Field Actions Science Reports, Special Issue 10

Field Actions Science ReportsThe journal of field actions

Special Issue 10 | 2014Improving Health Among Immigrant Populations

Édition électroniqueURL : http://journals.openedition.org/factsreports/3195ISSN : 1867-8521

ÉditeurInstitut Veolia

Référence électroniqueField Actions Science Reports, Special Issue 10 | 2014, « Improving Health Among ImmigrantPopulations » [En ligne], mis en ligne le 28 avril 2014, consulté le 20 mars 2020. URL : http://journals.openedition.org/factsreports/3195

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SOMMAIRE

FACTS Special Issue on Migration and HealthIntroductionMarc B. Schenker et Heather E. Riden

Access to Health Care Across Generational Status for Mexican-Origin Immigrants inCaliforniaEva M. Durazo et Steven P. Wallace

Physicians’ knowledge and communication about traditional, complementary andalternative medicine use among Latino patients at Kaiser Permanente, Oakland CAIngrid Bauer et Juan J. Guerra

Does Intergenerational Solidarity Buffer the Negative Effects of Residential Mobility?Evidence for U.S. ChildrenBrian Joseph Gillespie

Demographic and migration-related risk factors for low-level smoking in a farm workingsample of Latinos (the MICASA study)Erik J. Rodriquez, Maria T. Stoecklin-Marois, Tamara E. Hennessy-Burt, Daniel J. Tancredi et Marc B. Schenker

Depression, perceived stress and nervios associated with injury in the MICASA Study, aCalifornia farm worker populationHong Xiao, Maria Stoecklin-Marois, Chin-shang Li, Stephen A. McCurdy et Marc Schenker

Migration & Self-Rated Health: Comparing Occupational Cohorts in California & Spain(MICASA and ITSAL Projects)Emily Sousa, Maria Stoecklin-Marois, Jose Miguel Martinez, Fernando G. Benavides et Marc Schenker

Field Actions Science Reports, Special Issue 10 | 2014

1

FACTS Special Issue on Migrationand HealthIntroduction

Numéro spécial FACTS sur l'immigration et la santé

HECHOS Número especial sobre migración y salud

Marc B. Schenker and Heather E. Riden

1 Migration has, and will continue to be, a natural phenomenon for all living species. In

fact, approximately one seventh of the global population is migrant. The major causes of

global migration are likely to increase in the future – these include environmental

change, political conflict, and demographic and economic disparities. Migration can have

many positive effects, but it also can have negative impacts on the health of the migrant

in the origin, transit and destination locations. As we will see, these negative impacts

include mental health, chronic diseases, and occupational injuries. Despite higher

negative health outcomes compared to native residents, immigrants often have less

access to health care through social systems and their lower income status reduces their

opportunity to purchase services.

2 Study at the intersection of migration and health is highly multidisciplinary, and requires

unique approaches from numerous disciplines and specialties, including epidemiology,

sociology, public health, political science and anthropology. While the multidisciplinary

nature of the field can make it difficult for researchers to ‘talk to each other’ given the

different terminology and methodologies used across disciplines, this feature facilitates

valuable breadth and depth on the subject matter. There is also great opportunity to

better understand and improve the health of immigrant populations through

interdisciplinary collaboration in the study of migration and health. In addition to being a

multidisciplinary field of study, migration and health is topically diverse. Areas of study

span generational migration trends, mental health, human trafficking and refugees,

occupational injury risk, health care access and affordability, and rural to urban

migration – just to name a few. While Latino and Mexican immigrant experiences are


2

largely the focus of this special issue, the topics raised are relevant for immigrants from

other ethnic groups and countries around the world.

3 Topics covered in this special issue include:

1. Health care access across generations among Mexican immigrants;

2. U.S. physician knowledge of culturally specific alternative medicines;

3. Protective factors and residential mobility;

4. Low-level smoking among Latino farmworkers;

5. The association between mental health and occupational injuries in Latino farm workers;

and

6. A comparative investigation of self-reported health status in the U.S. and Spain.

4 Using the lens of the upcoming enactment of the Affordable Care Act (ACA), Eva Durazo

examines the effect of generational status on access to health care among immigrants of

Mexican-origin. She examines access to health care services among first, second, and

third generation Mexican- Americans compared to U.S.-born non-Latino Whites. Durazo

finds generational status to be a significant predictor of health care utilization, with first

and second generation Mexican Americans being significantly less likely than U.S.-born

non-Latino Whites to have health insurance. Third generation Mexican-Americans show

no difference in access to care when compared to U.S.-born non-Latino Whites. She

concludes that the ACA will benefit Mexican-Americans; however, restrictions to

insurance coverage due to immigration status may negatively impact first and second

generation immigrants more significantly. While Durazo focuses on Mexican immigrants,

the ACA is expected to create the opportunity for many immigrants to obtain health

insurance, depending on their immigration status.

5 Many Latinos use some form of traditional, complementary, or alternative medicine

(TCAM) in addition to, or in lieu of, seeking medical care from a physician. Forms of

TCAM include herbal remedies, spiritual practices, massage, and over the counter (OTC)

medication. The use of TCAM is often not reported to physicians. Through questionnaires

completed by physicians in Oakland, California, Ingrid Bauer explores physician

knowledge of Latino beliefs and practices related to TCAM use. Respondents described

their attitude toward TCAM as non-judgmental and many believe they have a good

understanding of Latino health beliefs and folk illnesses. It was more common for

physicians to know and ask about patient use of OTC and prescription medication than

herbal remedies or traditional healers.

6 Looking at migration broadly, as the residential relocation of a family from one locale to

another, Brian Gillespie is interested in whether intergenerational solidarity can help

offset the negative effects of moving on children. The parent-child relationship is found

to significantly buffer the negative educational and behavioral effects of moving on

children. Intergenerational solidarity is a significant predictor of behavior problems after

a residential relocation. While the focus of this study was relocations internal to the U.S.,

the findings suggest the important role of intergenerational solidarity on child academic

and behavioral outcomes for all families. Given the increased pressures and challenges of

transnational migration, parent-child relationships may play an even greater role.

7 Tobacco use is widely accepted as negatively impacting public health and cigarette

smoking is one of the most preventable causes of death in the U.S. Erik Rodriquez

examines low-level smoking (defined as smoking one to five cigarettes per day) among a

cohort of Latino farmworkers in California. Rodriquez finds that among this group,


3

current smokers are more likely to be low-level smokers, rather than smoking 6+

cigarettes per day (CPD). He also notes that while low-level smoking is more common

among Latino immigrants to California, there is some evidence that these smokers may

increase the number of cigarettes they smoke (and the associated health risks) over time.

The differing characteristics of low-level smokers and those who smoke 6+ CPD suggest

targeted smoking cessation interventions may be valuable.

8 Hong Xiao explores the association between mental health and occupational injuries

among Latino agricultural workers. While previous research has documented a link

between depression and agricultural occupational injuries, there has been less focus on

Latino workers – a demographic that makes up a significant portion of this workforce.

Xiao found depression and nervios to be significantly associated with occupational

injuries, while perceived stress and family support were not. This work highlights the

potential role of employers and public health officials to address both mental health

outcomes and occupational injuries hand-in-hand.

