Using univariable logistic regression analyses, the odds of being unprepared for a hurricane (**Table 3**) were 1.63 times higher for respondents aged between 18 and 44 years [95% CI (1.30, 2.05)] than the odds for respondents aged 45 years or older. Similarly, the odds of being unprepared were higher for those with 8 years of education or less [OR = 1.45, 95% CI (1.01, 2.10)] or a high school diploma [OR = 1.48, 95% CI (1.04, 2.10)] compared to those with a college or technical education. In addition, respondents who reported having health insurance were 33% [OR = 0.67, 95% CI (0.51, 0.88)] more prepared compared to those without health insurance, and respondents with homeowner's insurance were 40% [OR = 0.60, 95% CI (0.45, 0.80)] more prepared compared to those without homeowner's insurance.

Household size also had a significant effect on preparedness (**Table 4**). Respondents of smaller households, 1–2 people, or 3–5 people were 40% [95% CI (0.28, 0.56)] and 58% [95% CI (0.46, 0.73)], respectively, less likely to be unprepared compared to larger households of more than 5 people. Households with lower annual income were more likely to be unprepared compared to households with an income >\$35,000. Respondents reporting higher numbers of evacuation barriers were significantly more likely to be unprepared for a hurricane. With a 1 count increase in number of evacuation barriers, the expected increase in the odds of being unprepared was 3%. The evacuation barriers of "the entire family cannot leave," "think the roads would be too crowded to leave," "worry possessions would be stolen or damaged," "cannot afford to leave (travel expenses)," "think evacuating will be dangerous," "will be safe at home," and "unable to work will mean being replaced" were significantly associated with evacuation unpreparedness, where very high odds of being unprepared were observed in respondents where "the entire family cannot leave" [OR = 2.62, 95% CI (2.00, 3.40)], in respondents who "think the roads would be too crowded to leave" [OR = 2.37, 95% CI (1.76, 3.19)], and in respondents who reported that being "unable to work will mean being replaced" [OR = 2.25, 95% CI (1.55, 3.27)]. Additionally, respondents reporting a higher level of MSN were more

#### **TABLE 4 | Household level characteristics and barriers by hurricane preparedness**.

*Bold font indicates statistical significance.*

*SE, standard error.*

*aReference group.*

*The percentages, odds ratios, and 96% confidence intervals are weighted.*

likely to be unprepared compared to those reporting no MSN. Specifically, the odds of respondents reporting an individual requiring assistance with medical care administration (MSN Level 4) were 3.82 times higher [95% CI (2.08, 7.02)] to be unprepared for an evacuation compared to those reporting no MSN. Likewise, respondents reporting an individual who depends on others for routine care (MSN Level 1) were 2.46 times more likely to be unprepared [95% CI (1.64, 3.70)] compared to those with no MSN. Respondents reporting an individual requiring transportation assistance (MSN Level 0) were 1.88 times more likely to be unprepared [95% CI (1.37, 2.58)] compared to those with no MSN.

Univariable multinomial logistic regression analyses tested the individual, household, and evacuation barriers by MSN (data not shown). The odds of level 0 MSN versus no MSN was 26% lower for males compared to females [OR = 0.74, 95% CI (0.55, 1)]. We also found the odds of level 0 MSN versus no MSN toss be 71% lower in respondents aged greater than 45 years in comparison to those aged 44 years or younger [OR = 0.29, 95% CI (0.21, 0.41)]. The odds of level 0 MSN versus no MSN was 35% lower for unmarried respondents compared to married respondents [OR = 0.65, 95% CI (0.48, 0.9)]. Respondents reporting higher numbers of evacuation barriers were significantly more likely to be level 0 MSN. With a 1 number increase in evacuation barriers, an expected increase in the odds of reporting level 0 MSN was 13% [OR = 1.13, 95% CI (1.05, 1.21)]. Higher odds of reporting level 0 MSN were observed when respondents also reported "the entire family cannot leave" [OR = 6.58, 95% CI (3.73, 11.58)], or that "the roads would be too crowded to leave" [OR = 2.63, 95% CI (1.75, 3.96)], or "unable to work will mean being replaced" [OR = 3.03, 95% CI (2.00, 4.59)].

The multivariable logistic regression model for the probability of being unprepared for a hurricane (**Table 5**) shows that after adjusting for ethnicity, adults in household 65 years or older, cash savings of at least \$300, income, age of respondent by household size, distance from shore and level of MSN and number of evacuation barriers, the odds of Hispanics to be unprepared for a hurricane were 49% lower in comparison to non-Hispanics [OR = 0.51, 95% CI (0.27, 0.95)]. In addition households with incomes between \$25,000 and \$35,000 had 1.96 [95% CI (1.13, 3.39)] times higher odds of being unprepared compared to those with income greater than \$35,000. The odds of households with at least one adult aged 65 years or older to be unprepared is 32% [OR = 0.68, 95% CI (0.47, 0.98)] lower compared to households with no adults aged 65 years or older. Additionally, there was a significant statistical interaction between age and household size, where the effect of age on unpreparedness was significant only in household sizes with 1–2 people [OR = 0.98, 95% CI (0.97, 0.99)]. This result indicates that for every year increase in age of respondents among households with 1–2 people, there were slightly decreased odds of being unprepared. For every one mile increase in distance from the shore, the odds of being unprepared increased by 3% [OR = 1.03, 95% CI (1.02, 1.04)].

A significant interaction between the number of evacuation barriers and the levels of MSN resulted in varying effects of being unprepared across the MSN levels. Among households with individuals requiring transportation assistance (MSN Level 0), for every one additional increase in the number of evacuation barriers the odds of being unprepared increased by 18% [OR = 1.18, 95% CI (1.08, 1.30)]. Among households that reported individuals who depend on others for routine care (MSN Level 1), for every one additional increase in the number of evacuation barriers the odds of being unprepared increased by 29% [OR = 1.29, 95% CI (1.11, 1.51)]. Also, among households that reported individuals who require assistance with medical care administration (MSN Level 3), for every one additional increase in the number of evacuation barriers the odds of being unprepared increased 68% [OR = 1.68, 95% CI (1.21, 1.32)].

### **Discussion**

This study examined preparedness for a hurricane and barriers to evacuation among households reporting MSN and households without MSN along the South Texas Gulf Coast. We hypothesized that households with higher levels of MSN would experience more barriers to evacuation and less preparedness for disasters. Our hypothesis was not proven because the effect of MSN on preparedness is more complex than our proposed simplistic linear hypothesis.

Medical special needs alone did not explain the probability of unpreparedness, but rather MSN in the presence of barriers played a role in explaining unpreparedness. As the number of barriers increased, households reporting the presence of individuals with MSN of levels 0, 1, and 3 were significantly more likely to be unprepared, but this interaction effect was not significant in households reporting the presence of individuals with levels 2 and **TABLE 5 | Multivariable logistic regression model for probability of being unprepared for effects**.

*Bold font indicates statistical significance.*

*MSN, medical special needs.*

*aReference group.*

4 MSN and among households with no MSN members. Therefore, it was not as simple as the higher the level of MSN the greater the unpreparedness. Likewise, there is no simple explanation for these findings, but rather we propose potential scenarios to shed light on the complexities. For households (MSN Level 0) that need transportation assistance during an evacuation, the barriers of feeling the family will be safe at home and not having travel expenses among other barriers may have led respondents to report being unprepared for a hurricane. For households (MSN Level 1) with either small children or adults who need help with routine care, the barrier of the roads will be too crowded to leave may be tied to respondents reporting being unprepared for a hurricane. Finally, for households (MSN Level 3) that have individuals who are monitored by a nurse, receive medication assistance, are dependent on equipment, or have a mental health disorder, the barrier of the entire family not being able to leave, in addition to other barriers, may have influenced respondents reporting being unprepared for a hurricane. In essence, it appears that once a household reports MSN where individuals are primarily dependent on others in the household for care or have medication or equipment needs and the barriers increase, the result is a greater likelihood of unpreparedness. However, we did not find that level 2 (physical or developmental disabilities) or level 4 (extensive medical oversight) reported the same level of unpreparedness in the face of barriers. It is possible that households with individuals at level 2 and level 4 are more likely to receive aid from government institutions and local entities. For example, individuals with MSN level 2 (mental retardation, amputations, and blindness) have access to some services provided through the State Department of Health and Human Services. For individuals with level 4 MSN (requiring extensive medical oversight in the home), some level of access to services has already been obtained by these households and it is possible that preparedness plans are part of that medical oversight care. Further exploration of the interactions between barriers and MSN is needed not only in this Gulf Coast region where preparedness for hurricanes is essential but also in other geographic regions of the country and world where individuals with MSN may be at greater risk for morbidity or mortality in the face of a disaster.

We found that Hispanics were generally less likely to be unprepared for a hurricane than the non-Hispanic population in the region. Over 50% of the sample preferred Spanish language. Past research has found that primary Spanish-speaking Hispanics are more likely to report having an emergency evacuation plan although less likely to have the supplies necessary to survive during a disaster (11). Households with at least one person aged 65 years or older, and with less cash on hand were less likely to be unprepared for a hurricane. These results may indicate that individuals in those particular households have developed the networks and support needed to manage and create a sense of preparedness for hurricanes. We also found that as respondents' age increases in smaller households, the respondents indicated less unpreparedness. It is also possible that households with older individuals have faced and survived past hurricanes and therefore have a more accurate depiction of their preparedness for a hurricane. Finally, our results indicate that respondents living in households further from the shoreline indicated greater levels of unpreparedness. It is likely that this is a function of the belief that inland locations are safer from hurricane devastation than shoreline locations, and while not always an accurate belief could be an explanation of this finding.

Our study has limitations. One is that the surveys were based on interview and self-reported data and therefore potentially introduced respondent bias. The cross-sectional study design also limits any causation inferences. This study is based on a specific

### **References**

geographical location with the sample comprised predominately of low income Hispanic households and thus may not be generalizable to other geographic regions or populations. Also, respondents answered evacuation barriers in response to hurricanes which are prominent in the area and may not be representative of barriers to a different natural disaster or emergency evacuation situation.

Future research should examine the role support systems have in preparedness for individuals with MSN. Not all individuals who need assistance or qualify for assisted living are housed in a facility. While we found that 33.2% of respondents in our study sample reported at least one individual with MSN (Level 0–4) in the household, we expect that this is a higher rate of MSN found in home settings because of high levels of poverty and lack of health insurance found in this region. Future research also should characterize the strategies and effectiveness of the public health system's response to the evacuation needs of the MSN population. This characterization could identify gold standard evacuation processes for MSN and foster their dissemination broadly.

### **Conclusion**

Certain MSN populations in light of increasing barriers reported unpreparedness for hurricanes in a region of the country prone to such natural disasters. Our results characterize a population vulnerable to hurricanes, and highlight variables and interactions among variables influential in preparedness. This study contributes new understanding of preparedness among MSN populations.

### **Authors Contributions**

LM, SC, and BR conceptualized the research hypothesis. KV conducted statistical analysis and LM, KV, SC, and BR interpreted the data. LM, KV, SC, and BR drafted the manuscript. All authors read and approved the final manuscript.

### **Acknowledgments**

Work for the paper has been supported financially through the Texas Department of State Health Services (DSHS) #2008-027641 and the UT Health Clinical and Translational Science Award (UL1 TR000371). We would also like to acknowledge Jason Palmer Callahan for his early contributions to the idea of examining medical special needs populations.

**Conflict of Interest Statement:** The authors of this manuscript declare no conflict of interest. There have been no payments or services for the work of this manuscript. There is no financial relationships with any entities that may have influenced the work of this manuscript. There are no declarations for patent or copyright for work related to this manuscript.

