaela (age 53 years) describes how the elders in her family stayed in the home until the end of life, and how each of them died in the arms of their immediate family, implying that this is the way one’s life should end – with the family caring and present: Both of my grandmothers died in our hands. My mom was very ill, my mother-in-law was ill; I was almost all the time with my mother-inlaw when she was ill. My mom died in our arms, she didn’t die in the arms of just anyone, nor alone.

Many worried about loneliness, being forgotten by family members, and being left with no one to take care of them. This view of aging is usually associated with life in the United States, and the discussion of aging and the social connections of older people inevitably turn to comparisons of the way aging is perceived to be on the mainland and in Puerto Rico. The loneliness they associate with aging in the United States is broad, but is particularly connected to the practice of sending older people to nursing homes, a practice that is rather rare in Puerto Rico (Zsembik and Bonilla, 2000). In contrast, aging in Puerto Rico is associated with the comfort of one’s family all around, with people that “adore” you, where “it’s my climate, it’s my people” (Francisco, age 73 years). Many associate aging in Puerto Rico with “love,” while aging in the United States with “being abandoned,” “because here they abandon people” (Rafaela, age 53 years). She goes on to explain “it’s not that they don’t have the necessary things, that they lack things – what is most necessary is the family and the love.” The associations of aging in the United States are saturated with sadness: And old age in this country, is very sad. It’s very sad. I don’t know … if it’s that way for everyone, but I think it’s very sad. And if you’re alone it’s more so. It’s sadder still. (Cesár, age 53 years)

Juan is particularly emphatic about how terrible it is to age in the United States, and associates aging in the United States with everything negative, including loneliness, abandonment, mistreatment, and absence of trust. He compares getting old in the United States with being put in front of a firing squad: Life here is horrible. I pray to God, but to spend my old age here … would be the worst thing in the world. […] If I take [my father] to a nursing home, I send him to die. […] In Puerto Rico there’s still sentimiento.5 Here when you get old you’re not worth anything anymore. […] Here they don’t respect anyone. Here they treat you like you’re trash. In other words, … there is no sentimiento at

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all. There is not one bit of sentimiento. (Juan, age 62 years)

On the other hand, in Puerto Rico older people are seen as being more mobile and able to sustain social connections, since their environment allows easier access to the outside and to nature. They can go out in the yard since the weather is warm and connect with animals and neighbors. This leads to the following theme related to what pulls people to return to Puerto Rico in old age.

Experiences of aging within time and place From the narratives we can also see the distinctive experience of aging in the different places, and the relative nature of age and time. Time passes differently in these locations, and calendar age also can have different meanings. Some participants believe that time passes slowly in Puerto Rico and thus aging does not happen as fast. Daniel, age 60 years, says that “people last longer in Puerto Rico than here” which he connects to the idea of naturalness and spontaneity, particularly as related to the naturalness of food, compared to the chemically processed foods in the United States. Blanca (age 49 years) thinks that time goes by much more quickly in the United States, since everyone is always under time pressure. Dolores (age 61 years) also feels that time flies by more quickly in the United States because of the fast-paced life. Many of the participants considered themselves old not because of calendar age, but because of the health problems they have. Enrique (age 53 years) considers 60 as old age: he feels that he will not make it to 60 because of his lifestyle and health risk behaviors. Robert (age 64 years) believes that after 50, one is not complete: “I feel aged, because after you pass 50 you go on as if you’re half a package, as they say.” On the other hand, for Carmen (age 76 years), aging is related to choice, and she states that it is up to older people how they allow society to construct them. She rejects the inevitable connection of age and

illness and underscores that age is relative by stating that “No, no, no age doesn’t have anything to do with illnesses. I know people who are fourteen or fifteen years old who are already incapacitated.” The Puerto Rican adults were reflecting on their health and the aging process, while being pulled between their physical location on the US mainland, where at least to some extent they felt out of place (Lewis, 2009; Yahirun, 2012), and their nostalgia for Puerto Rico. Overwhelmingly they expressed their appreciation of the quality of the health-care system in the United States and its importance for maintaining their health or for treating existing medical conditions. Blanca (age 49 years) says, “Here everything is, look … here in comparison with those of PR [even the worst hospital] is a luxury … it’s like a hotel.” This issue becomes more salient as they age, since illnesses increase and thus the need and reliance on the medical system in the United States becomes more crucial. On the other hand, they longed for Puerto Rico, but associated it with a health-care system lacking in resources, implying that they may experience more difficulties there as they age, in obtaining needed services and medications. Carmen (age 76 years) says “I’m proud of being Puerto Rican, but the health care system is horrible … antiquated.” They talked about their plans to return to the island because of the emotional connection to Puerto Rico, the lifestyle on the island, which they preferred, and the general “warmth” they associated with it. Manuel often travels “in my mind” to Puerto Rico, which he considers his home: “I am physically here, but my mind is over there.” Their narratives flip back and forth between their plans to return to Puerto Rico and their concern about receiving medical care there, as well as the quality of medical care in the United States; between the care of the soul in Puerto Rico and the care of the body in the United States. Some made specific plans to return, while others talked of the return as an elusive fantasy, the pull of which becomes more and more intense with the passing of the years. Diana (age

