Abstract
Background
Type 2 diabetes (T2D) is a highly prevalent endocrine-metabolic disorder globally, with significant socio-health implications due to its high prevalence of associated complications. 1 Currently, 537 million adults aged 20 to 79 years are living with diabetes, with a higher prevalence in men compared to women. 2 In Mexico, the prevalence is 18.3%, while 22.1% of the population has prediabetes, with considerable prevalence in women. 3 However, diabetes-related mortality is higher among men under 65 years of age.3,4
Indigenous populations in Mexico have an increased prevalence of obesity, prediabetes, diabetes, and metabolic syndrome. These rural communities are characterized typically by lower incomes, limited access to education, and reduced access to health services.5 -7 In addition, there are striking differences in chronic disease risks: Indigenous men have a higher risk of hypertension and cardiovascular disease, while women have a higher risk of T2D. 8 Nevertheless, the sociocultural factors influencing diabetes risk in these populations have not yet been widely studied.
Sociocultural constructs comprise a complex array of attributes, roles, and beliefs that shape the behaviors and attitudes of individuals within society.9,10 These constructs have far-reaching impacts on various aspects, including economic, social, cultural, and health factors such as lifestyle, healthcare-seeking behaviors, and mortality. 11
In Mexican and Hispanic cultures, these constructs are reinforced set of behaviors and customary roles like Machismo and Marianismo, predominantly in rural and Indigenous communities.12,13 Machismo has been understood as a form of hypermasculinity, characterized by beliefs, values, and attitudes linked to traditional male roles, emphasizing negative features such as bravery, honor, and sex-role dominance. Traditional machismo has been linked to emotional repression and the role of provider,13,14 display stoic behavior toward health problems, deny pain, evade discussing their personal problems, and delay seeking medical care.15,16 These behaviors intend to reaffirm their masculinity and avoid showing weakness or traits considered feminine.17,18 These masculine beliefs are associated with an unhealthy lifestyle and an increased risk of suffering chronic diseases.19,20
Conversely, Marianismo beliefs represent a set of values and expectations linked to traditional female roles, emphasizing passivity, self-sacrifice, chastity, and a caregiver role focused on the home and family.12,21 Women adhering to Marianism often prioritize family needs over their own, including health-related needs, reducing their access to medical services, and increasing their risk of developing diabetes.22 -24 Additionally, these women tend to have lower educational levels, lower incomes, less physical activity, higher stress, and sleep problems, factors associated with a higher body mass index (BMI). 25 Beyond the gender perspective, these constructs, in addition with sociocultural factors, could influence family dynamics, including food choices, lifestyle patterns, and healthcare decisions.
Given the significance of socio-cultural constructs, it is important to investigate the increasing risk of T2D in the Indigenous populations of Mexico and its relationship with Machismo and Marianismo. Nonetheless, to date there are no studies examining these outcomes. This study aims at analyzing the relationship between Machismo and Marianismo and the risk of diabetes in 2 Indigenous groups of the Sierra de Puebla, Mexico.
Methods
Study Design and Population
A cross-sectional study was conducted among Indigenous Nahuas and Totonacs from the Ahuacatlán and Huehuetla communities in the Northeastern Sierra of Puebla, Mexico. Participants were selected according to the following criteria: men and women aged 18 years or older, Spanish-speaking, and residents of at least 1 of the 2 communities. We excluded subjects with a previous diagnosis of any diabetes type, neurological disorders (such as dementia or Alzheimer’s disease), or communication disabilities (such as being deaf or mute). The sample was purposively selected for convenience. The study was conducted between March and June 2019.
Questionnaires
The risk of T2D was assessed using the American Diabetes Association’s Diabetes Risk Calculator. 26 This tool evaluates factors such as age, sex (male or female), family history of diabetes, previous diagnosis of hypertension, body mass index (BMI), and history of gestational diabetes in women. The score ranges from 0 to 10, with a classification of low risk (0-4 points) or high risk (≥5 points).
Machismo was assessed using the Masculine Norms Conformity Inventory. 27 This questionnaire consists of 22 statements measuring 11 specific dimensions: Winning, Emotional Control, Risk-Taking, Violence, Dominance, Playboy, Self-Reliance, Primacy of Work, Power Over Women, Disdain for Homosexuals, and Pursuit of Status. Each statement is answered using a 4-point scale: 0 (Strongly Disagree), 1 (Disagree), 2 (Agree), and 3 (Strongly Agree). The total score ranges from 0 to 66, with higher scores indicating a strong presence of Machismo beliefs. The questionnaire demonstrated Cronbach’s alpha of 0.78.