9 In a comparative study, Emily Sousa investigates self-reported health in association with

occupational cohorts among Moroccan-born workers in Spain and Mexican-born workers

in the U.S. Despite demographic differences (in age, age at migration, education, and

history of agricultural work), Mexican-women were found to be twice as likely as

Moroccan-born women to report poor health. Similarly, Mexican-born men were more

than three times as likely to report poor health compared to Moroccan-born men. These

findings may be due in part to differences in socio-demographic characteristics,

agricultural work experiences, self-rated health and cultural differences, as well as actual

health differences. Sousa advocates for additional comparative research to explore health

effects across migrant populations.

Summary

10 Immigrants globally have reduced access to health care and social services relative to

native born residents. Public policy and legislation, such as the Affordable Care Act, have

the potential to improve immigrants’ access to care, however the impact will be dictated

in large part by immigration law and eligibility requirements. Those immigrants who are

able to access health care may face barriers due to physicians’ lack of knowledge of

cultural traditions and beliefs. Better education for health providers of immigrants’

beliefs and customs is necessary to facilitate thorough and effective treatment. Mental

health is an emerging area of study relative to migrants and deserves greater attention.

The association between depression and occupational injury, and conversely the

protective impact of intergenerational solidarity and engagement in social groups,

suggest an opportunity to improve health outcomes through mental health interventions.

Given the global nature of migration, with established patterns (such as that between

Latin America and the U.S. or Northern Africa and Europe), comparative studies offer

insight into the shared experiences of migrants as well as the potential to improve

immigrant health via effective strategies employed elsewhere. It is also true that the

central themes of migration and health transcend geography, and much can be learned,

both positive and negative, from examples around the world.

11 Across core areas of education, research, and outreach, the COEMH employs a

multidisciplinary approach to study and understand the complex field of migration and

health. The COEMH’s Research Training Workshop supports and fosters the intellectual


4

growth of future leaders in the field. The papers presented in this special issue exemplify

key areas of inquiry spanning different disciplines and lay the groundwork for future

studies on global trends in migration and health research.

Acknowledgments

12 We wish to acknowledge financial and personnel support from the University of

California Global Health Institute, Center of Expertise on Migration and Health, the

Health Initiative of the Americas and the Migration and Health Research Center that

made possible the Research Training Workshop. We thank faculty members who

participated in the Workshop and provided valuable feedback to student presenters:

Frank Bean, David Lopez Carr, Xochitl Castaneda, Shannon Gleeson, Luis Guarnizo,

Patrick Marius Koga, Alfonso Rodriquez-Lainz, Steve McCurdy, Michael Rodriguez, Marc

Schenker, Steffanie Strathdee, Steve Wallace, and Leslie Wilson. We also thank the

Workshop participants who fostered rich conversations and will lead the research agenda

in migration and health in the future.

ABSTRACTS

Migration is a global phenomenon involving hundreds of millions of people, with major social

and economic impacts on migrants in their countries of origin and destination and on their

communities. In the U.S., California is by far the most affected state by these population

movements. The University of California Global Health Institute (UCGHI), Center of Expertise on

Migration and Health (COEMH) is devoted to systematically studying the health consequences of

global population movements and developing more effective strategies to address them. A key

objective of the Center is to enhance educational opportunities related to migration and health.

To do this, the Center implements graduate education, conducts research on immigrant and

refugee communities, establishes distance education opportunities, and develops transnational

collaborations. These activities provide a rich, real-world environment for training the next

generation of leaders who will respond to emerging health issues related to migration. The

Center’s annual Research Training Workshop is one such activity, resulting in rich discussions,

cross-disciplinary interactions, and invaluable learning opportunities.

This special issue on migration and health stems from the Research Training Workshop held on

June 21-23, 2011, which was organized by COEMH. The workshop brought nineteen graduate

students and postdoctoral fellows together in a multi-disciplinary setting to present their

research and receive constructive feedback from University of California faculty members. Each

paper presented in this special issue represents a unique issue related to migration and health.

L'immigration est un phénomène mondial qui concerne des centaines de millions de personnes,

et qui a des conséquences socio-économiques majeures sur les migrants dans leur pays d'origine

et dans leur pays de destination, et également sur leurs communautés. Aux Etats-Unis, la

Californie est de loin l'état le plus touché par ces mouvements de population. Le COEMH (Center

of Expertise on Migration and Health) de l’UCGHI (University of California Global Health

Institute), est spécialisé dans l'étude systématique des conséquences des mouvements de


5

population sur la santé et dans l'élaboration de stratégies efficaces pour y remédier. L'un des

objectifs clés du Centre est d'accroître les opportunités d'apprentissage liées à l'immigration et à

la santé. Pour cela, le Centre met un œuvre un enseignement supérieur, conduit des recherches

sur les communautés d'immigrants et de réfugiés, crée des opportunités d'enseignement à

distance, et développe des collaborations transnationales. Ces activités constituent un

environnement concret permettant de former la prochaine génération de dirigeants qui devra

faire face aux problèmes de santé émergents liés à l'immigration. Le Research Training Workshop

est l'une des initiatives annuelles du Centre. Il consiste en des débats approfondis, des

interactions pluridisciplinaires et des opportunités d'apprentissage utiles.

Ce numéro spécial consacré à l'immigration et à la santé découle du Research Training Workshop

organisé par le COEMH du 21 au 23 juin 2011. Cet atelier a réuni dix-neuf étudiants diplômés et

post-doctorants dans un contexte pluridisciplinaire qui ont présenté leurs travaux de recherche

et reçu des commentaires constructifs de la part des membres de la faculté de l'Université de

Californie. Chaque article de ce numéro spécial traite d'un sujet spécifique lié à l'immigration et à

la santé.

La migración es un fenómeno de escala mundial que involucra a cientos de millones de personas

y tiene un impacto social y económico tanto en los inmigrantes, como ensus países de origen y

destino, y en las comunidades en las que viven. En los Estados Unidos, el estado más afectado por

estos movimientos de población es California. El Centro de Expertos en Migración y Salud

(COEMH por sus siglas en inglés) del Instituto de Salud Global de la Universidad de California

(UCGHI por sus siglas en inglés) se dedica a realizar estudios sistemáticos sobre las consecuencias

que estos movimientos de población mundial tienen sobre la salud, a fin de crear estrategias

efectivas para abordarlos. Un objetivo clave del Centro es mejorar las oportunidades educativas

relacionadas con la inmigración y la salud. Para ello, el Centro imparte enseñanza universitaria,

realiza estudios sobre las comunidades de inmigrantes y refugiados, crea oportunidades de

educación a distancia y desarrolla colaboraciones transnacionales. Estas actividades

proporcionan un ambiente rico en experiencias reales para formar a la próxima generación de

líderes que darán respuesta a los problemas de salud emergentes relacionados con la migración.

Una de estas oportunidades que el Centro ofrece anualmente es el Taller de Formación e

Investigación que propicia profusos debates, e interacciones interdisciplinarias, además de

valiosas oportunidades de aprendizaje.

Este número especial sobre inmigración y salud nació a partir del Taller de Formación e

Investigación celebrado del 21 al 23 de junio de 2011, organizado por COEMH. El taller reunió a 19

estudiantes de postgrado y becarios posdoctorales en un entorno multidisciplinario dónde

pudieron presentar sus investigaciones y escuchar opiniones constructivas por parte del cuerpo

de docentes de la Universidad de California. Cada trabajo presentado en este número especial

representa un aspecto único relacionado con la migración y la salud.