*Copyright © 2015 Meyer, Vatcheva, Castellanos and Reininger. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Emotional testimonies: an ethnographic study of emotional suffering related to migration from Mexico to Arizona

#### *Rebecca Crocker\**

*School of Anthropology, University of Arizona, Tucson, AZ, USA*

It is increasingly argued that social and economic inequities poorly affect overall health. One of the means through which these inequities are translated to the body is via negative emotions, which carry known psychological and physiological responses. This paper examines migration-related psychosocial stressors impacting first-generation Mexican immigrants in southern Arizona, and reports on the primary emotional experiences immigrants associate with these stressors. Data were drawn from a qualitative, ethnographic study conducted over the course of 14 months during 2013–2014 with first-generation Mexican immigrants (*N* = 40) residing in Tucson Arizona and service providers working directly in the immigrant community (*N* = 32). Results indicate that the primary structural vulnerabilities that cause emotional hardship among immigrants are pre-migration stressors and adversity, dangerous border crossings, detention and deportation, undocumented citizenship status, family separation, and extreme poverty. Many of these factors have intensified over the past decade due to increased border security and state level anti-immigrant legislation in Arizona. Immigrants connected these hardships to the emotions of trauma (50%), fear (65%), depression (75%), loneliness (75%), sadness (80%), and stress (85%), and most respondents reported suffering from three or more of these emotions. Given the heavy emotional toll of migration and the direct impact that regional legislation and border security had on well-being, this paper argues that emotion be considered an important mechanism for health declines in the immigrant community. In order to stem the frequency and intensity of emotional stress in the Mexican immigrant community in Tucson, it is imperative to support organizations and policies that promote community building and support networks and also expand access to and availability of mental health services for immigrants regardless of documentation status.

Keywords: mental health, emotion, depression and anxiety disorders, stress, Mexican immigrants, structural vulnerabilities, embodiment theory

### Introduction

This article aims to establish emotion as a critical means by which the context of immigrant life gets transferred to the bodies of individual Mexican immigrants. As the means by which individuals sense the structure of their larger environs, emotion can be understood to link our bodies to the outside world (1). Based on a qualitative, ethnographic study among first-generation Mexican immigrants

#### *Edited by:*

*Scott C. Carvajal, University of Arizona, USA*

### *Reviewed by:*

*Mary Odum, Texas A&M University, USA Erica T. Sosa, University of Texas at San Antonio, USA*

#### *\*Correspondence:*

 *Rebecca Crocker, School of Anthropology, University of Arizona, P. O. Box 210030, Tucson, AZ 85721-0030, USA<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health*

> *Received: 13 February 2015 Accepted: 29 June 2015 Published: 13 July 2015*

#### *Citation:*

*Crocker R (2015) Emotional testimonies: an ethnographic study of emotional suffering related to migration from Mexico to Arizona. Front. Public Health 3:177. doi: 10.3389/fpubh.2015.00177*

Crocker Emotional testimonies

in southern Arizona, this article highlights the contextual factors that Mexican immigrants commonly connect to emotional suffering, namely pre-migration stressors, dangerous border crossings, undocumented citizenship status, detention and deportation, family separation, and extreme poverty. I then use the words of the immigrants themselves to reveal the nuanced marks of stress, loneliness, fear, sadness, and trauma related to these factors. Emotional suffering often remains masked by the individual and disassociated from both the structural causes that contribute to it and from its broad and debilitating impacts on the body (2). By drawing intimate emotional experiences out of the realm of the secret body and into the light of critical academic analysis, this article seeks to expand the discussion on structural causes of health disparities and identify policy recommendations specifically geared toward reducing emotional stress.

This article employs the theoretical framework of structural vulnerability to examine how the daily "lived lives" (3) of Mexican immigrants in southern Arizona may generate emotional suffering. Quesada et al. argue that Mexican immigrants have come to "occupy a disjunctive liminal quasi-caste status" in which they are marginalized via processes of economic subordination, cultural depreciation, and legal persecution, all of which has left them structurally vulnerable to poor health [(4), p. 346]. While the most commonly identified structural barrier to immigrant health is limited access to medical care (5), a smaller body of literature has documented the occurrence and potential health consequences of other powerful psychosocial stressors present during immigration. These include discrimination (6); targeted enforcement by police and border authorities (7, 8); social isolation (9); mistrust of police authorities and fear of deportation and detention (10, 11); and family separation (12).

The presence of social suffering and stress related to contextual circumstances is increasingly being documented in the literature on marginalized groups. Yet, we know far less about the nuanced, day-to-day, and highly individualized emotional impacts of these experiences [see Ref. (2, 3, 12–14)]. Krieger (15) states that disentangling the causal mechanisms by which our bodies express and mirror our social environments is the key to future health studies (16–18). The phenomenological theory of embodiment holds that the body is in constant dialog with its surroundings and relationships (15, 19–21), and it follows that immigrants carry the intimate imprints of migration-related stressors in their physical bodies. In fact, periods of physical displacement, such as migration, likely produce intensified embodied consequences, because "geographic orientation is embedded in the whole body" [(22), p. 1518]. As such, migration may be experienced by Mexican migrants as a fundamental ungluing, a disembedding, and reembedding of the body into unfamiliar and often hostile spatial and social worlds.

The potential contribution of this research on migration-related emotional suffering lies in the wide-ranging health impacts of emotion. While the concept of emotion remains a contested concept in social theory (1), emotional suffering and stress carry known psychological and physiological responses with important consequences for overall health (23–25). It is increasingly argued that inequitable structural factors in society produce health disparities (26, 27). Using the theories of structural vulnerability and embodiment, this study highlights emotional experience as a key mechanism by which the marginalization of immigrant life gets translated to the bodies of individual Mexican immigrants. Given that the well-documented health declines that occur in the Mexican immigrant community post-migration remain poorly understood (28, 29), emotion offers an important means by which to explore how race and citizenship status "get under the skin" to impact the mental and physical health of Mexican immigrants (30).

### Materials and Methods

### Research Setting

Lying just 70 miles north of the current US–Mexico border, Tucson, AZ, USA is a rich setting for exploring the emotional experiences of migration. The city and surrounding areas house a large and diverse population of Mexican immigrants ranging from recent arrivals to established Mexican American families pre-dating the transfer of the region to American jurisdiction in 1854. According to the 2010 U.S. Census Bureau, 41.6% of Tucson's population was of Latin American origin and over a quarter of that population was foreign born. Statewide in Arizona, over 10% of public school students currently have at least one undocumented parent (31), further demonstrating the high percentage of Arizonans living in immigrant and mixed status families. Tucson's historical origins as a Mexican town and its enduring status as an immigrant receiving community are reflected in the city's wealth of Mexican storefront specialty shops and markets, cultural celebrations, historical landmarks, and bilingual community services. Yet, a longstanding and prejudicial "racial subtext" (32) underpinning Arizona state laws can be traced back to the state's founding and has climaxed over the past decade as Arizona has witnessed a dramatic spike in immigration from Mexico during a period of state recession (33). This surge in-state level exclusionary legislation has had very real and deleterious effects on immigrants' ability to access recreational, religious, educational, and health services (34).

### Study Sample and Procedure

This qualitative ethnographic research project was conducted over the course of 14 months in 2013–2014. Project approval from the University of Arizona Institutional Review Board (IRB) was obtained in November 2013 and extended for a second year in September 2014. The exploratory phase of research consisted of semi-structured background interviews (*N* = 32) with local activists and service providers selected on the basis of snowball sampling techniques in addition to extensive research into immigrant-serving organizations. The interview guide was designed to draw out information on conditions of daily life for Mexican immigrants, impact of state laws on the provision of medical services, structural vulnerabilities in immigrant life, and group-level health risks and outcomes. This exploratory research helped to establish the demographic parameters of the sample population, inform the immigrant interview guide, and identify appropriate venues to reach this vulnerable community.

I then conducted participant observation and in-depth semi-structured interviews (*N* = 40) with first-generation adult immigrants from Mexico. Because randomized techniques, such as phone sampling or recruitment of interviewees in public spaces, were not feasible or advisable given immigrants' high rate of mobility and their concerns about avoiding detection by police authorities, I employed the method of "venue-based application of time-space sampling," a convenience sample strategy using known venues where members of hidden populations gather safely (35). The sites identified for this study include a day laborers' center, a women's empowerment group, and two free medical clinics that serve the undocumented and uninsured communities. Due to the extreme vulnerability of undocumented individuals, study participants were consented verbally in lieu of signing a written statement. I recorded the interviews using a digital audio recording unless background noise was too distracting, and I also took copious notes regarding non-verbal cues to emotion. These precautions helped establish a safe environment for potential participants and only one person I approached for an interview declined to participate.

This study employed a life-history approach to immigrant emotional health, addressing factors intersecting with the emotional health of individual migrants before, during, and after the process of migration (36). Questions addressed early life in Mexico, and pre-migration stressors including childhood poverty, nutrition, emotional trauma, illness, and access to health care in order to establish a binational approach to migrant health capable of highlighting intra-group variations (37). Large-scale studies linking childhood exposure to poor health outcomes in adults make clear the necessity to examine health risks faced by migrants before arriving to the U.S. Though such studies lack inclusion of migration-related risk factors (8), a small body of qualitative research has demonstrated that variations in health exposures in Mexico have important ramifications for health behaviors including diet and pursuit of health care once in the U.S. (38–41). The life-course approach also highlights the increasingly lengthy and dangerous border crossing, which should be considered a health determinant in and of itself (42). Since the topic of illegal border crossing can be sensitive, I approached the issue by asking: "What mode of transportation did you use to reach the United States?" which enabled participants to address the experience of the crossing and related dangers and stressors.

I employed a fixed interview guide, which included a brief survey section tabulating basic demographic information on family background and physical and mental health problems. The majority of the interview addressed the structural challenges faced by immigrants once in Tucson, including those mentioned in the introduction as well as experiences of discrimination, barriers to healthy diet and exercise, and lack of access to medical care. I then presented participants with a list of both positive and negative emotions and asked that they identify those they related most strongly to their experience of immigration. I followed up on these response with tailored questions such as "how did you cope with being in jail during those weeks?" or "When the bills come in, where do you feel that stress in your body?" or "When your son was deported, how did that change your feelings about living here?" The interview guide also covered definitions of health, disease etiology, and healing traditions and practices pre and post-migration.

I conducted this research in Spanish, relying on my own professional training as a Spanish language interpreter and translator, as well as the assistance of native speakers and dictionary sources when necessary. I conducted the complete interview guide with all 40 participants, and interviews ranged in length from 1 to 3 hours. In addition, I conducted participant observation in courtrooms, political protests, churches, and participant's homes in order to gain intimate familiarity with the structural and social factors shaping immigrants' daily lives. My regular weekly appointments as volunteer English teacher and medical interpreter also enabled more extended and informal interactions with approximately one-quarter of sample participants who regularly attended either the health clinic or day laborers center where I worked. For the protection and privacy of all who participated in this study, I use pseudonyms throughout this article.

#### Analysis

Data analysis was an iterative process that spiraled back and forth between data gathering and examination during the course of the project. Using MAXQDA qualitative data analysis software, I first coded the service provider interviews using "focused coding" methods designed to identify salient themes in immigrant life. I then simultaneously transcribed and translated the immigrant interviews, and later coded them according to the principles of "selective coding" (43), highlighting the links between categories of codes addressing the most common migration-related hardships and their associated emotional responses, in order to define the relationship between migration-related stressors and declines in health and well-being in individuals.

### Results

The Section "Results" of this article is organized according to the six primary emotional stressors identified by study participants: premigration stressors, dangerous border crossings, undocumented citizenship status, detention and deportation, family separation, and extreme poverty.