Marianismo was measured using the Marianismo Beliefs Scale. 28 This scale includes 24 statements related to traditional feminine values, focusing on being the family pillar, being virtuous and chaste, subordinating to others, self-silencing and harmony, and the spiritual role. Each statement is answered using a 4-point scale: 1 (Strongly Disagree), 2 (Disagree), 3 (Agree), and 4 (Strongly Agree). The total score ranges from 24 to 96, with higher scores indicating higher adherence to Marianismo beliefs. The scale demonstrated a Cronbach’s alpha of 0.85.
Covariates in the study included education level, family history of hypertension, systolic/diastolic blood pressure, alcohol consumption, and tobacco use.
Data Collection
In both communities, local leaders extended verbal invitations, providing details regarding the location and date of the assessments. Data collection took place at the multi-use courts in each community, which serve as well-known meeting points for a variety of community activities. All participants were informed of the study’s aim, and the informed consent form was read aloud to them. Participants who agreed to participate signed the form and received a copy. Anthropometric measurements were subsequently taken, and questionnaires were completed in one-on-one interviews. In cases where individuals did not speak Spanish or were unwilling to sign the consent form, only diabetes risk assessments were performed (data from these cases were not captured or analyzed). Participants were oriented, and if necessary, they were referred to local health services with the assistance of bilingual nursing students.
Ethical and Legal Considerations
The ethics and research committees of the Intercultural University of the State of Puebla approved the study. Written informed consent was obtained from each participant after providing sufficient information and explaining the aim and importance of the study.
Statistical Analysis
Data were entered and analyzed using SPSS version 26. Descriptive analysis involved reporting categorical variables through frequency tables and percentages, while continuous variables were expressed as means and standard deviations. To compare the risks associated with Machismo, Marianismo, and T2D among indigenous groups, we employed Student’s t-test or the Mann-Whitney U test for comparisons between 2 groups and Kruskal-Wallis for comparisons among 3 groups. Spearman’s correlation analysis was conducted to examine associations between diabetes risk and the variables of Machismo, and Marianismo, both globally and by dimension. Additionally, multiple linear regression models were performed to predict diabetes risk based on sex, In the first model, the total scores of the machismo and marianismo variables were included as predictors. In the model 2, the dimensions of each scale were incorporated. Finally, only the significant dimensions of machismo and marianismo were reported in the tables.
Results
Sociodemographic Characteristics
A total of 491 individuals from 2 Indigenous communities participated in the study. The mean age of participants was 39.5 years (SD = 7.0) and 6.6 years of education, equivalent to an elementary school level (SD = 3.8). Most participants were women and identified as Totonac. Regarding T2D risk, 20.1% (n = 99) were classified as high risk, with 16.7% in the Nahua population and 22% in the Totonac population. Most participants reported no known family history of diabetes or hypertension or were unaware of such a history. Only 19.1% of participants reported a prior diagnosis of hypertension. Concerning lifestyle, 23.8% engaged in physical activity, 30.8% consumed alcohol, 14.7% smoked, and 61.5% were overweight or obese (see Table 1).
Participant Characteristics.
Abbreviations: %, percentage; T2D, type 2 diabetes; f, frequency.
Analysis of Machismo regarding T2D risk factors revealed that individuals with a family history of hypertension and obesity had higher Machismo scores. In contrast, women with a previous diagnosis of hypertension who were non-physically active, non-alcoholic, and non-smokers reported higher scores on Marianism beliefs. No significant differences were found between ethnicity and T2D risk (see Table 2).
Comparison of Machismo, Marianismo, and T2D Risk by Participant Characteristics.
n = 244 men.
n = 247 women.
Variables included in the calculation of diabetes risk.
Correlation Analysis
The risk of T2D was positively and significantly correlated with both Machismo (
Correlation Analysis Between Participant Characteristics, Machismo, Marianismo, and T2D Risk.
1 = Age, 2 = Education, 3 = Body Mass Index (BMI), 4 = Systolic Blood Pressure, 5 = Diastolic Blood Pressure, 6 = Alcohol Consumption, 7 = Smoking, 8 = Machismo, 9 = Marianismo, and 10 = Type 2 Diabetes Risk. nmen = 244, nwomen = 247.
Variables included in the calculation of diabetes risk.
Multiple Linear Regression Model by sex
Two multiple linear regression models were conducted to examine the relationship between Machismo and T2D risk in men. In Model 1, the overall Machismo score included as a predictor (β = .237
Multiple Linear Regression Models for T2D Risk in Men.