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Todorova et al. 49 years) has concrete plans to return when she retires from her work in the United States. She has planned to open a bakery business in Puerto Rico with her mother and sister to make traditional pastries and fritters, such as alcapurrias and pastelillos de guayaba: “That is something that I’m looking to, looking to, wanting to do.” She has worked in the United States and she wants to experience what those daily routines of getting up and going to work are like in Puerto Rico, she wants “to be able to finish,” which we can only wonder if she means to complete the circle of life. Juan (age 62 years) also has unwavering intentions to return, which are associated with his identity of being Puerto Rican. He wants to be buried in the homeland of Puerto Rico, because he is Puerto Rican: “I feel a hundred percent [pure] Puerto Rican. And there is no culture that can make me change. I want them to bury me there. I don’t want … I don’t want to be buried here. It’s our culture.” The longing for Puerto Rico had several dimensions, many of them related to the richness of the social interactions they remember and to some extent sustain there. The lifestyle they associated with Puerto Rico is one of being outdoors in the casitas y balcones,6 where one is seen, responded to and responds to others on an ongoing daily basis (Gorry and Falcon, 2009). The movement to these open spaces was spontaneous and easy, even for older people, and thus the boundaries between inside and outside, between self and other were seen as permeable. Over all, participants associated Puerto Rico with warmth and the United States with the cold. At one level this is literally related to the weather in Puerto Rico, compared to the cold New England winters, which impeded people’s movement outdoor. Aging meant becoming more and more vulnerable to this coldness: If the time came that [the cold] will attack us so much that we need to go, because when one is young the cold doesn’t attack you much but when the years come, those years, the cold attacks you more so you have to do something. I tell you I, if God permits, I will not stay here, I have plans to

go to Puerto Rico, how many more years? I do not know, wait and see what’s there. (Rosario, age 61 years)

At other levels, as we can infer from the themes above, the vulnerability of old age to the “attacks of the cold” in the United States also relates to the coldness of immobility and social isolation. This is contrasted to the “warmth” of Puerto Rico, where there is more freedom to be in the sunshine of the outside, as well as the warmth of social connections.

Discussion Our study identified several prevalent themes and tensions within them, in relation to meanings and experiences of aging and health for the Puerto Rican adults. These were related to the normalization and acceptance of aging and health problems in age, entwined with being proactive and taking responsibility for one’s health; gratitude for the health one has, which is associated with not complaining about problems; emphasizing the importance of aging within social networks as well as preserving independence; and longing to return to Puerto Rico at older age, while needing to stay in the United States to care for the aging body. These themes give insights into what it means for Puerto Rican adults and what their embodied lived experience of aging is like in the United States, with the specific social, cultural, and economic situations in which they are positioned as citizens of the United States yet immigrants emphasizing their cultural identity and longing to return to their home in old age. A prevalent meaning of aging was related to acceptance and normalization of illness and the inevitable aging process. This resonates with findings from other studies with Latino groups in general (Hilton et al., 2012) and Puerto Ricans in particular (Ramos, 2004) and can be related to the broader discussions in the literature regarding relevant cultural worldviews such as fatalismo as prevalent in Latino culture. This Latino worldview has been used to interpret health attitudes and behaviors in Latino

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populations (though rarely the process and experience of aging). It is often defined as a passive acceptance of one’s fate, or even a pessimistic view of the future, thus seen as problematic for health-care seeking, screening (Espinosa de los Monteros and Gallo, 2011), medication adherence, and self-care (Walker et al., 2012). Acceptance of one’s ill health and one’s difficult circumstances has been shown to be relevant to groups in other geographical areas but in similar disadvantaged situations (Breheny and Stephens, 2010). There were some examples, but overall participants in our study rarely talked about attempts to change their bodies, to slow down the aging process or to significantly change their appearance. This is in contrast to (western) discourses of disciplining the body, fighting old age and denying death, which have been identified in other contexts (Paulson and Willig, 2008; Pond et al., 2010). This relates to a central question—the relationship between “fatalism” as a dominant cultural belief on the one hand and as a function of the material and structural barriers that these groups face. Some authors have focused on challenging the dominant stereotype of Latinos as fatalistic and have underscored the role of prejudice, institutional racism, poverty, and other external forces, which limit access to health care, or contribute to narratives of pessimism and disempowerment, which have fatalistic connotations (Abraído-Lanza et al., 2007). They also argue for a “more thorough examination of different concepts cloaked under the notion of fatalism … and a closer analysis of how socioeconomic and other factors may be masked as ‘fatalism’.” (p. 156) However, we have delineated multiple dimensions of the prevalent attitude of acceptance of aging. Acceptance was on a continuum in which aging also meant taking care of one’s health—they discussed multiple ways in which they actively take responsibility for their health, including through care seeking, and particularly emphasizing the avoidance of health risk behaviors in one’s youth, in order to sustain a healthy old age. In a similar vein, the work of Flórez