### Demographic Portrait of Study Population

The study sample was evenly divided between men and women, with a median age of 42 (**Table 1**). This study sample included mostly long-term stable residents of Tucson, with the median number of years spent in residence being 15. Participants were evenly divided between having been raised in rural versus urban environments in Mexico. Just over one-half of this sample population was from Arizona's bordering state of Sonora. Other highly represented states were Sonora's southern neighbor Sinaloa and two southern states, Oaxaca and Chiapas, while remaining states of origin included Veracruz, Distrito Federal, Michoacán, Jalisco, Chihuahua, Guanajuato, Zacatecas, and Puebla. This sample reflects the recent diversification of the historically Sonoran-origin

#### Table 1 | Study sample demographics.

Mexican population in Tucson in response to shifting patterns of emigration from Mexico as well as the purposeful funneling of migrants through the deserts of Arizona (33).

### Childhood Adversity

The majority of participants came from large, working class families with the average number of children in the family being just over 6. Most cited economic scarcity in their childhoods, and many noted common experiences of lacking money for basic clothing and enduring periods of nutritional deprivation. Less than onequarter of the sample completed high school, with most having left school in order to augment family resources through informal employment. Many participants cited beginning to work at a very young age, sometimes selling gum or cleaning cars out on the streets. While the majority of participants cited being healthy as children and having little need for medical intervention, less than half of participants had health insurance during their childhoods in Mexico, and most reported relying primarily on home remedies and traditional modalities for their non-emergency medical care. Eighteen percent of participants came from families in which one or more siblings died during infancy.

Despite these common economic challenges, participants largely described their childhoods in a positive light, recalling the warmth and safety of their extended family networks. When extreme deprivation, emotional trauma, or abuse was present, however, this delicate balance was upset, and several participants demonstrated lasting damage from childhood suffering in their adult life in the US. Approximately, one-fifth of participants reported this degree of childhood suffering, with the most common experiences cited being parental abandonment, domestic violence either in childhood homes or adult romantic relationships, severe material deprivation, and sexual abuse. Those participants who reported childhood trauma also reported on-going suffering from emotional imbalance and depression at the time of the interview.

Enrique is a 54-year-old man from the state of Zacatecas who grew up in dire poverty in a family of 15 children, only 6 of whom survived their first year of life. Although he is now a citizen and once had stable employment, Enrique's health problems have steadily worsened, and he is now physically disabled and severely depressed. He believes his current state of ill health results from having started to work at age 11, often under very harsh and exploitative conditions in both Mexico and US. He said:

All of this comes from my childhood. I never knew what it was to go from childhood to adolescence. I went from childhood straight to adulthood, to the responsibility. And when you see other young getting to enjoy life, you say 'why didn't I ever get to do that?' But we came from a very poor family. If we ate breakfast, we didn't know whether there would be any more food that day, because my father didn't have that awareness that he had to work in order to feed his children… So I had to leave school and play the role of father.

These pre-migration emotional and physical risk factors underscore the importance of employing a binational and life-course approach to immigrant health studies.

### Border Crossing

Slightly over half of the participants crossed the border without legal permission, many of them crossing two or more times (**Table 2**). More men in the sample crossed without legal permission than did women (80 and 25%, respectively). Likewise, participants from Sonora had greater access to temporary tourist visas and thus were more likely to have crossed legally. Most study participants who immigrated without legal permission crossed on foot through the Arizona desert, reflecting the impacts of the federal "Border Strategic Plan" in the 1990s that shut down traditional points of entry in Nogales, San Diego, and El Paso (44). The majority of study participants who crossed the desert spent between \$1,000–3,000 for a "*coyote*" to guide them and walked for several days. A nurse who regularly treats distressed migrants concludes that the stressors of crossing the desert on foot are so intense, that "if migrants have crossed the desert, their emotional health is very affected by that experience" (Roberts, personal communication).

Most desert crossers in this sample referenced the intense physical exertion, extreme temperatures, and bodily injury endured during the crossing period, which often resulted in dehydration and hunger. Aid workers in the desert reported that common injuries include blisters, sprained and broken lower extremities, cuts and scratches, snake bites, exposure to the elements, and emotional trauma due to assault and near-death experiences (Price and Wallin, personal communications). Serious bodily injury, such as acute kidney failure and broken bones, are likewise not uncommon.

Fear and trauma were the most commonly cited emotional experiences related to the crossing, which immigrants identified as a period of extremely heightened anxiety. Participants reported fear of criminal extortion and kidnapping, and several cited attacks and robbery by "*bajadores*" – Mexican criminals who assault migrants just before they cross the border. Once in US territory, participants feared detection by Border Patrol agents and Mexican drug runners, as well as non-human surveillance and threats to safety, such as animals, aerial drones, and ground sensors. Recovery from the emotional and physical stress of the border crossing was often slow. Lalo, a 37-year-old native of Chiapas, has crossed the border and been deported multiple times. He described the bodily sensation of crossing in this way:

When you are crossing, you have one 100% adrenaline; you are alert the entire time.  So at the time you don't feel anything, but the problem starts after you arrive and you relax. I remember that I was taking spines out of my body for many days, like I didn't feel all the scrapes and cuts for a long-time afterward.

#### Table 2 | Migration-related conditions and experiences (%).

Between 1990 and 2012, approximately 2,238 migrants are believed to have died in the Arizona deserts (45). Crossers often lack the control to improve their own conditions or help others in their group, and traumatic experiences therefore cause feelings of helplessness, anxiety, guilt, and deep sadness. Jacobo Tellez of the Mexican Consulate in Tucson recalls the day a boy faced 15-year-old desert crosser from Oaxaca was placed into the custody of the consulate after his father fell dead in the desert. After offering the youth whatever comfort they could, he said he was ready to tell his mother the news. "I connected the phone line and went to sit back down," Tellez recalls. "But as soon as the boy heard his mother's voice on the phone, he started wailing and screaming: 'Mamá! Mamá! He died on me, I couldn't do anything! I couldn't do anything!' and the pain in his voice ran chills through my body, because it was his sheer impotence, his inability to do anything for his father."

Moreover, the perils of the desert crossing reverberate far beyond the individual crossers and into the immigrant community more broadly. Many participants described periods of high anxiety and worry as loved ones were attempting the desert crossing, with some having been extorted by criminals in exchange for the release of abducted crossers. A small minority of the sample had experienced the death of friends or family during the crossing. Elena Burgos, who offers "healing touch" massage therapy in Tucson, reports that many families come to her because of trauma related to the desert crossing. Burgos can relate to others' experience because her own brother died crossing the desert.

Someone called my mom and said the animals had eaten [my brother's] body and that they just found the bones, and that is when she had a heart attack. And we felt like we were losing our minds, because of course we never thought this would happen – we kept thinking that he was coming, that he would arrive. He had five kids and was 32 years old. So you feel like your heart is just breaking to pieces.

#### Legal Status

The majority (67.5%) of the sample was undocumented, 22.5% had work permits or were legal residents, and 10% were citizens (**Table 2**). There was not always a direct correlation between the illegal border crossing and current status an undocumented immigrant. Several participants who initially had to trek across the desert had since been able to achieve legal status. Contrastingly, almost half of the Sonorans in the study sample had initially crossed the border legally with a tourist visa, but had since outstayed the visa and were undocumented. The majority of service providers and immigrant participants independently noted the damaging impacts of Arizona state legislation, specifically State Bill 1070, in increasing the dangers, frustrations, and stressors of undocumented life in Arizona. These compounding hardships in the lives of undocumented immigrants cause such emotional upheaval that Cavazos-Rehg et al. call undocumented status itself "a persistent and insidious psycho-environmental stressor" (2007: 1126). Participants with temporary work visas and permanent residency likewise expressed feeling vulnerable both to the whim of local and federal politics as well as that of individual law enforcement agents.

When I asked Abelardo, a 54-year-old day laborer from Chihuahua, how it felt to be undocumented in Arizona, he took off his worn sports cap, put his arm down on the table to rest his head and began to quietly sob. "It feels so hard," he managed softly. "It just feels so bad." Undocumented participants reported that their lack of legal status obstructed their ability to live "*a gusto*" or at ease, and caused emotional expressions including fear, sadness, trauma, frustration, helplessness, and loneliness. Due to the fact that Tucson houses the overlapping jurisdictions of local police forces, country sheriffs, Border Patrol, and Immigration and Customs Enforcement agents (ICE), fear of arrest and deportation was a very common experience for participants (65%). Many participants lamented the feeling of having to always "*andar muy recto*" (not make any mistakes) and to leave home only for work and other mandatory activities, often causing them to bypass necessary medical attention. Diana, who has lived in Tucson for 15 years without legal status, suffers from an autoimmune disease called pemphigus, the onset of which has been linked to emotional stress (46). She states:

For me, fear has been the most direct impact on my condition, what I suffer from. Fear of leaving the house or not returning, that at any moment I could be captured and identified as what we are, as immigrants. Even though I have an application in through my mom, it is still not a legal condition, so I am still dealing with the fact that I am here in limbo, without being anybody, without being a true entity as we say, a somebody.

Many participants described how their fear of police detection, particularly following the passage of SB 1070 in 2009, prevented them from participating in community activities and from fulfilling civic duties, such as reporting crimes in their neighborhoods. Moreover, their lack of legal residency and the dangers of the crossing made returning to Mexico virtually impossible (see Family Separation). This isolation in turn generated feelings of loneliness, which was a salient theme in the lives of 72.5% of study participants. According to Leticia, a 34-year-old married woman from Guanajuato:

I don't have a lot of community – I think that's because of the laws they've passed here. I feel like at any moment they can decide that we all need to leave. So my life, I feel like today it is good, but tomorrow I don't know how it will be. That is why I started to feel depressed, because I feel like in reality I don't have a stable life here. I feel part of Tucson but sometimes, like when I have to present an ID, my reality hits me and makes me feel like, no, I am really not a part of it.

Undocumented status likewise impeded immigrants' ability to progress toward their goals, leading to feelings of hopelessness and frustration in regards to their educational and vocational opportunities. Many participants used words such as *estancado* (stuck) and *impotente* (helpless or hopeless) to describe their day-to-day feelings about being undocumented. Adrián, a 24-yearold who was brought from Sonora by his family as a small child recalled that: "In school growing up I always wanted to continue my education. But when I understood more of what it meant to be undocumented, it brought me down and I felt hopeless. I thought "why the heck should I go to high school if I can't go to college?" I felt depressed and in my senior year I lost all motivation and almost dropped out."

### Detention and Deportation

Forty-five percent of women and 65% of men had faced experiences of detention, deportation, or both in their immediate families (**Table 2**). Undocumented immigrants were most commonly detained during the initial crossing, on routine traffic stops, and workplace raids. One participant was arrested in the process of reporting a crime to police. Deportation and detention carried acute emotional responses including trauma, loneliness, fear, and sadness, both for the person directly involved as well as for family members who faced concomitant emotional and financial challenges. Service providers also noted the impact on the wider community, as "the community is always fluctuating and is really unstable with detentions, deportations, and loss of jobs. This is really challenging for people without papers – there is an emotional tax in seeing people here one day and simply gone the next" (Sharer, personal communication).

Many participants reported that their fear and anxiety levels increased following their own deportation or detention or that of a loved one. Yesenia, a 42-year-old undocumented immigrant mother from Sonora, said that her brother's deportation changed her daily experience in Tucson:

After my brother got deported six years ago, my fear got worse and I got sick from all the anxiety. It was like psychological terror. I can't sleep until everyone in my family is altogether – I worry that one of them won't come home one day. The last time the police pulled us over, I shook the policeman's hand and said '*felicidades*. If what your government wants is to make us sick and keep us scared, then congratulations, you're doing your job.'

Other participants described the sadness and loneliness that resulted from losing family members who had been deported and were unable to return. Teresa's husband of 28 years was deported one day without notice, leaving her struggling to raise their teenaged son alone. Since his departure, Teresa has been evicted from their apartment and has fallen into a deep depression.

When he first left there were many days that I hardly ate, could barely sleep. I am embarrassed to say this but there are still days when I don't even want to bathe myself or get dressed. It seems like no matter what I am doing, if I am on the bus, or walking somewhere, or going to the market, that I start to cry. And it seems like wherever I am that everything is ugly now. Even my plants, which used to be so beautiful to me, seem ugly now.