INDEX

Keywords: Agriculture, Alternative medicine, Farmworker, Health, Immigrant, Latino, Mental

health, Migration, Occupation, Smoking


6

Access to Health Care AcrossGenerational Status for Mexican-Origin Immigrants in CaliforniaAccès aux soins des différentes générations d'immigrants d'origine mexicaine en

Californie

Acceso a cuidados de salud en las distintas generaciones de inmigrantes de

origen mexicano en California

Eva M. Durazo and Steven P. Wallace

Introduction

1 The passage of health care reform in 2010, known as the Patient Protection and

Affordable Care Act (ACA), will potentially extend health insurance coverage to the

majority of the currently uninsured United States (U.S.) population. Latinos, especially

Mexican immigrants, have the highest rates of uninsurance, making the implementation

of the ACA particularly important for this group. Yet many Latinos face a number of

social and economic factors, in addition to health insurance, that shape their ability to

access health services when they need them. California is home to the largest number of

Latinos of Mexican-origin in the country, making it a natural location to investigate the

range of issues they face in access to health care and in assessing the possible

implications of the ACA. Limiting the analysis to one state also avoids the possible

confounding of differences in state health policy with group-specific access issues.

2 A key component of the ACA is to increase insurance coverage through a series of

insurance exchanges and expansion of Medicaid (KFF 2011). In California alone, it is

expected that 1.7 million of the total uninsured will be eligible to participate in the

insurance exchanges and an additional 2.3 million will be newly eligible to receive

Medicaid (Pourat, Kinane and Kominski 2011; Pourat, Martinez and Kominski 2011). Many

Latinos, because of their high rates of uninsurance, stand to benefit from health care


7

reform. In 2007, 30% of Mexican-origin Latinos in California had no health insurance,

compared to 16% of all adults statewide (CHIS 2007). As California begins to prepare for

the implementation of health care reform, there is a need to better understand the health

care access patterns of the Latino population, particularly what factors, in addition to

insurance, affect their access to health care.

3 Immigrants often experience limited access to health care, which is especially true for

Latino immigrants of Mexican-origin (Lara et al. 2005; Morales et al. 2002). Studies find

that access to care increases for Latino immigrants the longer they are in the U.S. (Lara et

al. 2005; Ortega et al. 2007; Wallace et al. 2008). Several reasons may account for the access

barriers Mexican-origin Latinos experience. For example, recent immigrants are more

likely to have jobs that do not provide insurance (Carrasquillo et al. 2000). Latinos, both

immigrant and U.S.-born, have high rates of low socioeconomic status (Lara et al. 2005;

Portes and Rumbaut 2001), which makes it impossible to privately purchase insurance

and can result in other financial barriers, such as not being able to afford high out-of-

pocket costs or losing a day’s wages to take off from work to seek care. Other barriers to

accessing care include a lack of familiarity with the U.S. health care system, limited

English proficiency, or documentation status (Cordasco et al. 2011; Vargas Bustamante et

al. 2010). These obstacles to accessing care can differ in their impact and effect for each

Latino subgroup. Latinos are a heterogeneous group with various demographic

characteristics, such as immigrant status, time in the U.S., nativity, acculturation, and

generational status, that can result in a variety of access patterns and barriers to health

care.

Assimilation Theories and Generational Status

4 Recent research has begun to examine the role of generational status on health and

access (Acevedo-Garcia et al. 2010; Afable-Munsuz et al. 2010; Burgos et al. 2005; Popkin

and Udry 1998; Ta, Holk and Gee 2010). Generational status moves beyond the foreign-

born versus U.S.-born dichotomy found in most research by disaggregating the U.S.-born

into second, third and later generations since immigration. Immigrant health research

typically focuses on the first (immigrant) generation, although there is a growing

attention to the second generation (immigrants’ U.S.-born children) as well. Few studies

examine the third generation, limiting our understanding of the impact of immigrant

integration into mainstream society on health and access. In order to examine

generational status and its association with access to care, this study focuses on Mexican

Americans, which make up 83% of the Latino population in California (U.S. Census 2010)

and have an established history in the United States with several generations in

California (Pew Hispanic 2011).

5 Traditional assimilation theory would posit that by the third generation the economic

and social integration of Mexicans would make them mostly indistinguishable from the

larger non-Latino population (Portes and Rumbaut 2001; Portes and Zhou 1998). However

continued immigration from Mexico, the proximity of Mexico to the U.S., and the

availability of resources and opportunities might create divergent patterns (Portes and

Rumbaut 2001; Portes and Zhou 1998; Telles and Ortiz 2008). Segmented assimilation

theory identifies alternate paths in the assimilation processes of Mexicans and other

racial minority immigrant groups. A first path follows the classical route to assimilation

in which immigrants are integrated into the mainstream and lose their ethnic identity,


8

usually by the third generation; a second path involves upward economic mobility while

also maintaining the group’s ethnic identity (Portes and Zhou 1998). An alternative

course, downward assimilation, leads in the opposite direction in which the immigrant

group retains an ethnic identity and faces barriers that cause socioeconomic stagnation

and limited social mobility, resulting in high rates of poverty (Portes and Zhou 1998).

6 Examining Latinos by generational status allows for a better understanding of the access

of U.S.-born Latinos, as well as the level of integration into U.S. society for immigrants

and the later generations. Generational status may serve as a proxy for the unique racial

and immigrant experiences of Latinos, taking into consideration the larger social context

that can facilitate or impede integration into the mainstream over time. Each generation

may vary on several characteristics, such as in their levels of education, economic status,

racialized experiences, place of residence, current and potential social mobility and social

integration levels, all of which can impact access to health services.

7 We draw on immigrant health research and sociological assimilation theories to better

understand health care access for Mexican-origin individuals by generational status.

Generational status is conceptualized as the number of generations the respondent is

removed from the time of immigration (Rumbaut 2004; Telles and Ortiz 2008). Following

Portes and Rumbaut (2001), this study defines first generation Mexicans as individuals

born in Mexico currently living in the U.S., second generation Mexican Americans as U.S.-

born individuals with at least one foreign-born parent, and third generation Mexican

Americans as U.S.-born individuals with both parents born in the U.S. With cross-

sectional data we are limited to examining generation since immigration as cohorts, as

opposed to generations within families, which would directly link generation from parent

to child to grandchild. This is an important distinction because although with generation

since immigration we examine different generations, those cohorts have similar

historical experiences (Rumbaut 2004; Telles and Ortiz 2008). Since we are not sampling

by families we cannot measure intergenerational change, but instead examine changes by

cohorts.

8 This study has two aims. First, to examine how access to health care services for first,

second, and third generation Mexican Americans compares to that of U.S.-born non-

Latino Whites (hereafter referred to at U.S.-born Whites). Using U.S.-born Whites as a

benchmark, the study observes how access measures differ for each Mexican generation.

Secondly, we identify if there is improvement in access to care with each passing

generation, and if so, if improvements in access of the later Mexican generations leads to

an equalizing of access.

Methods

Data

9 The study uses the 2007 California Health Interview Survey (CHIS) public use file. CHIS is a

random-digit-dial telephone survey of all counties in California conducted every two

years. A small sample of cell phone owners with no landline are also surveyed. A complex

sampling design, which includes geographic-stratification and oversampling, ensures that

small counties and minority populations are represented in the sample (CHIS

Methodology 2009). CHIS data is collected in English, Spanish, and several Asian

languages. The final sample consists of 51,048 adults, of which 825 are cell phone owners


9

without a landline. The 2007 CHIS has a screener completion rate of 35.5%, and 52.8% of

those screened completed a full interview. These rates are comparable to similar

telephone surveys (CHIS Methodology 2009).