Abbreviation: β, unstandardized beta.
n = 244.
standardized beta.
Model adjusted for Indigenous group, education, systolic blood pressure, diastolic blood pressure, family history of hypertension, alcohol, and tobacco consumption. In Model 2, only the dimensions that were significant are shown.
For women, 2 multiple linear regression models were conducted with the risk of T2D as the dependent variable. In Model 1, the overall score for Marianismo beliefs was used as a predictor (β = .156,
Multiple Linear Regression Model for T2D Risk in Women.
Abbreviation: β, unstandardized beta.
n = 247.
standardized beta.
Model adjusted for Indigenous group, education, systolic blood pressure, diastolic blood pressure, family history of hypertension, alcohol, and tobacco consumption. In Model 2, only the dimensions that were significant are shown.
Discussion
This study examined the relationship between Machismo, Marianismo, and T2D risk in 2 Indigenous groups from the Sierra de Puebla, Mexico. Our findings indicate that Machismo in men and Marianismo in women are independent predictors of T2D risk among the Nahua and Totonac Indigenous populations of Northeastern Puebla, Mexico.
The risk of T2D, assessed with the American Diabetes Association calculator, was higher in the Totonac Indigenous population than in the Nahua population. However, physical inactivity and overweight/obesity were 2 predominant factors contributing to T2D risk in both populations. T2D is associated with several factors, including genetics and environmental factors. In recent years, Indigenous and rural populations have undergone significant lifestyle changes, including road construction, the introduction of public transportation, the incorporation of ultra-processed foods, increased prevalence of overweight/obesity, and elevated risk of chronic diseases such as T2D.29 -32 The prevalence of metabolic syndrome in Indigenous communities was related to low high-density lipoprotein concentrations and central obesity in females. 6 It has been reported that the increase in prevalence of T2D in the Mixe community, an indigenous group located in southern Mexico, is associated with adopting a high-carbohydrate Western diet. 33
Indigenous populations frequently encounter limited access to healthcare services, prompting them to seek private healthcare options, which disproportionately impacts the most impoverished communities. 34 Reports indicate that diabetes care is less effective in Indigenous communities in Mexico, primarily due to restricted access to essential resources and the presence of social disparities. 35 While metabolic factors associated with T2D in Indigenous people have been explored, the investigation of social factors contributing to T2D risk remains under-researched.
The correlation analyses and multiple linear regression models identify Machismo as an independent factor that increases the risk of developing T2D. Specifically, the primacy of work, winning, power over women, and dominance were associated with T2D risk. There is limited evidence of the relationship between Machismo and T2D risk. In traditional Indigenous communities in Mexico, men are considered the head of the family, responsible for making important decisions for family members and themselves.36,37 In studies focused on perceptions from men, women and clinical staff, machismo has been considered as a barrier to seeking preventive services as it encompasses the attitude that needing or seeking healthcare is a sign of weakness among men. 38
In addition, a previous study on men with diabetes reported that those with greater adherence to Machismo received less family support. 39 Furthermore, men are often immersed in a competitive environment where they strive to stand out and demonstrate masculinity. 37 In qualitative studies, it was described that Mexican men at risk of T2D and Machismo inhibit health prioritization 40 or could be perceived as a barrier to obtaining diabetic eye care. 41 In the health domain, men are viewed as models of well-being, while women are perceived as more vulnerable to diseases. In this context, men feel the need to demonstrate physical strength and avoid behaviors associated with healthcare (generally linked to femininity) to prevent appearing less competitive or more vulnerable.18,42 Therefore, this role may lead men to reject any support from their wives or other family members regarding their healthcare, making it difficult for them to seek medical care, change their lifestyle, and adopt preventive measures for chronic diseases.
The multiple linear regression analysis identified the primacy of work, risk-taking, and pursuit of status as predictors of increased T2D risk. According to Courtenay, men tend to uphold their masculine ideals and social priorities, such as focusing on work, when facing health problems. In adulthood, work is considered the primary priority for men, as they perceive it as the means to maintain their status within the family and society. 18 Therefore, even when experiencing health problems, men often attempt to continue their work activities as usual, avoid discussing their health issues in the workplace, and are less likely to take medication. 43 This is a health-risk behavior, which includes eluding medical check-ups for chronic disease detection and denying or avoiding medical diagnoses related to chronic illnesses to prevent compromising their masculinity in front of other men.17, 44 When faced with the risk of developing a chronic disease, men often prioritize maintaining risky behaviors that affirm their masculinity over adopting health-beneficial behaviors, as their masculine identity is at stake. This phenomenon may contribute to the higher morbidity and mortality rates in men compared to women.37,45,46 In summary, these findings suggest a critical point to understand the construct of machismo and how it could influence decision making regarding health care. Future investigation is needed from a multidimensional perspective to design and include specific health education and interventions with a more inclusive and complete understanding.