Detention also led to extended periods of separation, which were exacerbated because undocumented family members were unable to visit the jail due to their own lack of legal status. Eva, a 42-year-old who has lived in the US for over 15 years recalls the isolation of her 60-day separation from her then 4- and 7-year-old sons while in detention following a traffic violation. "It is so hard, imagine how lonely and sad you feel, without anyone there to accompany you. And on the weekend everyone else had visitors, but my sons and my husband couldn't be there." Study participants who had been detained also cited common experiences of discrimination and mistreatment, including overcrowded cells, freezing temperatures, lack of proper nutrition, intentional family separation, and denigrating treatment by guards, all of which has been extensively documented (7, 47).

According to a medical doctor who works in a federal prison in Arizona, the combination of these factors leads to toxic levels of stress and anxiety while incarcerated, which carry potential physical consequences including high blood pressure and blood sugar levels (Olsen, personal communication). Lalo recalled the desperation that set in soon after his arrival to a federal detention center in Eloy following a routine traffic stop in Tucson:

The doctor asked me if I suffered from schizophrenia, if I heard voices, or if I had tried to kill myself, and it seemed weird to me, because I have never wanted to do any of those things. But then I understood that the problem was when they locked us up, when they closed the door. And the guard yelled "don't move, don't make noise, go to sleep now!" And I started to feel desperate, my heart beat like crazy, and I felt claustrophobic and I started to sweat, and I wanted to throw open the doors and just fly out of there or disappear. I even wanted to hurt myself so they would take me out of there.

### Family Separation

While participants mourned many aspects of what they missed about Mexico, including traditional foods, their personal freedoms, and the more relaxed pace of life, the vast majority cited family separation as the most emotionally challenging part of leaving Mexico. The primary emotions immigrants associated with these separations were loneliness, frustration, and sadness, which sometimes led to longer-term depression. Forty percent of participants were separated from a child or spouse for at least 1 year during their immigration experience, and the vast majority faced on-going separation from siblings and parents (**Table 2**). This high occurrence of family separation reflects the increased costs, dangers, and legal penalties of the border crossing, which have encouraged migrants to settle for longer periods in the US without the possibility of return or cyclical migration (48, 49).

Service providers frequently addressed the negative mental health impacts of immigrants' long-term loss of family-based social and support networks. For immigrants, the inability to return to Mexico due to both financial and legal constraints for family events, funerals, and celebrations was a source of on-going sadness and loneliness. Araceli, a 48-year-old from Puebla recalls that during her years without papers she felt very lonely. "When my mother died, they told me from Mexico but I couldn't go. My grandfather and then my dad, and my uncle who was like a father to me, they all died and I couldn't go to their funerals. Later I went back and saw their graves. That is my own little piece of loneliness: to have so many years go by without seeing my family." Participants worked hard to stay in close touch with family via regular phone calls and internet communication, but the physical distance and passage of time frustrate efforts to maintain closeness and many participants bemoaned lost or strained emotional connections with children, siblings, and parents.

Approximately half of study participants reported having little community support in Tucson, and even those with intact nuclear families and strong community ties in Tucson still commonly reported missing the close-knit spontaneous gatherings with extended family in Mexico. Thirty-two-year-old Gregorio who came to the US 4 years ago from Sonora explained that, "Sometimes I am happy here because I have my own family but I also miss my family in Mexico, so I am not totally content. Here my family is just my wife and my kids. There I have my brothers and sisters and my mom and dad, and one also misses them." For those participants separated from spouses and children, or who have been unable to establish community in Tucson, the feelings of sadness and loneliness are often debilitating and accompanied by depression. Teresa, who remains separated from her husband following his deportation over 1 year ago, described her emotional state: "I have some family here but it's like it makes no difference, they don't ask me how I am doing or if we have food, or how my son is. I still feel so alone. I don't know if I can handle this anymore, I am so lonely here. I don't go out or talk to anyone – I just go to work and come home."

#### Financial Stress

Financial stress was a constant theme during my interviews, with 77.5% of the sample stating that they were only "surviving" or "barely surviving" economically (**Table 2**). The average monthly income in this study was \$1,400 for households consisting of an average of 3.7 people, with several low outliers earning as little as \$600 or less (**Table 1**). Many service providers described a debilitating level of economic stress among Mexican immigrants in Tucson, and observed that this stress had increased over the past 10 years in response both to the economic downturn and the 2007 passage of state legislation requiring all Arizona employers to use the federal E-Verify technology to verify legal status. Many immigrants stated feeling frustrated and impotent against the legal barriers that prevented them from securing more stable and remunerative employment.

Although three-quarters of participants stated that they were financially better off in the US than they had been in Mexico, most reported greater financial stress in the US due to the inflexibility of the American billing system. Referred to ubiquitously as "*los biles*," monthly bills were a perpetual source of worry for both men and women. The need for adults to work long hours and multiple jobs in order to survive financially put major stressors on families. Women addressed the stress that came from both parents needing to work, and lamented how this left little time for family relaxation and healthy eating habits. Isabella, a 35-year-old participant corroborated the experiences of many other women in this study:

We have more work to do in the house than [the men do]. They go to work and come home and relax. But we don't get to relax. And so what happens is our health gets worse every day. We can eat all the vegetables and lentils that we want, but if we don't have peace in our homes and in our minds, then we can't be healthy. It's just that the stress of all the rules with everything here. My head hurts here from all the pressure of paying the bills and the go-go-go. We wanted a better life: We got more things, but less life.

Men in the sample commonly emphasized the need to work in order to have positive self-esteem and feel healthy. The majority of men in this sample worked as day laborers and struggled to secure jobs on a daily basis. Many men blamed this lack of job security and stable income for their unhealthy sleep patterns and high levels of generalized stress. Esteban, a 55-year-old undocumented laborer from Sonora explained:

When I don't work the full 40 hours, I don't feel like a normal person. A normal person works every day. And I can work – I am a carpenter, I have energy. And I have a nice truck (he points to a truck sitting idly in the parking lot) – I am all ready. So I just feel this stress and a depression that's like a sadness. The stress gives me a headache so I cannot sleep, and I am up almost all night.

Because the vast majority of sample participants had no economic reserves, many underwent feelings of stress, hopelessness, sadness, and even trauma during periods of transition and hardship. Common stressors included the deportation or incarceration of a spouse, evictions, overcrowded living conditions, temporary homelessness, and reliance on soup kitchens and food banks. Tomás, a 39-year-old father from Sonora described a period of time in which he could not find work for an entire month.

I felt so much stress and *nervios* that my mind got all twisted up. I had to go see the doctor at the clinic because the muscles on one side of my face stopped working completely, so that when I tried to drink water it would just dribble out of my mouth. But the doctor just told me not to worry so much about my life, because that worry became stress and that was damaging my body. And he gave me some pills that I took for awhile.

#### Mental Health Outcomes and Access to Care

The compounding and cumulative effects of these emotional experiences took a serious toll on the self-reported mental health of this study sample (**Table 3**). Participants most commonly cited experiencing the emotions of trauma (57.5%), fear (70%), depression (75%), loneliness (77.5%), sadness (82.5%), and stress (87.5%), and most respondents reported suffering from three or more of these emotions. The three-quarters of the sample that stated feeling depressed connected the depression with either long-term declines in well-being or with particularly challenging periods, such as during detention or following the deportation of loved ones. Mental health practitioners I interviewed uniformly reported

Table 3 | Self-reported emotional condition of participants (%).

that the most common mental health issues they witnessed in the immigrant community were depression and anxiety related to economic stress, fear of detention, family separation, social isolation, family stress, and the desert crossing. Practitioners stated that the incidence of depression and anxiety in the immigrant community had increased since the recent economic downturn in Arizona and passage of anti-immigrant legislation. Reverend Raul Trevizo, long-time pastor of Tucson's largest Mexican-origin Catholic parish, describes what he has seen among his congregants in recent years:

It's a collective depression, a desperation that is epidemic in the immigrant community. You begin to see all the effects of what could probably be diagnosed as clinical depression. This is very collective; this is not individual. They feel that they are in a country where they are not wanted, they are looked upon suspiciously, they face deportation at any moment, and they are struggling to survive.

Strikingly, the vast majority of Mexican immigrants lack access to mental and behavioral health care services that could help mitigate migration-related stress. The passage of House Bill 2008 in 2009 blocked immigrant access to preventive and follow-up mental health care (50). These provisions make it nearly impossible for immigrants to receive behavioral health services unless they are visibly presenting psychotic symptoms and are remanded to crisis response services by police authorities. Even in those dire cases, very little can be done to address on-going issues or secure necessary follow-up care for immigrant patients suffering from psychosis.

Immigrants suffering from lower grade conditions like depression and anxiety were limited to a handful of low-income and free clinics with limited volunteer-staffed counseling programs. However, there are barriers to accessing the scant services available, including limited knowledge about available services and individual willingness to seek emotional support in a community that still has many reservations and negative stereotypes about mental health services (Meza, personal communication). Moreover, even the sliding scale offered by the low-income clinics can be prohibitive for immigrant patients, and many immigrants feel debilitating fear and lack of trust in medical facilities due to having seen Border Patrol policing area hospitals or having known someone who was detained or deported after accessing care (Al-qaraz Ochoa, personal communication). In addition, even those few immigrants who qualify for state Medicare coverage are often afraid to use it because they fear that it will label them as a "public charge" and therefore damage their citizenship applications (Roberts, personal communication).

While access to care is severely curtailed in this community, immigrant participants and services providers alike noted the benefits for those who were able to receive therapy services. Many participants expressed reticence to share openly with friends and family. Leticia explained that talking to the psychologist about her depression related to being undocumented made her feel better "because I really don't have friends, just my sisters and my husband. And with [the therapist] I can say things I can't tell my sisters or my husband because they would talk to each other." Having access to a trained therapist offered an outlet for self-expression that afforded potential emotional and physical healing. Therapist Michelle Humke described a teenager who came to counseling because she lost her ability to walk following the imprisonment of her undocumented mother.

This was a mental health issue that manifested as physical issue – all she knew was that she couldn't walk, and I said 'this is all related to the family issue.' She was in the care of her extended family, and the whole family was traumatized. So I brought them all in and helped them learn how to better verbalize when they were feeling strong emotions and how to talk about it. And this is what helped her walk again.

These results demonstrate the cumulative impact that migration-related emotional suffering has on the overall mental health of immigrants and the potential for expanded mental health services to play a role in healing.

### Discussion

Rather than directly testing the biological impacts of psychosocial stress on the body, this article uses self-reported emotional suffering to place the incidence of such stressors in a broader contextual framework. I use the words of first-generation Mexican immigrants to portray the oppressive nature of living within the structural vulnerabilities at force in their lives and their resulting experiences of emotional suffering and trauma. Because "emotional practices can … be seen as social acts which are significant in revealing the complex interrelationships between the individual and society via the body," the emotional testimonies presented here offer insight into how Mexican immigrants in southern Arizona experience the daily context of their lives on a body level [(1), p. 396]. These are testimonies to how individuals embody social inequalities, which may in turn help to make sense of existing health disparities.

### An Emotional Perfect Storm

The vast majority of the interview sample for this paper report experiencing multiple negative emotions related to the compounding experiences of childhood adversity, family separation, dangerous border crossings, undocumented status, detention and deportation, and financial stress. Many of these "psychic costs" of migration [(51), p. 297] have been studied previously and linked to self-reported declines in well being and mental health. The pervasive fear of detention and deportation, which dramatically curtails freedom of movement and promotes distrust (12), has been linked to a direct decrease in perceived emotional and physical health status (52). Border crossing and militarization have been linked to the severing of family and social networks and related feelings of isolation and loneliness (11, 53), while deportation itself has been associated with poor self-reported physical and mental health (54). Discrimination and stigma related to immigrant status have been shown to increase self-reported stress and health declines (29). The undocumented community (52), children and separated families (12), and migrant workers (6, 55, 56) have all reported particularly high levels of migration-related stress.