Sample

10 Analysis of this study is limited to adults ages 18 and over who identify as Latino of

Mexican origin (n=7,001) and U.S.-born non-Latino Whites (n=30,615). Thus we exclude all

other Latino subgroups, other racial groups and foreign-born non-Latino Whites. U.S.-

born Whites serve as the comparison group since they are the dominant population and

generally experience the least barriers to access and use of care. The U.S.-born White

reference group consists of those born in the U.S., excluding the foreign-born generation,

which may have some barriers to access because of their immigrant status.

Dependent Variables

11 The study focuses on three dependent variables, all of which are yes/no dichotomous

measures. Access to care outcomes include the following: being insured all or part of the

past year, visited the doctor in the past year, and visited the emergency room (ER) in the

past year. These measures have previously been used in the literature to measure access

and use of health care (Ortega et al. 2007; Vargas Bustamante et al. 2009; Weineck et al.

2000). As a measure of access, having insurance is an enabling factor that, when available,

can facilitate the use of health care services (Anderson 1995; Spatz et al. 2010). Seeing a

doctor in the past year measures the ability to access and use health services, and can

increase the likelihood of receiving preventive care as well as the timely treatment of

chronic diseases. Visiting the ER is a measure of access to health services, albeit an

undesired use because of the high costs and usual delay of care related with ER visits.

Alternatively, use of the ER can be an indicator of poor access to primary care resulting

from an inability to navigate the health care system.It can also be an indicator of poorer

health, resulting in increased use of emergency services (Ku and Matani 2001). For this

study, we expect higher levels of access to correspond with having insurance, having had

a doctor visit, and visiting the ER.

Independent Variables

12 The main predictor, generational status, is constructed from a combination of variables

including self-reported race/ethnicity, nativity, and parent nativity. Respondents must

have self-identified as Latino of Mexican-origin or U.S.-born White. Generational status

was then assigned based on the respondents’ and their parents’ place of birth. The

resulting generation variable consists of four categories that distinguish between the

following: U.S.-born Whites (reference); third generation Mexican Americans who are

born in the U.S. and identify as Latino of Mexican origin with both parents born in the

U.S.; second generation Mexican Americans who are born in the U.S. and identify as

Latino of Mexican origin with at least one foreign born parent; and first generation

Mexicans who are born in Mexico and identify as Latino of Mexican origin. There is no

way of distinguishing the third generation from later generations, thus this category

includes third and subsequent generation Mexican Americans. In addition, since coding


10

generational status relies on self-identity, it is likely that some third and higher

generation Mexican American no longer identify as Mexican Americans and are therefore

missing from the analysis.

13 A series of covariates are included in the logistic regression model in order to control for

factors the literature indicates impact access and use of health care services (Anderson

1995; Weinick et al. 2000). These variables include: gender, age, marital status, education

level, income, insurance status, and self-reported health status. Having health insurance

all or part of the past year is used as a covariate for all outcomes, except when insurance

is the dependent variable. Insurance can be a facilitator to health care and those with

insurance will be expected to have better access and increased use of services (Anderson

1995). Socioeconomic status, measured here by education, income level, and insurance

status, is an important factor to consider for Mexican-origin individuals because research

finds differences in socioeconomic status by generational status (Acevedo-Garcia et al.

2010; Telles and Ortiz 2008). The literature identifies additional factors that impact

access, such as language or citizenship status, that are not included in the final model

because of the lack of variation in the second and third generations. While

documentation status may be pertinent to the access of health care for first generation

immigrants, this information is not available when using public use files.

Statistical Analyses

14 Analysis begins with descriptive statistics of all variables. Percentages for the dependent

and independent categorical variables are presented for each Mexican-origin generation

and U.S.-born Whites. Multivariate analysis using binomial logistic regression is

conducted on each of the three access outcome variables in order to determine whether

each Mexican generational status differs from U.S.-born Whites. For each dependent

variable, two models are created. The first model establishes the bivariate association

between generational status and the access outcome variable. The second model includes

the covariates previously listed in order to examine how the generation variable changes

once controlling for demographic and socioeconomic differences in the population.

STATA software version 11.2 was used for all analyses (Stata 2009). The analysis uses the

probability and replicate weights provided by CHIS in order to account for the complex

sampling design in calculating standard errors (CHIS Methodology 2009).

Results

15 Table 1 provides descriptive statistics for the outcome and independent variables for the

total sample and by generational status. About twenty percent of the total sample of

adults has poor access to health care. One in five of the total sample does not have health

insurance, about 18% have not seen a doctor in the past year, and 18% have had an ER

visit in the past year. First generation Mexicans generally have the lowest rates of access,

with increasing rates for subsequent generations. U.S.-born Whites have the highest rate

of access. Access rates for second and third generation Mexican Americans fall in

between, with the third generation reaching similar rates to that of U.S.-born Whites.


11

Table 1. Weighted Percentages of Outcome Measures and Covariates by Generation, Mexican-origin and U.S.-born White Adults in California, 2007.

Data source: California Health Interview Survey (CHIS) 2007

Unweighted sample size

16 The independent variables also show a trend of the first generation doing poorly with

improvement for the successive generations. This is especially true of education and

income. For example, the rate of a college degree is seven times higher for U.S.-born

Whites than first generation Mexicans. Education and income rates for the second and

third generations are much improved compared to the first generation; however, there is

still a considerable gap in high education and high income between third generation

Mexican Americans and U.S.-born Whites.

17 Table 2 presents odds ratios and 95% confidence intervals for the access outcomes:

insured, doctor visit, and ER visit. The analyses use logistic regression to control for

population differences and examine the relationship between generational status and the

three access outcomes. Model 1 presents the bivariate relationship between generational

status and each access measure. In Model 2 we control for basic demographics, such as

gender, age, and marital status; socioeconomic status (SES) as measured by education,

income, and health insurance status; and self-reported health status.

Health Insurance Status

18 All three Mexican generational groups have statistically significant lower odds of being

insured than U.S.-born Whites in the unadjusted Model 1, Table 2. First generation

Mexicans have the lowest odds of being insured all or part of the year when compared to

U.S.-born Whites. The odds of having insurance improve for second and third generation


12

Mexican Americans; however, both groups are still less likely to have insurance than U.S.-

born Whites, with the third Mexican American generation still having only about half the

odds as U.S.-born Whites.

19 Part of the disparity in being insured is a result of the compositional differences of the

populations, as shown in the improved odds for all generations in Model 2. Once we

control for sociodemographic differences, the third Mexican American generation has a

similar rate of health insurance as the U.S.-born White reference group. However first

and second generation Mexican Americans continue to have lower odds of being insured

than U.S.-born Whites even when adjusting for sociodemographics. The immigrant first

generation maintains the largest disparity, with less than half the odds of having health

insurance compared to Whites when controlling for sociodemographics.

Table 2. Logisitc Regression Models (Odds Ratios) Predicting Access (Being Insured, Doctor Visit,ER Visit) among Mexican-origin and U.S.-born White Adults in California, 2007. Weighted.n=37,565.