et al. (2009) problematizes a one-dimensional view of fatalism and, instead, foregrounds an alternative cultural worldview of destino (destiny) which interweaves the role of (external) forces which predetermine one’s health and a life with agency. Similarly, Sanchez and Garriga (1996) propose a model which addresses the continuum of dimensions within what has been identified as the fatalistic Latino worldview. They delineate more pessimistic and more “positive fatalism” parts of this continuum, which offers opportunities for working toward empowerment. An important meaning of aging given by the participants related to the place and social connections in which aging happens. This observation could be connected to the Latino cultural value of familism, which speaks to the interconnectedness, communication, loyalty, and reciprocity among family members, including extended family members (Ramos, 2004, 2007). Many turned to their more abstract hopes or more concrete plans to return to Puerto Rico in older age, and some stated that that is the land in which they would like to be buried. Existing studies have illustrated that for older adults, “feeling in place” is important for their well-being as they age (Lager et al., 2012), while immigrants have additional challenges due to “aging out of place” (Lewis, 2009; Yahirun, 2012). Our findings resonate in some aspects with what previous studies with Latino participants have found (Beyene et al., 2002; Hilton et al., 2012; Romo et al., 2013) and also underscore some dimensions of the meaning of aging specific to Puerto Ricans. This needs to be contextualized within the political and economic ties between Puerto Rico and United States. The opportunity to move back and forth is always present (Duany, 2011), and so the idea of where one decides to age can remain more open. The way that longing for one’s country of origin is entwined with the need to stay in the United States because of health care and services available to them is specific to Puerto Ricans due to their more direct access to health services compared to other immigrant groups (before they

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Todorova et al. attain citizenship). Yet the legal status of Puerto Ricans and thus their assumed access to health services should not mask other barriers and inequalities, which researchers should explicate. In addition, the dependence on US mainland programs that do not exist or are of lesser quality in Puerto Rico replicates the more macrolevel dependence of Puerto Rico on the United States for economic support. Puerto Ricans’ reluctance or avoidance of complaining is no doubt connected to their religious gratitude and thankfulness in general for what one has. Considering Puerto Rico’s history and continued dependence on the United States (Taylor, 2013), the reluctance to complain may come also from beliefs that one is being provided with services and support that others are not entitled to (through citizenship) and that one has the privilege and “luck” to receive; therefore, one should not complain. Cultural meanings and beliefs of different ethnic minority groups may present risk factors that contribute to health inequalities or protective factors that contribute to health in the face of structural inequalities (Betancourt and Flynn, 2009). Our study illustrates the relevance of history, structure, and cultural meanings and values to the experience of aging. Focusing on eliminating health disparities among older populations, we must take into account the cultural meanings of health and aging. Funding We are grateful to the National Institutes of Health, who have funded this project, under grants P01AG023394 and P50HL105185.

Notes 1. We use the terms “Latino” and “Hispanic” interchangeably. 2. All participant names have been changed and pseudonyms are used. 3. The word viejo means “old one,” adding the suffix “it is,” to create the term viejitis, implies that being old is a condition or diagnosis in itself. It is not just a matter of having illnesses and pains, but of having the condition of being old.

4. Ay bendito: This phrase is defined as an interjection that denotes anguish, sadness, pity, and supplication. As can be gleaned from this definition, the phrase has many and sometimes contradictory meanings for the speaker, depending on the circumstances. For example, it can be used in general (e.g. Ay bendito, there is so much corruption in this government), used in reference to others to show pity and empathy for someone else’s circumstance (Ay bendito, the children don’t have shoes) and it can also be used to show anguish for one’s own circumstance or situation. The participant here says that one should avoid the “ay bendito” referring to oneself, as if to say that one should avoid the “woe is me” way of thinking in which one pities oneself (Vaquero and Morales, 2005). 5. Sentimiento literally translates as “feeling.” In this context, it is used similarly to the word “sentiment,” referring to expressions of love, caring, and compassion for others (in this case, older adults). 6. Traditional wooden homes and large balconies.

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Gratitude and longing: Meanings of health in aging for Puerto Rican adults in the mainland.

Puerto Rican adults in the United States mainland live with socioeconomic and health disparities. To understand their contextual experience of aging, ...
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