#### Science of Emotion

Some researchers argue that emotional stress may help explain health disparities patterned across lines of race and socio-economic status. A small but promising body of literature has begun to use bio-marker data to link migration-related stressors to physical health declines (57–59). Says Sternberg: "we are discovering that while feelings don't directly cause or cure disease, the biological mechanisms underlying them may cause or contribute to disease" (2001: 13). The emotional suffering reported on in this article – namely stress, loneliness, fear, depression, and trauma – implies varied and well-documented biological consequences.

Stress has been so closely linked to widespread and generalized health declines that Sapolsky determines that "chronic stress can be pathogenic" [(60), p. 395]. Deficiencies in social networks have been shown to impact all-cause mortality (61), and loneliness is now understood to produce immune deficiencies and disruptions to cardiovascular functioning and complex cognitive functioning (62). Moreover, the fear response has been linked to the onset of anxiety, depression, and other mental disorders in addition to physical health problems, such as weakened immune function, hypertension, and insulin resistance (63, 64). Likewise, depression is posited to cause dysregulation of the metabolic, immuno-inflammatory, and autonomic and hypothalamic–pituitary–adrenal axis, potentially increasing the incidence of morbidity related to cardiovascular disease, stroke, and obesogenic co-morbidities (65). Lastly, trauma has been shown to disrupt homeostasis via impacts on the brain, endocrine system, and sympathetic nervous system, and "through a physiological domino effect, these changes affect many other body systems, including the cardiovascular system, respiratory system, and muscular system" [(66), p. 52].

### Limitations and Strengths

This paper takes a life-course approach to immigrant mental health, incorporating pre-migration factors as well as a complex web of post-migration stressors. According to the theory of "cumulative adversity," individual hardships cannot be holistically evaluated in isolation, as they both compound and overlap with one another to produce long-term ill effects on physical and mental health (67). The categories I presented in the Section "Results" of this paper are by definition interwoven and iterative, and thus do not break down for neat analysis of the impact of individual factors on immigrant emotional health. Certain categories, namely family separation and undocumented status, undergird all aspects of immigrant experience and are challenging to tease out from their associated impacts on other areas of immigrant's daily lives. At the same time, the factors I address in this paper are by no means exhaustive of the emotional hardships that may contribute to immigrant's cumulative toll of adversity over the lifecourse. I only investigated emotional experiences closely linked to migration, and therefore intentionally did not address emotions related to more intimate changes in family dynamics and relationships, such as changing gender roles (68) and role loss (69).

In addition, this paper does not argue that all emotional experiences related to migration are negative. While study participants overwhelmingly reported emotional hardship related to migration, a minority of participants (25%) also stated ways in which immigration had a positive impact on their emotional or physical health. This was especially so for participants who had made a significant life change upon migrating – such as overcoming drug or alcohol addiction, leaving an abusive relationship, or conversion to a new church or religion – or for those who had faced debilitating levels of poverty in Mexico. These examples highlight the possibility for migration to be associated with positive emotions and experiences depending on pre-existing circumstances and individual motivation for change.

### Conclusion

The immigrants and service providers I interviewed indicate that the recent rash of state level exclusionary legislation in Arizona has intensified and compounded emotional hardship in the immigrant community. The state passed English-only legislation in 1987 and 2005, denied undocumented immigrants access to in-state tuition and state scholarship monies through Proposition 300 in 2006, limited immigrant access to state services under HB 2008 in 2009, banned Mexican American Studies from the Tucson public schools in 2010 under HB 2281, and that same year passed SB 1070, requiring immigrants to carry identifying documents at all times and institutionalizing cooperation between police and immigration authorities. The immigrants I interviewed lived with the tangible results of this rash of legislation, including increased risk of detention and deportation, longer family separations, more dangerous border crossings, and restricted access to full employment, education, and medical care. Their emotional reactions to these changes are embodied testimonies to the ways these policies touch individual lives.

In the absence of an overhaul of state and federal immigration policy, the findings presented in this paper indicate several pragmatic solutions that could serve to reduce the incidence and intensity of emotional suffering among Mexican immigrants in southern Arizona. I make the following recommendations in regards to strengthening community support and public safety: (1) expand local networks of support called "*redes de proteccion*" that offer leadership training, community building, and assistance to immigrants in the event of detention or deportation, and thus buffer against related fear, stress, and loneliness; (2) increase access to identification cards currently available from the Mexican Consulate and in discussion by the City of Tucson, which provide migrants with a valid form of identification and thus foster a sense of increased personal security; (3) encourage further dialog between community groups and local police agencies to reduce fear and likelihood of unnecessary non-criminal detention and family separations. In addition, in order to increase immigrant access to mental health services, I make the following recommendations: (1) educate medical personnel regarding the emotional stressors affecting this community and encourage wider application of screening measures for immigrant patients; (2) expand the availability of Spanish language mental health services to screen for mental illness, offer an outlet for immigration-related stress, and aid immigrants in making practical choices to improve their living conditions; and lastly, (3) increase outreach to Spanish speaking immigrants about available health and support services via regularly updated pamphlets and improved communication between service providers.

### References

### Acknowledgments

This article is dedicated in thanks and loving memory to Rafe Sagarin. I would like to thank all the immigrant and service provider participants for sharing their stories and perspectives with me, and the staff and members of the Southside Workers Center. I would also like to thank Tom Sheridan, Ivy Pike, Susan Shaw and Airín Martínez for feedback and edits on this paper. This research was supported by grants from the University of Arizona Social and Behavioral Sciences Research Institute and the Bureau of Applied Research in Anthropology. The analysis and write-up phases were supported by a dissertation grant from the Research Program on Migration and Health.

**Conflict of Interest Statement:** The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The Guest Associate Editor Scott C. Carvajal declares that despite being affiliated to the same institution as author Rebecca Crocker, the review process was handled objectively and no conflict of interest exists.

*Copyright © 2015 Crocker. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Structural vulnerability among migrating women and children fleeing Central America and Mexico: the public health impact of "humanitarian parole"

#### *Elizabeth Salerno Valdez1 \*, Luis A. Valdez 2 and Samantha Sabo2*

*1 Family and Child Health, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, USA, 2Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, USA*

### *Edited by:*

*Jay E. Maddock, Texas A&M University, USA*

#### *Reviewed by:*

*Justin B. Moore, University of South Carolina, USA Mark Stoutenberg, University of Miami, USA*

#### *\*Correspondence:*

 *Elizabeth Salerno Valdez, Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, The University of Arizona, 1295 North Martin Avenue, Tucson, AZ 85727, USA<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health*

> *Received: 18 March 2015 Accepted: 09 June 2015 Published: 24 June 2015*

#### *Citation:*

*Valdez ES, Valdez LA and Sabo S (2015) Structural vulnerability among migrating women and children fleeing Central America and Mexico: the public health impact of "humanitarian parole". Front. Public Health 3:163. doi: 10.3389/fpubh.2015.00163*

Since October 2013, US Customs and Border Patrol has apprehended 15,979 families on the Southwest Border of the US. Daily, migrating women and children from Mexico and Central America that qualify for *humanitarian parole* are released from immigration detention to a humanitarian aid organization in Southern Arizona. After several days in detention facilities, these families arrive tired, hungry, dehydrated, and with minimal direction regarding their final destination, and adherence to the parameters of their parole. *Project helping hands* (PHHs) utilizes a network of volunteers to provide the women and children with food, water, clothing, hygiene products, hospitality, and legal orientation. The aim of this assessment was to document the experiences of families granted humanitarian parole through the lens of structural vulnerability. Here, we apply qualitative methods to elicit PHH lead volunteer perspectives regarding the migration experience of migrating families. Using inductive analysis, we found six major themes emerged from the qualitative data: *reasons for leaving*, *experience on the journey*, *dehumanization in detention*, *family separation*, *vulnerability*, and *resiliency.* These findings elucidate the different physical and psychological distresses that migrating families from Mexico and Central America experience before, during and after their arrival at the US–Mexico border. We posit that these distresses are a result of, or exacerbated by, structural vulnerability. Structural vulnerability has life-long health implications for a sub-population of young mothers and their children. The number of migrating families who have experienced traumatic events before and during their migration experience continues to expand and thus warrants consideration of mental health surveillance and intervention efforts for these families. More public health research is needed to better understand and combat the health challenges of this growing population.

Keywords: structural vulnerability, humanitarian parole, immigration, detention, US–Mexico border

## Introduction

Since October 2013, US Customs and Border Patrol (USCBP) has apprehended 15,979 families on the Southwest Border of the US (1). Approximately 1,663 families traveling mostly from Mexico and Central have been apprehended in the Tucson sector of the border (1). After spending several days in detention, qualifying families are released to the local bus station to continue travel and reunite with their families in the US. However, due to language and cultural barriers, it is difficult for most families to navigate the national bus system. In the absence of federal or state involvement, humanitarian aid organizations have come to the aid of these families.

Multiple reasons exist for the current surge of Mexican and Central American families arriving at the US–Mexico border. Persistent economic deprivation and the resulting inability of families to adequately support themselves, as well as interminable violence are pushing people north. Recent studies indicate that the primary reason that people leave Guatemala, El Salvador, and Honduras is forced child recruitment into gangs, drug- and gang-related violence, gender-based violence, and extortion (2, 3). Violence is compounded by the lack of economic opportunities, lack of access to quality education, and the subsequent inability for families to support themselves financially in their home countries (4).

The government response to this surge is humanitarian parole, which is one of many temporary protection programs offered by the United States Citizenship and Immigration Services (USCIS). US temporary protection programs are dependent on parole, which is the primary avenue for temporarily admitting individuals into the US for extenuating circumstances, including catastrophic weather-related emergencies or violent conflict in sending countries. Humanitarian parole is a discretionary authority used sparingly in situations to grant entry to individuals who would otherwise be inadmissible into the US. The strict parameters of parole require the parolee to report to an immigration and customs appointment within 1–3 months at their final US destination, whereby their immigration status will be re-assessed. Parolees must leave the US before their parole expires, usually within 12 months, unless they gain a more permanent status given their specific circumstances (5).

In order to qualitatively assess the potential impact of the experiences of these families, we elected to assess this problem through the lens of structural vulnerability (6). The concept of structural vulnerability stems from Galtung's (7) structural violence, which he defined as "the indirect violence built into repressive social order creating enormous differences between potential and actual human realization." Kohler and Alock (8) explain that physical violence is when an actor (e.g., number of armed men) uses an instrument (e.g., ammunition) to cause a violent output (e.g., number of persons killed). They explain structural violence as systemic violence caused by structural attributes such as maldistributive policy that differentially allocates resources based on class oppression and economic injustice (6, 8). Alternatively, structural vulnerability was conceptualized to be more inclusive, encompassing maldistributive systems that are based on race, ethnicity, gender, and culture (6). Moreover, structural vulnerability refers to a positionality that imposes physical and emotional suffering on specific population groups and individuals in patterned ways. This positionality is a result of class-based economic exploitation and cultural, gender/sexual, and racialized discrimination (6). Furthermore, vulnerability results from an individual's place in a hierarchical social order and its networks of power relationships and subsequent effects (9, 10). Currently, there is no systematic documentation of the demographics, immigration trajectory, and health status of these women and children. Therefore, the aim of this assessment is to document the experiences of families granted humanitarian parole through the lens of structural vulnerability.