Data source: California Health Interview Survey, 2007

Doctor Visits

20 Similar patterns emerge by generational status for doctor visits in the bivariate and

adjusted models. In the unadjusted Model 1, Table 2, all three Mexican generational

groups are less likely to have had a doctor visit than U.S.-born Whites. First generation

Mexicans have the lowest odds of having a doctor visit compared to U.S.-born Whites, and

each successive generation has higher odds. When we control for population differences

in sociodemographics, insurance, and self-reported health status, third generation

Mexican Americans emerge with similar odds of any doctor visits as U.S.-born Whites,

while the first and second generations continue to have lower odds than U.S.-born Whites


13

(Model 2). Thus, differences in sociodemographics account for variations in insurance and

doctor visits for third generation Mexican Americans and Whites, but not entirely for the

first and second generations.

Emergency Room Visits

21 In the unadjusted model, only the immigrant Mexican American generation has lower

odds of emergency room (ER) use compared to U.S.-born Whites (Model 1, Table 2). Once

we control for differences in sociodemographics, insurance, and health status, the odds

for all generations fall modestly, and the resulting pattern for ER use becomes similar as

for health insurance and any doctor visit (Model 2). Both first and second generation

Mexican Americans have statistically significant lower odds of visiting the ER than U.S.-

born Whites. Third generation Mexican Americans have similar odds of visiting the ER as

U.S.-born Whites, adjusting for sociodemographic differences.

Discussion

22 The aim of this study was to compare each Mexican generational status with U.S.-born

Whites, focusing on the progression of access to health care across the generations. Of

specific interest was whether the levels of access for the third generation were more

similar to U.S.-born Whites, indicating improvement, or to the second generation

Mexican Americans, indicating stagnation of progress in access to health care. We find

that for all access measures (health insurance status, doctor visits, emergency room (ER)

visits), third generation Mexican Americans exhibit no statistical difference from U.S.-

born Whites once we control for population and sociodemographic differences. First

generation Mexicans have the least access to health care, with lower odds than Whites in

accessing insurance, doctor visits, and ER visits. Second generation Mexican Americans

also have lower odds than Whites; however, the differences are not as pronounced as for

the first generation. The covariates included in the analyses, such as age, gender,

education, and income, were generally found to follow the expected patterns in the

health literature. Being female, married, older, having higher education and income

levels are predictive of better access to health care. The contribution and focus of this

analysis is the effect of generational status on access outcomes.

23 This study finds important differences in access to health care among Mexican Americans

when examined by generational status, with the greatest disparities for the generations

closest to the immigrant experience, the first and second generations. The native born

usually do better than the foreign born, however in our study once we disaggregated the

second and third U.S.-born Mexican Americans, access disparities for the second

generation emerge. Other studies have found similar trends, with the first and second

generation exhibiting poorer health outcomes than the third generation (Acevedo-Garcia

et al. 2010; Afable-Munsuz et al. 2010; Ahmed et al. 2009).

24 In the unadjusted models third generation Mexican Americans are less likely to be

insured or have a doctor visit compared to U.S.-born Whites, however these differences

are eliminated once we control for socioeconomic and health status. This suggests that

after several generations of integration into U.S. society, third generation Mexican

Americans may have enough experience with the health care system and other U.S.

institutions, assuming similar educational, economic, and health backgrounds as U.S.-


14

born Whites. The third generation may have more resources and experiences than the

first or second generations that allow them to better navigate the health care system,

advantages that come from being born in the U.S. and having U.S. born parents. However,

persisting health access barriers between third generation Mexican Americans and U.S.-

born Whites at the bivariate level are in part the result of continued educational and

income disparities between the two groups, such as the poverty rate that is three times

higher for third generation Mexican Americans than for U.S.-born Whites.

25 We also considered differences in age cohorts between Mexican-origin Latinos and U.S.-

born Whites as a possible source of the observed disparities in access to care. Second and

third generation Mexican Americans are younger with a smaller older adult population

compared to U.S.-born Whites, thus we performed a sensitivity analysis restricting the

groups to ages 18-64. Differences in doctor visits observed between second and third

generation Mexican Americans and Whites disappear after restricting the age and

adjusting for sociodemographics. Thus, differences in doctor visits may be driven in part

by the size of the older U.S.-born White population. However, excluding ages 65 and over

from the analysis had little impact on the patterns for insurance status and ER visits,

suggesting that there are differences between U.S.-born Whites and Mexican Americans

by generation not accounted by age variations in the population.

26 While controlling for socioeconomic status and other population variations eliminates

differences in access for third generation Mexican Americans and U.S.-born Whites in our

study, disparities in other related dimensions continue to exist. Research has observed

educational and occupational segregation and discrimination in U.S. institutions against

all Latinos, regardless of immigration status or generation (Portes and Zhou 1993; Telles

and Ortiz 2008; Williams 1999). These observations are supported by legal findings that

legislation at the state level allowing police to inquire about immigration status leads to

racial profiling and discrimination (Bauer 2009; Cervantes et al. 1995; Sabia 2010). A

variety of reasons explain the bivariate disparities in health care access and

socioeconomics between Mexican Americans of all generations and U.S.-born Whites. In

the short term, the ACA’s expansion of health insurance should significantly reduce the

health care access disparities between third generation Mexican Americans and U.S.-born

Whites; in the long-term, it is important to improve educational and occupational equity

to remove the underlying basis for the access disparities for Latinos of all generations.

27 This study finds that those closer to the immigrant experience, first generation

immigrants and the second generation children of immigrants, have worse access to

health care compared to U.S.-born Whites, even after controlling for demographics and

socioeconomic status. Our findings suggest that generational status may be serving as a

proxy for the broader social and structural barriers that Latinos face in accessing health

care. Specifically, first generation Mexicans may face obstacles in accessing health care

due to citizenship and documentation status, language barriers, and limited skills in

navigating the U.S. health care system (Cordasco et al. 2011; Kandula et al. 2007; Vargas

Bustamante et al. 2010). Structural factors, such as where immigrants live and the

availability of quality health services, can also be barriers in accessing health care

(Cordasco et al. 2011; Osypuk et al. 2009). Fear of U.S. institutions, in particular of the

health care system, is another potential obstacle to accessing care for undocumented first

generation Mexican immigrants and all Latinos in general. These fears may have been

heightened as policy discussions for the ACA often coincide with increased anti-

immigrant sentiment (Galarneau 2011). Few studies have examined the actual impact of


15

fear and anti-immigrant policy on health care access, and those that have find less use of

services or are inconclusive (Berk and Schur 2001; Spetz et al. 2000). While the ACA may

provide insurance to many immigrants in California, several other factors will continue

to impact their health care access and use. Undocumented immigrants, the most

vulnerable among Latino immigrants and those least likely to have health insurance

(Vargas Bustamante et al. 2010) will not be able to participate in the ACA, which may

create or further intensify barriers for the undocumented and their families. Our study is

unable to directly account for many of these social and structural factors that affect

health care access for immigrants, nevertheless generational status may serve to broadly

capture the barriers Mexican Americans experience.

28 Second generation Mexican Americans have a demographic and socioeconomic profile

that is similar to that of the third generation, but the second generation follow the access

patterns of the first generation with lower odds of being insured, having a doctor visit, or

having an ER visit compared to U.S.-born Whites. What might explain the differences in

access between second generation Mexican Americans and U.S.-born Whites, considering

that the second generation should not have the citizenship or language barriers that the

first generation might encounter? Although this study accounts for education and income

differences, socioeconomic status may impact the second generation in such a way that

those with low education and low incomes are at a greater disadvantage when accessing

and using health care than those within the second generation with higher incomes and

education. Other studies have found varying socioeconomic gradients between

generations, which may not have been captured in this study (Acevedo-Garcia et al. 2010;

Ahmed et al. 2009).