According to Marianismo beliefs, the correlation and multiple regression analyses revealed an association with a higher risk of T2D. Within traditional beliefs, women are expected to follow men’s decisions, principally when they dedicate themselves to household tasks, where men are the primary economic providers. These social dynamic conditions lead to adopting a submissive and subordinate posture in women out of fear; if not, conflicts or violence may arise within the relationship.22,36 Consequently, women tend to resort to self-silence to maintain family harmony, even though this behavior may trigger mental health issues.22,47,48 Furthermore, when facing difficulties of any kind and lacking the opportunity to express themselves, they turn to spirituality to cope with adversities, seeking support, hope, and strength.47,49 This search for comfort reinforces the idea that suffering can translate into gaining social recognition as an exemplary woman, which is related to religious beliefs. 21
Previous studies have shown that women with strong Marianismo beliefs tend to avoid physical activity and focus predominantly on caring for family members, seeing caregiving as a natural part of their feminine identity, often with a sense of duty.50 -52 However, this orientation increases the risk of developing T2D. 53 Marianismo beliefs promote a lifestyle based on sacrifice for others without expecting a reward, which can increase women’s vulnerability to chronic diseases. Additionally, this focus on caring for others at the expense of their well-being can lead to a lack of time for self-care, as observed in women already diagnosed with T2D.8,54
In the multiple linear regression analysis, the dimensions of being virtuous, chaste, and subordinated to others were the key predictors of T2D risk. Traditionally, women have been expected to offer their best for their partner’s or family’s well-being, a notion deeply rooted in societal expectations of being a woman, wife, or mother. 21 This dynamic often leads women to conform to the roles and ideas imposed by the men in their lives (fathers, grandfathers, brothers, or partners), prioritizing these responsibilities over their health and well-being. 23
Additionally, women who report not consuming alcohol and not smoking tend to score higher on the Marianismo Beliefs Scale. This finding may be interpreted as protective since women, due to social and familial expectations, are supposed to project a positive image and serve as role models within the household. 55 The relationship between traditional feminine ideals and alcohol consumption is complex. Some studies identify these ideals as a risk factor for alcohol use, while others argue that values such as sexual fidelity, modesty, affection, and purity can help reduce alcohol consumption.55,56 However, these same beliefs serve as a risk factor for physical activity and weight gain, as they tend to prioritize household duties and face time constraints.50,51,57 Marianismo provides a protective effect against alcohol and tobacco use, but on the other hand, it negatively impacts physical activity levels.
Strengths and Limitations
As a cross-sectional study, this research cannot establish causal relationships between the analyzed variables (Machismo, Marianismo, and T2D risk). The use of convenience sampling may have introduced selection bias, limiting the generalizability of the findings. Additionally, the study was conducted in 2 Indigenous communities (Nahua and Totonac) within a specific region of Mexico, restricting the extrapolation of results to other Indigenous or rural populations with different cultural contexts. Furthermore, data collection relied on self-reports, which may be influenced by recall bias or social desirability bias. This study did not assess the consumption of ultra-processed foods or stress in relation to machismo and marianismo. Strengths: This study offers a novel perspective by exploring the influence of Machismo and Marianismo beliefs on the risk of T2D among Indigenous populations, an area that remains underexplored in the scientific literature. By focusing on Nahua and Totonac Indigenous communities, the study highlights a historically marginalized population with a high burden of chronic diseases. This contributes to filling a critical gap in the literature on health disparities and inequalities in vulnerable groups. The gender-focused approach enables the identification of specific differences between men and women in relation to cultural beliefs and health behaviors, providing deeper insights into the underlying factors driving health disparities. Furthermore, the study’s findings have significant potential to inform the design of culturally adapted interventions for diabetes prevention in Indigenous populations, taking into account the unique roles of gender and cultural beliefs in shaping health outcomes.
Conclusions
Beliefs associated with Machismo and Marianismo have been identified as predictors of Type 2 diabetes (T2D) risk among the Totonac and Nahua Indigenous populations in Puebla, Mexico. Addressing the health needs of these communities requires a culturally sensitive approach that considers how such sociocultural constructs influence chronic disease risk. Health programs should be designed to help these populations recognize the importance of health and disease prevention within the context of their specific cultural frameworks.
Footnotes
ORCID iDs