## Materials and Methods

### Setting and Participants

Investigators from the University of Arizona Mel and Enid Zuckerman College of Public Health partnered with p*roject helping hands (*PHHs) for this study. PHH provides services to migrating families who have been arrested and released by USCBP from short-term detention facilities in southern Arizona. Services include hospitality, food, water, clothing, basic medical attention, and instruction on the intercity bus system. In consultation with our research partner PHH and in order to protect the anonymity and privacy of the migrating women and children, researchers used purposive sampling to interview information-rich key informants, specifically lead PHH volunteers who serve migrating families (11). Lead volunteers hold a supervisory position, are the most likely to consistently interact with migrating families, and are required to speak Spanish fluently. PHHs volunteer coordinator provided the names and contact information of 20 lead volunteers. The investigators attempted to contact all volunteers via email on three separate occasions. Willing individuals replied to the investigators with their availability. A disclosure statement was provided to all volunteers. Face-to-face interviews took place in locations in the local community per the request of the participant. One interview was conducted over the phone. Interviews varied in length from 30 to 90 min. Data were gathered until empirical saturation was reached, i.e., participant responses ceased to vary greatly across questions (11).

Due to the non-generalizable nature of the data gathered, the authors submitted an exemption from human subject's research to the University of Arizona's Internal Review Board (IRB) and were approved on the grounds that non-generalizable data does not constitute as human research as defined by federal regulations.

### Interview Guide

A semi-structured interview guide (**Table 1**) was designed to ascertain PHH volunteer perspectives of the migration experience, from departure from their home country to their arrival at PHHs. The open-ended interview questions were developed based on a literature review and consultation with border health and transnational migration field experts. The interview moderator guide was designed to elicit the following information: motivations for leaving the home country, the migration experience, experiences while in detention, PHH services and delivery, and migrating families' health challenges.

#### Table 1 | Interview moderator guide.

### Data Analysis

Interviews were audio recorded and transcribed. Two researchers with qualitative research experience independently read and coded the data for major themes using NVivo 7 Software (12). The researchers then compared notes on themes and through a process of consensus agreed on major and minor sub themes and developed a code book (**Table 2**). These same researchers again reviewed the transcripts and coded for the major and sub themes based on the codebook developed. Through face-to-face discussion, researchers developed a code memory to summarize each major and minor theme and identified illustrate quotes that best represented the themes encountered (13).

### Results

Interviews were conducted with eight lead volunteers of PHHs. Six of the eight volunteers were female, and two were male. Ages in years ranged from the mid 20s to late 60s. Six of the eight volunteers were born in the US, and all but one of the volunteers was fluent in Spanish. All volunteers had been volunteering with PHH for a minimum of once per week for 4 months. Pseudonyms were assigned to each participant for de-identification purposes.

Six major themes emerged from the qualitative data: (1) reasons for leaving, (2) experience on the journey, (3) dehumanization in detention, (4) family separation, (5) vulnerability, and (6) resiliency.

### Reasons for Leaving Escaping Violence

In discussing why migrating families were fleeing their home countries, volunteers cited escaping violence as a primary cause for migrating north. Specifically, volunteers mentioned the pervasive drug violence affecting families and small businesses. Drug cartels demand money and resources, and when the families no longer have something to give, the cartels threaten them and their family members. Volunteers recalled mothers whose children had been recruited by drug cartels, and out of desperation, they gathered their belongings and fled. Volunteers stated that females often reported leaving due to domestic violence or sexual abuse by the men in their lives. Other reasons included extortion by government officials and police, kidnappings, and the high prevalence of crime in general. In one extreme case, a volunteer recalled the story of an 8-year-old boy from Honduras:

At that moment the little boy came and he had a little bag of cookies and he offered one to me and I noticed that four of his fingers were missing. I didn't say anything. The little boy noticed that I was looking and he told me the story like matter of fact.  I ran home and I was bleeding and bleeding and they told me to tell my mom that she was going to be killed and me too because we didn't have anything more to give them. My mom was screaming and screaming and she just took me and we ran."

### Economic Deprivation

Volunteers also cited economic deprivation as a reason, stating that many migrating families could no longer provide for their children with the current economic situation at home. Many families expressed that they needed better jobs with more pay in order to send their children to school.

One of the ladies said, "I want to provide an opportunity for my children to get educated, to get a good job cause the only thing that they're going to end up doing is getting into drugs and the gangs and they won't do anything good in their lives if they stay."

### Experience on the Journey The Train or the Bus

The two overarching modes of transportation that migrating families used to arrive at the US–Mexico border from the southern border of Mexico were either by train or by bus. The trajectory through Mexico is heavily dependent on material, social, and human capital. Volunteers stated that those with sufficient means took the bus, which is generally safer than travel aboard the roof of a train. Their point of departure determined whether migrating families will either arrive at the Mexican border with Texas or Arizona. The large majority of those that arrive at the PHH house travel the route to the city of Agua Prieta, which borders Douglas, AZ, USA. The alternative mode of transportation is known as "La Bestia" (The Beast), a name that was earned by the slow moving cargo trains that cross Mexico from south to north. Migrating families told volunteers about having to remain awake on the top of the train, for risk of falling off while asleep.  As one of the volunteers mentioned:

Even if you aren't subject to violence from the horrible people who are waiting to prey on people [riding on the train] there is still the reality of you riding on top of the cargo train for thousands of miles so that's pretty awful.

The people who get booted off the bus and the people who ride the top of the train are [going to] be the most vulnerable to begin with you know the most destitute the most desperate and ones you maybe don't speak the language as well are probably be the ones who get put into these more dangerous categories and are probably more will likely to be taken advantage of.

#### Table 2 | Qualitative codebook.

### Blending In

Additionally, even when migrating families had the economic means to avoid the dangerous trajectory of the train, their success was heavily reliant on their abilities to speak Spanish and blend in with Mexican nationals. Immigration checkpoints in Mexico often required people to bribe federal officials, or be forced off the bus. One of the volunteers exclaimed:

So we only see the success stories here we see the people didn't get kicked off the bus and the way they do that is either they're a little wealthier, they have some pesos with them so that they can pay a bribe to the federales (federal police) … But another way to do is to blend in more or less. So one woman, was actually a Honduran woman, she knew that like the government was [going to] get on the bus and be looking for suspicious looking Central Americans. So she gets on the bus and there's the Central Americans are in the back of the bus and they are cowering and avoiding eye contact and such.

### Risk at the Border

Travel on the bus eventually brought migrating families to the Sonora, Mexico border-area towns of Agua Prieta, Nogales, Altar, Sonoyta, or San Luis. While in these towns, migrating families were at risk of extortion and kidnapping, according to volunteers.

Another woman had one little kid and someone grabbed her before she got across the border someone grabbed her in Nogales and imprisoned her in some room that she had to eventually escape from out of the window, I suppose it was a coyote (human smuggler), she had like 1000 dollars or something and he took that money and imprisoned her and she didn't know what his plans were for her but she finally got out a window.

Upon their arrival by bus or train, migrating families must pay a *coyote* to get across the border undetected. Volunteers described how migrating families were at the mercy of the *coyotes*, their law evasion strategies at the border, and their route through the arid Arizona desert.

[The coyotes] left with all of their money. They took all their money … and they are put up in a hotel and they'll come and feed them whenever they can so they can go days without eating.

#### A Confusing Journey

Here, a volunteer described how confused migrating families become during the journey:

So they would be on the bus and they had there would be a series of payments made for those people and they would be riding buses until they get to the border area and in the border area depends on where they're going to be crossed. If they spent the night in Altar Sonora they were in a rural area somewhat isolated, and they really had no idea was going on, they're brought to the border, and for those who are familiar with Southern Arizona it's a very open desert. For people who don't, or aren't familiar with this area, it's desolate and they don't know where they are.

#### Dehumanization in Detention

Several themes related to the *treatment, feeding, sleeping*, and *health status* of the migrating families during the apprehension and detention process. According to the volunteers, US Immigration and Customs Enforcement (ICE) attempted to process humanitarian parole as quickly as possible; however, setbacks in procedures forced families to spend anywhere from a couple of nights to several weeks in detention facilities. Volunteers also mentioned that families were often jailed in cold, windowless rooms, and were forced to sleep on the floor with only an emergency Mylar blanket for warmth. Volunteers described that the women and children often left ICE detention in a state of dehydration, not because of the journey prior to apprehension, but because they were not allowed to adequately hydrate while in detention. Moreover, they noted that most migrating families were not aware than the water available in the cells was potable, a fact that Border Patrol did not always share with their charges. Finally, the volunteers mentioned that the food provided to migrating families while in detention exacerbated their dehydration and made them sick.

Everyone says that the jail is way too cold and they sleep on floors they give them these like aluminum blankets and they feed them frozen burritos, which is like the worst thing you can have if you're dehydrated from being on the desert … They feed them burritos, Austin crackers, and juices.  So its funny when people were getting dropped off to us and they were dehydrated and they said they hadn't eaten in a while I thought it was because they had been out in the desert but it was because they had been in the jail.

Many of them had no idea what was it just went through. The border patrol wakes people up at two in the morning and 'processes them'. Meaning they interview them about the reasons why they left and they make some judgment legally about what that means at two in the morning. That's normal procedure.

### Family Separation

Another service provided by PHH was the location of missing family members. The parameters of humanitarian parole mandate that only one adult may remain to accompany any children, and any other adult is to be placed in short-term detention for deportation proceedings. This manifested itself in family separation; for example, a mother and father and their children may have been apprehended and the mother and children were released to PHH, while the father was detained. If they were not aware of where other members of the family were sent, PHH attempted to make contact with detention facilities to locate the men. Another situation that separated families is that some migrating families knew that as a male family member, if they crossed with women and children and were apprehended, they would be put in longer-term detention and separated from their families. As a result, that person may have attempted to enter the US separately. If this occurred, apprehended families were desperate to contact the missing members, and PHH worked to locate them with the Mexican or Guatemalan consulate. If they were able to communicate, this may have been an extreme relief, especially during the months of May through mid-September as that was the hot season and lives may be at stake in the desert.

 They just have to be so desperate to have to head off when she's about to deliver a baby and then this other woman was there who had a 15 month old and she had a newborn and she was coming through and her husband got detained and ended up somewhere so she was counting on him to help her with the kids and he was detained.

### Vulnerability

Another emergent theme that arose from the interviews was the vulnerability of the migrating families both during their journey and upon their arrival in the US. Volunteers cited language barriers, lack of money, and a general lack of understanding of their immigration status as significant concerns for the migrating families. Language barriers were major obstacles for the migrating families as they moved through Mexico and into the US. Volunteers reported that the majority of families arriving at PHH were from rural areas of Guatemala and spoke indigenous languages. Their limited Spanish skills and inability to communicate added to their vulnerability and made it difficult to navigate through risky areas of Mexico. If they made it across the border, the inability to speak English added to their isolation when they were apprehended by the border patrol and detained by ICE. Understanding the process of apprehension, detention, the parameters of their humanitarian parole, and their future journey through the US became increasingly difficult when communication was impossible. Upon their arrival at PHH, the families were about to embark on yet another journey through an unfamiliar country, and may have spent up to 4 or 5 days navigating buses and stations before reaching their final destination. Another issue was that most migrating families arrived with no money for a variety of reasons. Some were robbed on the journey, while others fled imminent danger from cartel violence and had limited time for preparation and saving.

They're just dropping these people off that don't speak any English and don't have any money and I thought that's really horrible.

I think the scariest thing is that they arrive almost exclusively from ICE from what we know with no dollars no money okay so they have to make the trip across the country with no basically to me that would be very scary to be a mom traveling with young kids and not have any money and be going from Arizona to Pennsylvania or Rhode Island.

### Resiliency

While volunteers commented on the state of vulnerability of the migrating families, they also overwhelmingly remarked on the courage and resiliency of these individuals. They stated that in contrast to the manner in which immigrants are usually portrayed in the media as victims or as weak, their experience with migrating families has shown these individuals to be strong, resilient, and brave. They described them as individuals who are willing to do whatever it takes and overcome adversity in order to make a better life for them and their children.