29 There are additional factors that impact access to health care for the second generation

that we have not been able to address in our study. These factors may include residence

in segregated neighborhoods, experiences with discrimination, or poor quality of care

(Ahmed et al. 2009; Smedley et al. 2003; Viruell-Fuentes 2007). Additionally, considering

segmented assimilation theory the second generation may be experiencing limited social

mobility, which would impact their educational and occupational opportunities. A

segmented labor force may place the second generation at a disadvantage with low-

paying jobs with minimal health benefits or sick leave (Valenzuela Jr. and Gonzalez 2000),

discouraging them from seeking care. Residence in segregated neighborhoods can result

in less availability of services or poorer quality of care for the second generation,

deterring access to services (Acevedo-Garcia et al. 2003). Having an immigrant parent may

impact the social and human capital of the second generation (Portes and Rumbaut 2001),

resulting in limited knowledge or resources in navigating the health care system. Future

studies should consider the social context for the second generation and the experiences

that may be impacting their access to care. Using a life course perspective may be

especially useful for the second generation as barriers experienced in early life as the

children of immigrants, such as limited socioeconomic status or limited family and

neighborhood resources, may last into adulthood and impact access to health care.

Limitations and Strengths

30 The results of this study should be considered within the context of several limitations.

The CHIS is a cross-sectional survey, which limits the establishment of a causal

relationship between generational status and access to health care measures. There may


16

be other variables that we have not considered that confound the possible effect of

generation on access to health care. Additionally, all access measures are self-reported,

leaving the dependent variables prone to historical inaccuracies and response bias. The

findings are specific to California, which has historical and policy differences from other

states that might result in varying access patterns. There may also be third generation

Mexican Americans that no longer identify with being of Mexican or Latino descent,

which would result in excluding the most assimilated from the analysis. However,

excluding the most assimilated from the study strengthens our findings of the third

generation having access patterns similar to U.S.-born Whites, even without those who

are most assimilated.

31 Despite the limitations, this is one of a few studies to examine access to care and the role

of generational status among Mexican Americans, specifically including the third

generation. While generational status is not a new dimension of research in immigrant

health, this study is able to further disaggregate the U.S.-born population by generation.

Additionally, the study is based on the California Mexican-origin population, a state with

one of the largest concentration of Latinos. Results from this study may anticipate the

health trends for Latinos at the national level.

Policy Recommendations and Conclusion

32 This study finds that those closest to the immigrant experience, specifically Mexican

immigrants and U.S.-born Mexican Americans of immigrant parents, have the lowest

rates of health insurance and utilization of health care. There are several policy

recommendations that can be enacted immediately and over the long term to address the

access barriers of these populations. The Affordable Care Act (ACA) presents a unique

opportunity to extend health insurance coverage to an unprecedented number of

individuals. Estimates predict that between 1.8 and 2.7 million individuals will be able to

receive health insurance through the ACA in California; however several groups will still

remain uninsured, for example segments of the Latino population or some Californians

with limited English abilities (Lucia et al. 2012). Specific strategies and policies can be

implemented now in order for the ACA to incorporate the largest amount of eligible

individuals. Based on our findings, third generation Mexican Americans may benefit the

most from health care reform since the elimination of socioeconomic barriers improves

health insurance status and access to care most for this group. First and second

generation Mexican Americans may not fare as well as the third generation and require

additional assistance to improve access.

33 Most significantly, access may be improved through the ACA with focused and increased

outreach to the Mexican American groups with the least access, the first and second

generations. Reaching out to these groups and informing them of ways in which they may

be eligible for the ACA can increase access to health insurance. Outreach will need to be

available in both English and Spanish and dispel any fears for immigrants involved with

the residency process or those belonging to mixed families (Gomez and Artiaga 2011). In

addition to education and outreach for ACA eligibility, issues of navigating the health

care system will also need to be addressed. Mexican immigrants may be unfamiliar with

the health care system in the U.S. and Mexican Americans born to immigrant parents

may lack the knowledge and capital if they were not exposed to the health care system

across their lifespan.


17

34 Outreach and education is critical, but just as important is who is providing the

information. Established ethnic organizations and trusted community programs will be

instrumental in providing ACA outreach for immigrants and second generation Mexican

Americans, as well as with improving navigation of the health care system (Gomez and

Artiaga 2011). Community health workers, or promotoras, have long been used in the

Latino population to improve outreach and program implementation because of the trust

and cultural capacity brought by the community health workers (Elder et al. 2009; Swider

2002). Use of community organizations will be important to increase the number of

applicants to the ACA and to increase the use of appropriate health care utilization by

first and second generation Mexican Americans.

35 Also, as with any recent policy implementation, the application process can be new and

confusing. Streamlining the application process and simplifying the documentation

needed to apply, especially for Medicaid, can facilitate access to health insurance for first

and second Mexican Americans, and all eligible individuals (Gomez and Artiaga 2011).

While community organization can provide assistance and set up processes that work on

the ground, state and federal governments will need to ensure that ACA information is

available and provided in accessible formats for all individuals, including for those with

limited education levels or with limited English language abilities. Additionally, support

for safety net clinics will be critical to provide continued access to low-income and racial/

ethnic minority populations (Andrulis and Siddiqui 2011).

36 In addition to the implementation of the ACA, other policies will be needed over time to

promote equity of access for first and second generation Mexican Americans. For the

generations closest to immigration, additional factors beyond health insurance and

socioeconomic status impact access to health care. Addressing quality of care,

discrimination within the health care system, and educating first and second generation

Mexican Americans of their eligibility to benefits and health programs may improve

health care access in the immediate term. Improving educational and occupational

opportunities for immigrants and their children will be critical to improving health and

access for current and future generations.

Conclusion

37 We find generational status to be a significant predictor to accessing health care services.

Specifically, first and second generation Mexican Americans are less likely to have

insurance, see a doctor, and visit the ER than U.S.-born Whites. Despite the differences in

access by generational status, policies rarely address the unique factors that distinguish

the Latino immigrant and U.S.-born population. This study finds that even when

adjusting for sociodemographics, generational status remained a predictor for health

insurance, limited doctor and ER visits. Further research into the unique experiences of

each generation, especially the second generation, can provide a better understanding as

to why some groups continue to face obstacles in accessing health care. However several

strategies can be implemented to address the access barriers of first and second

generation Mexican Americans, in particular when considering the implementation of

Affordable Care Act.


18

Acknowledgements

38 We thank Vilma Ortiz for her valuable comments to an early version of the paper. Helpful

comments were also provided by Xóchitl Castañeda and Shannon Gleeson.

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Minnesota, 2010, accessed August 2011 at http://usa.ipums.org/usa/sda/

ABSTRACTS

The Patient Protection and Affordable Care Act (ACA) of 2010 expands health insurance coverage

to a substantial number of persons without health insurance. In California, Latinos, especially

Mexican immigrants, have one of the highest rates of uninsurance, making the ACA particularly

important for that group. Using the 2007 California Health Interview Survey, this study examines

how the generation in the U.S. of individuals of Mexican-origin is associated with their access to

health insurance, doctor visits, and emergency room visits in California compared to that of U.S.-

born non-Latino Whites. Results indicate that third generation Mexican Americans have similar

levels of being insured, having a doctor visit, and having an ER visit compared to Whites,

controlling for demographic, socioeconomic, and health status. First generation (immigrant)

Mexicans have the least access to health care services with lower odds than Whites of accessing

care across all measures. Second generation Mexican Americans also have lower odds than

Whites, however, the differences are not as pronounced as for the first generation. This study

finds that there are important differences in access to health care among Mexican Americans by

generational status, with the greatest disparities for the generations closest to the immigrant

experience. Implementation of the ACA will benefit Mexican Americans across generational

statuses, but gaps will likely remain for first and second generation Mexican Americans.

Le Patient Protection and Affordable Care Act (ACA), voté en 2010, étend la couverture

d'assurance-maladie à un grand nombre de personnes qui en étaient jusqu’à présent dénués.

Cette loi est particulièrement importante pour les Latinos de Californie, et en particulier pour les

immigrés mexicains, le groupe ethnique qui présente l'un des taux de non-assurance les plus

élevés. En se basant sur l'enquête 2007 California Health Interview Survey, cette étude examine le

lien entre la génération des individus d'origine mexicaine vivant aux Etats-Unis et leur accès à

l'assurance-maladie, aux médecins et aux urgences en Californie comparé aux Blancs non latinos

nés aux Etats-Unis. Les résultats indiquent que les Américains d’origine mexicaine de troisième

génération ont des taux similaires de non-assurance, de visites chez le médecin et de visites aux

urgences à ceux des Blancs, pour des statuts démographique, socioéconomique, et de santé

comparables. Les Mexicains de première génération (immigrants) sont ceux qui ont le moins


22

http://usa.ipums.org/usa/sda/

http://usa.ipums.org/usa/sda/

accès aux services de santé avec moins de chances que les Blancs d'accéder aux soins pour tous

les groupes de mesures. Les Américains d’origine mexicaine de deuxième génération ont

également moins accès aux soins que les Blancs mais les différences sont moins prononcées que

pour la première génération. Cette étude montre qu'il existe des différences notables au niveau

de l'accès aux soins entre les Américains d’origine mexicaine en fonction du degré de génération,

les disparités les plus importantes concernant les générations les plus proches de la date

d'arrivée dans le pays. L'application de l'ACA va bénéficier aux Américains d’origine mexicaine

des différentes générations mais des écarts vont probablement perdurer pour les première et

deuxième générations.

La Ley de Protección al Paciente y Cuidado Asequible (ACA por sus siglas en inglés) de 2010

amplía la cobertura del seguro de salud a un importante número de personas que carece de dicho

seguro. En California, los latinos, especialmente los inmigrantes mexicanos, registran una de las

tasas más altas de no-asegurados, lo que convierte a ACA en una ley especialmente importante

para ellos. Usando la Encuesta de Salud de California de 2007, este estudio examina como la

generación a la que pertenecen los individuos de origen mexicano en California afecta su acceso a

seguro médico, a consultas médicas y a consultas en la sala de emergencias en comparación con

los blancos no-latinos nacidos en Estados Unidos. Controlando demografía, nivel socioeconómico

y estado de salud, los resultados indican que la tercera generación de estadounidenses de origen

mexicano tienen un nivel similar de cobertura, consultas médicas y atención en salas de

emergencias comparados con los blancos. La primera generación de mexicanos (inmigrantes)

registra el menor acceso a los servicios de cuidados de salud y menor probabilidad que los

blancos de acceder a cuidados en todas las categorías. La segunda generación de estadounidenses

de origen mexicano también tienemenos probabilidades que los blancos, aunque las diferencias

no son tan pronunciadas como en la primera generación. Este estudio concluye que existen

importantes diferencias en el acceso al cuidado de salud entre los estadounidenses de origen

mexicano dependiendo de la generación a la que pertenecen, con las diferencias más grandes en

la generación más cercana a la experiencia migratoria.. La implementación de ACA beneficiará a

las distintas generaciones de estadounidenses de origen mexicano, aunque probablemente sigan

existiendo deficiencias para la primera y segunda generación.

INDEX

Mots-clés: ACA, Accès aux soins des Latinos, Accès aux soins en Californie, Statut générationnel

Palabras claves: ACA – (siglas en inglés de Affordable Care Act), Acceso a cuidado de salud en

California, Acceso a salud de los latinos, Estado generacional

Keywords: ACA, California health care access, Generational status, Latino health access

AUTHORS

EVA M. DURAZO

M.P.H., UCLA Fielding School of Public Health, Department of Community Health Sciences, P.O.

Box 951772, Los Angeles, CA 90095-1772, [email protected]

STEVEN P. WALLACE

Ph.D., UCLA Fielding School of Public Health, Department of Community Health Sciences and

Center for Health Policy Research


23

mailto:[email protected]

Physicians’ knowledge andcommunication about traditional,complementary and alternativemedicine use among Latino patientsat Kaiser Permanente, Oakland CAConnaissances et attitudes des médecins vis-à-vis du recours à la médecine

traditionnelle, à la médecine complémentaire et à la médecine alternative des

patients latinos du Kaiser Permanente, d'Oakland en Californie

El conocimientos y comunicación sobre el uso de medicina tradicional,

complementaria y alternativa entre doctores y los pacientes latinos del centro

Kaiser Permanente, Oakland (California)

Ingrid Bauer and Juan J. Guerra

Introduction

1 California has the largest Latino population in the nation, with over 14 million Latinos

representing 38% of the state’s total population1. Latinos have lower overall mortality and

infant mortality than non-Hispanic white and black Americans, a phenomenon known as

the “Latino health paradox” 2-4. At the same time, Latinos suffer disproportionately high

rates of diabetes, HIV/AIDS, tuberculosis, certain cancers, depression, and death from

homicide or incarceration.

2 Many social factors contribute to Latino health disparities, including income, lack of

access to health care, insurance status, immigration status, language barriers, working

conditions, environmental contamination, neighborhood safety, and unhealthy lifestyles4,6. Cultural barriers between patients and health care providers, as well as individual-


24

and institutional-level discrimination, also contribute to poor health among Latinos and

other ethnic minorities 7.

3 Cultural competence, cultural humility, and patient-centered communication have all

been promoted as strategies for reducing health inequities 8-12. Since the federal Office of

Minority Health released its standards for Culturally and Linguistically Appropriate

Services (CLAS) in 2000, many health care systems have complied with language services

standards. However, cross-cultural communication skills and knowledge about the

particular health beliefs and practices of Latinos remain an area of weakness in health

care research and practice 13.

4 For many Latinos, their health beliefs and practices do not fit within the framework of

Western biomedicine, which has been cited as a barrier to care 4,14. Although rates of use

vary by region and national origin, at least 25% of Latinos use some form of traditional,

complementary or alternative medicine (TCAM) 15,16. Some studies show that up to three

quarters of Mexican-Americans use TCAM 17.

5 A common theme throughout Latino cultures is a holistic perspective on health, where

spirituality, physical and mental/emotional health are equally important and intertwined18-21. Illness may result from natural causes or may be related to emotional, spiritual, or

supernatural causes. Folk illnesses, also known as “culture-bound syndromes,” are

collections of symptoms not recognized by conventional medicine but with popularly

understood mechanisms of causation and often treated using TCAM. Commonly cited folk

illnesses include ataque de nervios (nervous attack), susto (fright), mal de ojo (evil eye),

empacho (blocked bowel in children), caída de mollera (fallen fontanel), and caida de matríz

(fallen uterus) 11,22.