 She was by herself and she wasn't with a group. And they arrived just exhausted, just right on the edge. You wouldn't know it because they're just so tough, they wouldn't have made it all the way here if they weren't so tough but they were just right on the edge.

I would say that the people I've talked to do not fit the stereotype image that people coming of being super traumatized and you know almost shaky or anything like that. I see these and they're not fragile these women are like incredibly resilient.

## Discussion

These findings elucidate the different physical and psychological distresses that migrating families from Mexico and Central America experience before, during and after their arrival at the Tucson sector of the US–Mexico border. We posit that these distresses are a result of, or exacerbated by, structural vulnerability. Structural vulnerability argues that inequality results from systemic political, economical, and material marginalization that contributes to oppression through gender, ethnic, and class-based discrimination (6, 9, 10). Migrating families find themselves in a particularly vulnerable situation due to the intersections of their status as economically marginalized indigenous women and children. Thereby, their status subjects them to class- and gender/sex-based exploitation, as well as culture- and race-based discrimination (6).

Our findings show that migrating families in question are fleeing situations characterized by structural vulnerability. Consistent with literature on the topic (2, 4, 6), we found that the primary motivation for women and children to flee their home country is persistent violence, specifically drug, gang, and gender-based violence, which largely occurs as a result of economic deprivation and maldistributive economic policy. Moreover, it has been found that children from Guatemala, El Salvador, and Honduras cited their primary reason for leaving their homes as forced child recruitment for gangs, and drug- and gang-related violence. Girls specifically have cited gender-based violence, including rape as a means of control by local gangs. Guatemalan children mentioned increasing poverty, poor agricultural yields, and unemployment as their reasons for leaving (2). Central American families overwhelmingly named deep structural conditions of economic security and chronic violence as reasons to migrate. Furthermore, the persistent threat of violence elicits fear and anxiety in children, increased risk of post-traumatic stress disorder (PTSD) and depressive symptoms in pre-adolescent and adolescent youth (14, 15).

In addition to experiencing violence at home, migrating families experience abuses while on the journey. Consistent with our findings, studies suggest that each year, hundreds of thousands of people from Guatemala, El Salvador, and Honduras attempt to cross Mexico, where they are regularly subjected to abuse, police brutality, extortion, rape, dismemberment, and death (16–18). However, violence does not cease upon their arrival at the US– Mexico border as migrants are vulnerable to violence from US immigration and law enforcement (19–21). Our findings illustrate the impact of USBP policy that separates, detains, and eventually deports men, and releases the women and children of the same family unit. While, there are many implications for all parties involved, research indicates that children suffer the greatest consequences from family separation. The immediate consequences of parental incarceration include traumatic separation, stigma, and isolation (22). Moreover, the effects of parental deportation are similar to that of other recognized negative childhood experiences, including family violence, a parent's death, parental drug abuse, and neglect (19).

Turning to the issue of maltreatment while in custody of the USBP, volunteers reported that once they are apprehended, migrating families are subject to inhumane treatment, including verbal abuse, exposure to unbearably low temperatures, prohibited use of warm clothing, inadequate food, and limited water. Our findings are consistent with recent studies that found that migrants reported persistent abuse during USCBP apprehension, detention, and deportation proceedings (20, 21). Moreover, studies have shown that mistreatment during the apprehension and detention process may be psychologically distressful; data indicate that detention and adverse mental health are causally associated. Detention of asylum seeking migrants, even for short periods of time, results in acute psychological distress, the cause of new mental health disorders, and or the exacerbation of existing conditions (23–25). Additionally, children asylum seekers can suffer life-long psychological consequences as a result of detention, including acute psychological distress, anxiety depression, affective PTSD, and intentional self-harm (26–28).

Our findings elucidate that before, during, and after the migration journey, these migrating families are subject to class- and gender/sex-based exploitation, as well as culture- and race-based discrimination (6), thereby defining them as a structurally vulnerably population. It is important to note that their structural vulnerability is a result of systemic issues without simple solutions, and without broad-based political, economical, and social change, the US will not likely see a decrease in migration from these countries in the near future. For this reason, it is important to establish a public health framework for understanding these vulnerable populations as they transition into US society. The current immigration status of humanitarian parole provides little protection to vulnerable families. We believe that given the circumstances from which they flee, migrating families merit a more permanent state of protection than what is currently offered. We recommend that the US expand its capacity to admit migrating families who are at risk of violence or harm in their home countries, specifically by establishing a non-immigrant "protection" visa that would be made available to members of vulnerable groups (29).

Based on our findings and supporting literature, we recommend that Tucson sector USCBP detention conditions drastically improve in order to prevent the perpetuation of trauma, and subsequent negative health outcomes among migrating families. Processing of detainees should be expedited in order to reduce the time that families spend in detention. If USCBP custody is to become more humane, detention facilities must meet basic health needs. Families must have access to water in a sanitary manner and in sufficient quantities to ensure safe hydration, access to adequate foods that to not exacerbate dehydration, and adequate access to medical care. Moreover, detention facilities should have more adequate

## References

regulation of temperatures, allowance of more than one article of clothing per person in order to promote the recuperation and not exacerbate conditions of physical exhaustion and emotional trauma. Additionally, policies that promote the necessary separation of families should be eradicated, as they only serve to distress families and perpetuate trauma (17, 18, 22).

We recognize that this study has some limitations. Although we believe our methods provided adequate contextual understanding, second-hand inquiry limits the data given that we were unable to interview families directly. However, collecting volunteer perspectives was also a strength of the study, given that they are front-line humanitarian aid volunteers that work one on one with migrating families. Another potential limitation was the inclusion of data from a participant who was not fluent in Spanish. However, the researchers considered the contributions of this participant to be meaningful due to her consistent interactions with migrating families and simultaneous interpretation by Spanish-speaking volunteers. Finally, interviews were conducted with PHH volunteers serving only one site; thereby, the findings and related implications cannot be generalized to other migrating families that are crossing and being processed at other points of the US–Mexico border without further research.

Structural vulnerability has resulted in life-long health implications for a sub-population of young mothers and their children. The number of migrating families who have experienced traumatic events before, and during their migration experience continues to expand and thus warrants consideration of mental health surveillance and intervention efforts for these families. Although immigration policy-based solutions are beyond the scope of this article, we recognize that immigration and USCBP policy has critical public health implications, and therefore, should be considered in future investigations. Additional public health research is needed to better understand and combat the health challenges of this growing vulnerable population.

### Acknowledgments

The authors would like to acknowledge the noble work of the local community members and organizations who volunteer their time and resources, and more importantly, we acknowledge the courageous men, women, and children who against adversity risk their lives for the hope of a better tomorrow.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2015 Valdez, Valdez and Sabo. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Risk factors and current healthseeking patterns of migrants in northeastern Mexico: healthcare needs for a socially vulnerable population

*Philippe Stoesslé1 \*, Francisco González-Salazar 2,3, Jesús Santos-Guzmán4 and Nydia Sánchez-González 5*

*1Department of Social Sciences, University of Monterrey, Monterrey, Mexico, 2Mexican Social Security Institute (IMSS), Monterrey, Mexico, 3Department of Basic Sciences, University of Monterrey, Monterrey, Mexico, 4School of Medicine, Monterrey Institute of Technology and Higher Education, Monterrey, Mexico, 5 Faculty of Nutrition and Public Health, Autonomous University of Nuevo León, Monterrey, Mexico*

#### *Edited by:*

*Jill Eileen Guernsey De Zapien, University of Arizona Mel and Enid Zuckerman College of Public Health, USA*

#### *Reviewed by:*

*Armin D. Weinberg, Life Beyond Cancer Foundation, USA Anna Ochoa O'Leary, University of Arizona, USA*

#### *\*Correspondence:*

 *Philippe Stoesslé, Department of Social Sciences, University of Monterrey (UDEM), Av. Morones Prieto 4500 Pte., San Pedro Garza García 66238, Mexico<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health*

> *Received: 20 March 2015 Accepted: 22 July 2015 Published: 06 August 2015*

#### *Citation:*

*Stoesslé P, González-Salazar F, Santos-Guzmán J and Sánchez-González N (2015) Risk factors and current health-seeking patterns of migrants in northeastern Mexico: healthcare needs for a socially vulnerable population. Front. Public Health 3:191. doi: 10.3389/fpubh.2015.00191*

This study identified risk factors for health and access to healthcare services of migrants during their journey across Mexico to the United States. Data were collected in shelters located in Monterrey, the largest city of northeastern Mexico, through a basic clinical examination and a survey completed by 75 migrants; 92% of them were undocumented Central Americans. During their transit, they are at a high risk of contracting, developing, and transmitting diseases. The need of working to survive affects health-seeking behavior and a constant fear of being traced keeps migrants away from public health services, which delays diagnosis and treatment of diseases. Negligent lifestyles, such as smoking, drinking (31.8% of men and 11.1% of women), and drug abuse (13% of men and 11% of women), were found. Regarding tuberculosis (TB), undocumented migrants are usually not screened, even though they come from countries with a high TB burden. Besides, they might be overexposed to TB because of their living conditions in overcrowded places with deficient hygiene, protection, and malnutrition (54.7% of the sample). Possible comorbidities like acquired immune deficiency syndrome (AIDS; 4%) and diabetes (2.7%, but probably under-diagnosed) were referred. Migrants have little TB knowledge, which is independent of their level of education or a previous experience of deportation. About one-third of the migrants were totally unfamiliar with TB-related symptoms, while 36% had correct knowledge of basic TB symptoms. We conclude that a shortage of information on the highly vulnerable migratory population combined with a lack of social support and health education among migrants may play a significant role in the spread of communicable diseases. We recommend that health authorities address this urgent, binational, public health concern in order to prevent outbreaks of emerging infections.

Keywords: risk factors, undocumented migrants, social vulnerability, tuberculosis knowledge and perceptions, barriers to health

**Abbreviations:** AIDS, acquired immune deficiency syndrome; BCG, Bacillus Calmette–Guérin; DM, diabetes mellitus; HIV, human immunodeficiency virus infection; INM, National Institute of Migration; KAP, knowledge, attitude and practices; NGO, no governmental organization; SD, standard deviation; TB, tuberculosis; US, United States; WHO, World Health Organization.

### Introduction

In 2013, 214 million migrants lived for at least 1 year in a country different from their home country (representing 3.1% of the world population), against 150 million migrants in 2000 (1). Apart from a rapidly increasing migration number, migration also involves a wider diversity of cultural groups. About 82 million people per year migrate from a developing country to a developed one. Furthermore, the latest estimations suggest that around one-third of migration from developing countries could be irregular (2). With migration being a growing tendency, migrants experience a unique diversity in health needs and profiles.

Worldwide, migrants are more vulnerable than nationals, as they have fewer rights than people with a citizenship. In Mexico, the life style, journey, and work of migrants, especially the undocumented migrants from Central and South America, lead to considerable risks to personal, physical, and mental well-being (3–5). Migrants' well-being is further compromised by irregular access to social and health services, immigrant status, and a prevailing anti-migrant attitude of the general public (6–8). Indeed, legal and practical obstacles limit access to health services on both sides of the Mexican–United States (US) border, and the consequential late detection of illnesses negatively affects the health of immigrants (9).

Transnational migration through Mexico affects the public health situation by connecting areas with diverse disease prevalence and other socioeconomic factors. Most of these health issues represent challenges for the limited territorial public health systems, because migrants are by definition mobile and hard-to-reach persons. Thus, the interest of our research is to determine to what extent the migration process affects the health of both the migrants and the general population. Hereto, the present pilot study aims to identify the risk factors of illnesses among migrants, as well as to get insight into the health-seeking patterns and TB knowledge among North, Central, and South American (im)migrants who pass through the city of Monterrey, Mexico, in their quest to reach the US. To our knowledge, this is the first report on current patterns of migration and their impact on health in this specific population in northeastern Mexico. Our results provide a basis for rethinking the specific healthcare needs in order to protect the health status of the general population.

### Materials and Methods

This study is an observational, transversal, and descriptive study realized from September 1st to November 30th, 2014, at temporary shelters for migrants in Monterrey. Data were collected through a basic clinical examination and a survey.

### Population Definition

We adopted the definition of the International Organization for Migration's definition for "undocumented immigrants": "Persons who change their place of usual residence" but without having a legal residence situation (10).

### Ethics and Consent

The research protocol followed principles of the Declaration of Helsinki and was approved by the University of Monterrey under the project code UIN15012. Written informed consent was obtained from all participants. In case of minors, informed consent was obtained from the parents or accompanying adults. No unaccompanied minor participated in the study.

### Sample

The sample consisted of 75 temporal immigrant volunteers of any age and gender who attended one of the two migrant shelters managed by the Catholic Church in the Monterrey Metropolitan Area; the "Centro de Apostolado San Nicolás de Tolentino – CasaNicolás" and the "Casa Santa Martha." It is important to underline that in México the shelters for undocumented migrants are mostly managed by different churches, the majority of them were managed by the Catholic Church. Rather than realizing evangelization, these shelters provide help and assistance to the (im)migrants. They do this independent of their religious beliefs or those of the migrants. Therefore, we consider that the formal religious characteristic of the shelters does not affect the origin or representativeness of the population sample.

Subjects with incomplete information or immigrants who dropped out the study before completion were not considered. The sample encompassed 71 undocumented South and Central American immigrants and 4 North Americans. We decided to include the latter because they complied with the definition of migrant and suffered the same mental and physical health stressors and social vulnerability similar to undocumented immigrants (11) (**Table 1**).

### Sampling Location

Monterrey is a cosmopolitan city located in northeastern Mexico and is the capital city of the state of Nuevo Leon. Over 4.4 million people live in this metropolitan area. It is one of the most important cities of the country and it represents one of the traditional routes of migrants coming from southern states of Mexico and from the other Central and South American countries (12).

### The Questionnaire

Our team, which included experts in TB and migration, designed a semi-structured, Spanish questionnaire with closed and openended questions, which included quantitative and qualitative methods. The questionnaire was based on previous national and international validated questionnaires (13–18), recommendations from a literature review (19), and the guidelines of the WHO "Tuberculosis PREVALENCE SURVEYS: handbook" (20).

To ensure that the survey is in accordance with the education level of the participants, the questionnaire was adapted to the education level specified in the Program of the last level of the Elementary School in Mexico (21). The questions were focused on specific topics, contained congruency control, and were limited in scope to avoid exhaustion of the participants; all to promote the reliability of the responses. A draft version was

#### Table 1 | Demographic data.

piloted in a 12-person group, and pointless, duplicated, or unsuitable questions were eliminated. The resulting succinct, clear, and unequivocal questionnaire was reorganized into logical sections and standardized. The reliability of the survey was confirmed by supplying the survey questionnaire twice to the same individuals with a long enough time difference to make it highly unlikely the respondents remember their first responses. Translation from Spanish to English was used once.

### Procedures

The survey was applied at the shelters during 45-to-60-min, face-to-face interviews in a relaxed atmosphere, which enabled to clarify the eventual unclear answers. Random surveys were cross-checked for continuous reliability. As a result, we collected a limited, but consistent and trustworthy amount of information, which was analyzed for the following characteristics:

In the same session, we determined anthropometric measures (height, weight, waist, and hip circumference) and blood pressure. Furthermore, we performed walk-through inspections of the shelters, to be familiar with the dormitories and the living spaces. Data collection and interpretation followed confidentiality procedures.

### Data Analysis

All data were collected in an Excel Spreadsheet and subsequently fed into a Stata Software v11.0 database (College Station, TX, USA). The data were then coded and displayed according to Miles and Huberman's methods (22), before being processed through descriptive statistical analyses. Outcomes were reported as means ± standard deviation (SD) or frequencies.

### Results

In our sample, most of the immigrants were males (88%) and their mean age was 32 ± 11.1 years (range: 14–60 years); the predominant age group was from 20 to 30 years (43%). More than half of the migrants came from Honduras (54.6%), whereas other Central American countries (Guatemala, El Salvador, and Nicaragua) represented 37.3% of the sample (**Table 1**).

As a matter of fact, this sample is consistently similar to the total population of undocumented immigrants in the Monterrey Metropolitan Area during the year 2014, according to the annual report of CasaNicolás (the unique liable and available source of information on undocumented migrants). In fact, during 2014, CasaNicolás studied 87% of male immigrants including 63% from Honduras (23).

More than half of the volunteers (53%) had only elementary school education, either complete or incomplete. One-third (25 subjects, 34%) had high school or baccalaureate education, and only four subjects (5.3%) had higher level education, of either a technical or professional career. Religion and marital status are reported in **Table 1**.

The weight, height, and body mass index (BMI) of the participants were 69.6 ± 10.6 kg, 164.7 ± 8.5 cm, and 25.7 ± 3.9 (mean ± SD), respectively. Almost half of the subjects were overweight (46.6%) or obese (10.6%). None of them was underweight, despite the fact that more than half of the immigrants referred diminished or limited food intake during their journey (**Table 2**).

With respect to personal habits, the subjects presented good hygiene (74.7%), but alcohol and tobacco consumptions were referred in the same proportions: 31.8% and 11.1% of males and females, respectively. Almost half of them (44.8%) had started drinking and 80% had started smoking as teenagers. Among males, 38% consumed both alcohol and tobacco, whereas only 11.1% of the females consumed both. Illegal drugs were

referred in 13.6% of males and 11% of females. Of them, 66% referred using marihuana at least once and 22% referred cocaine (**Table 2**).

Moreover, 10.7% of men and 22.8% of women mentioned having health problems, with upper respiratory disease being the most common (15.2%); there were trauma or lesions in 6.1%, gastrointestinal disease in 4.6%, and urinary disease in 3% of the sample. More women than men had medical insurance (22.2% and 12.1%, respectively). Most preferred public health services (22.7%) and 14.7% did not seek medical attention even when sick (**Table 3**).

Twenty percent of women and 17% of men had high blood pressure, and most of them declared to have had visited the healthcare system rarely. One quarter (25.3%) affirmed having been in touch with the healthcare system two or more times over the past year, and 12 of them (16%) once, but more than half (57.4%) had contacted less than once over the past year. In addition to this poor pattern of healthcare seeking behavior, 14.7% referred to be close to a patient with TB, 4% referred to have acquired immune deficiency syndrome (AIDS) and 2.7% diabetes mellitus (DM); 98.7% referred having received the Bacillus Calmette–Guérin (BCG) vaccine (**Table 3**).

#### Table 3 | Health status.

Participants understood that TB is a disease associated with significant morbidity and mortality, and 81.3% of the subjects considered TB a serious or very serious disease. While 17.3% mentioned vague symptoms that may relate to any kind of discomfort; only 30.7% correctly identified coughing for more than two weeks and 13.3% mentioned fever for more than one week, but none mentioned shortness of breath and weight loss. Also, 30.7% mentioned at least one wrong symptom and 33.3% had no idea at all (**Table 4**). Besides, less than one-fifth (18.7%) thought they were infected. Physicians and television were cited as the two most important sources of information on TB (**Table 4**).

It was the first migratory journey for 57.5% of our sample. Poverty and economic reasons had been the motive of emigration for the majority (65.3%), violence for 22.7%, family reunion for 8%, and political persecution for 4%. A quarter had had a previous undocumented experience and 21.3% had been deported from the US back to their home country (**Table 5**). For over half

#### Table 4 | TB knowledge and perception.

#### Table 5 | Emigration Experiences.

of them (53%), the journey's endpoint was the US; the majority of them (90.7%) had an exact destination.

Almost two-thirds (64%) reported problems during their travel, most often with the authorities (37.3%), criminal organizations (22.7%), and with the smugglers ("polleros"; 5.3%). Over a quarter (26.7%) reported violent assaults and a similar percentage had suffered economic extortions. Verbal and physical threats were reported by 20% of the cases and 8% of the migrants mentioned being victims of kidnapping.

To fund their journey, 28% had borrowed money from a relative or friend and 61.3% had used their savings, but most depended on work or financial support during their trip (**Table 5**).

### Discussion

#### Socio-Demographic General Overview

Undocumented migration represents 5–30% of the total immigrant population depending on the country (24). Unauthorized migration through Mexico is a major and growing issue for both Mexico and the US. The number of undocumented migrants in the US increased from around 3 or 4 million in 1993 to 12.2 million in 2007, and 11.2 million in 2012 (25). In US, the Latin American undocumented immigrants have greater problems to access the healthcare system and consequently use it less than undocumented immigrants from other parts of the world (26). However, the exact burden of undocumented immigrants in northeastern Mexico and the impact on public health are not known.

The socio-demographic profile of our population sample is in line with the available data on the 1,112 persons who attended the CasaNicolás between February and October 2014; the others' shelters have not been registered. Most immigrants were male (88% in our sample and 73% in the CasaNicolás register) and from Honduras (55% and 63%, respectively). Together with other Central American countries, they represented 92% of our sample (**Table 1**), versus 84% of the shelter's total population.

Likewise, the reasons for migration are similar between our 75-person sample and the total population of CasaNicolás. In both the groups, poverty and economic reasons were the most frequent causes of emigration: unemployment, salaries too low to mitigate high inflation, debts, and economic crisis (65.33% of our sample and 61% of the total CasaNicolás population). Violence was mentioned in second place (22.66% of our sample; 7% of the total population), followed by family reunion (8 and 2%, respectively) (**Table 5**).

#### Migration and Health Interaction

Monterrey is an economically growing city where the undocumented immigrants live temporarily and where they usually do not struggle to find a job. However, this population lacks adequate healthcare due to their immigrant status. Accordingly, their only access to healthcare generally limited to some local clinics at best, when they accept to treat them for free.

Migration and health interact and cause a decline in the general health of migrants. Undoubtedly, migrants' health depends on individual characteristics (gender, age, education, substance use, etc.), but it is also determined by contextual factors that cover far more than the individual health aspects. The migrant's well-being is vulnerable because of a complex interaction among the aforementioned individual characteristics, lifestyles (e.g., dehydration, habits, and food shortages), personal beliefs and attitudes, living and working conditions, and environmental characteristics (27).

Migrants face complex problems ranging from housing shortage to overcrowded shelters with poor ventilation, propitious conditions for the transmission of diseases (TB, influenza, fungi). They are also confronted with cultural and psychosocial obstacles, such as poor education and knowledge on health issues, which impede their access to health services. Another challenge is maintaining their personal safety and security within an unfriendly environment that combines food insecurity, social vulnerability in general, and overexposure to violence. When arrested by the Mexican or US migration authorities, they are usually imprisoned in overcrowded places that serve as incubators for contagious diseases and infections (28). Lastly, some of their behaviors, like untreated substance abuse and mental illness, might affect their physical health status.

Smoking, and alcohol and substance abuse are known risk factors for many diseases, including infections, because they compromise the immune response. However, adopting healthier habits may be harder for migrants than for the general population, because they have to handle much more stressful situations they rely with the use of tobacco, alcohol, and substances (29). For this reason, migrants need special counseling and medication to help them quit.

Regarding TB, we suspected TB in a volunteering migrant, but chest radiography excluded such a diagnosis. Still, TB is an excellent illustration of the complexity of healthcare issues in relation to migration. The failure to detect TB, or its late diagnosis, and the inadequate treatment follow-up in migratory TB patients precisely reflect the underlying educational/cultural factors (absence of information), economical (shortage of resources for transportation and housing), and psychosocial factors (e.g., feeling ashamed or guilty about the disease, or failure to establish a strong doctor–patient relationship), and several other social barriers (professional, familiar, etc.) (30–32).