6 Herbal remedies, folk chiropractors (sobadores), massage, spiritual practices, and

relaxation techniques are some of the most frequently reported forms of TCAM among

Latinos 16. Over-the-counter (OTC) and non-prescribed prescription drugs (purchased

across the border or under-the-table in the U.S.) also form part of the

“ethnopharmacology” of Latinos 23. Despite much curiosity about folk healers, such as

curanderos, most studies indicate that no more than 4% of Latinos have visited such a

healer within the past year 17,19,24,25, although other studies report rates as high as 13%21,26.

7 Self-care through diet and lifestyle, as well as herbal home remedies, appear to be the

most important features of Latino health maintenance and are the first steps many

Latinos take before consulting a medical professional 22,27,28. In fact, some argue that the

preference for self-care and natural remedies leads Latinos to seek conventional medical

treatment as a last resort 21.

8 Of particular concern to physicians and public health officials is the underreporting of

TCAM by Latino patients. Studies have shown that up to 80% of Latino patients do not

report TCAM use to their physician 29. Poor communication not only increases the risk of

herb-drug interactions or missing potentially serious health problems, but also points to

a profound breakdown in the patient-provider relationship. Improving clinicians’

communication skills and knowledge of patients’ health beliefs and practices can enhance

doctor-patient relationships and improve health outcomes 11,30.

9 Lacking among research on Latino health beliefs, practices, and outcomes is an

investigation of what health care providers who serve Latinos know about their patients’

health beliefs and practices and how they communicate with their patients about TCAM.


25

This study exploresthe cultural knowledge and communication skills of physicians

regarding Latino health beliefs and TCAM practices at a bilingual clinic in Oakland,

California. Later stages of the research will examine the health beliefs and practices of

Latino patients served by the same clinic. Research questions include: (1) How do

physicians rate their understanding of Latino patients’ health beliefs and use of TCAM

and pharmaceuticals? (2) Which TCAM therapies do they consider most effective or most

problematic? and (3) How do physicians communicate with Latino patients about TCAM

and health beliefs?

Methods

10 This is an exploratory mixed methods study at Salud en Español (SE), a bilingual module

at Kaiser Permanente in Oakland, California, founded in September 2009. SE serves a

diverse Latino patient population from across Alameda County, providing medical

services in family and internal medicine, obstetrics and gynecology, and pediatrics. The

study involves questionnaires conducted with 10 SE physicians and a telephone survey of

65 adult Latina patients. Results from provider questionnaires conducted May through

July 2011 are presented here. The results from patient surveys will be presented

separately. The study was approved by the Kaiser Permanente Institutional Review Board

and the UC Berkeley Committee on the Protection of Human Subjects.

Questionnaire instrument

11 All physicians at SE were invited to participate in a 20-minute questionnaire administered

in person by the graduate student researcher. The questionnaire included questions

pertaining to (1) personal background and use of TCAM; (2) knowledge about Latino

patients’ TCAM use; and (3) communication with patients about TCAM. Both open-ended

and scaled questions were included; notes were taken to record responses to open-ended

questions, as audio recording was not permitted.

Analysis

12 Physician questionnaires were analyzed using qualitative techniques. Scaled questions

were analyzed to generate frequencies that described the characteristics, knowledge and

skills of the group of interviewees. Open-ended questions were coded and sorted into

themes, and lists of herbs, supplements, OTC, and prescription medications were sorted

and compared.

Results

Demographics

13 Participants included 10 physicians (3 men and 7 women), including 6 internal medicine

doctors, 3 family practice physicians, and one pediatrician. Their ages ranged from 32 to

57 years old, and their length in practice ranged from 5 to 31 years since beginning their

medical residency training. All of the physicians self-identified as Hispanic or Latino/a.

Nine physicians felt most comfortable with English but also spoke Spanish fluently; one


26

felt equally comfortable speaking both languages. Eight were born in the US; one was

born in Mexico and another in Trinidad and Tobago.

14 The participants had diverse experiences with using TCAM in their personal health

maintenance. Three physicians had no experience using any TCAM therapy. The other

seven physicians had some experience with some kind of TCAM, including herbal

medicine, yoga, meditation, tai chi, acupuncture, and other TCAM practices (massage,

acupressure osteopathy, reiki, craniosacral therapy). None had ever visited a curandero or

other traditional/folk Latino healer.

15 Physicians had varying levels of cultural competency training. Six of the 10 participants

mentioned receiving information about cultural health beliefs and practices during an

orientation when they began working at Kaiser Permanente, while three reported having

participated in cultural competency programs elsewhere. One physician leads such

trainings at Kaiser Permanente and other settings. Five physicians underwent

“extensive” cultural competency training during their medical residency training or

fellowships at academic institutions.

Cultural Knowledge

16 The majority of physicians felt that they had some knowledge and understanding

regarding their Latino patients’ health belief system (Table 1). One participant did not

respond to this set of questions because she did not feel that she could generalize about

all of her Latino patients due to the diversity of their cultural backgrounds and

socioeconomic status.

17 The physicians had a wide distribution of knowledge and understanding about folk

illnesses. Physicians expressed a greater understanding of ataque de nervios (nervous

attack), mal de ojo (evil eye), susto (fright), and caída de matriz (fallen uterus). They

reported less understanding of empacho (blocked stomach) and caida de mollera (fallen

fontanel). Another commonly encountered syndrome mentioned by three physicians was

the description of low back pain as dolor de riñones (kidney pain) in the absence of urinary

tract symptoms. Two others cited the widespread belief that exposure to cold air causes

illness.

18 Similarly, physicians varied in their level of knowledge and understanding about Latino

patients’ use of traditional, alternative and complementary therapies. Nine out of ten

reported having some knowledge of herbal remedies commonly used by their Latino

patients, while they had more knowledge about their patient’s use of OTC medications

and non-prescribed prescription drugs.

19 Four participants discussed how socioeconomic status, educational attainment, and level

of acculturation, as well as patients’ experiences with health care in their country of

origin, affect Latino patients’ health beliefs and practices. Among less acculturated

immigrants, said one doctor, “they first try herbal remedies, then they get antibiotics

from a friend, then they call me.” More traditional/less acculturated immigrants “are

more deferential; they will nod and say ‘yes’, but they don’t necessarily trust me.” The

physicians agreed that Kaiser Permanente members were more likely to believe in and

use Western medicine than traditional systems, possibly due to education, income,

acculturation, and their membership in a managed care plan. “Most of these folk illnesses

don’t come up in my patients, except some older or recent migrants,” said one physician.


27

“Most tend to be pretty Westernized; [they] have a Western mechanistic understanding

with various inflection points.”

Table 1. Physicians’ self-reported knowledge about Latino health beliefs & practices

Knowledge of Latino patients’ health beliefs (n = 9)

Health belief No

knowledge

Some

knowledge

Extensive

knowledge

Definition of health 8 1

Definition of illness 9

Causes of illness/disease 1 8

Help-seeking behaviors 1 8

Health decision-making 6 3

Role of spirituality in health 6 3

Knowledge of Latino patients’ use of TCAM (n = 10)

Traditional/alternative therapy No

knowledge

Some

knowledge

Extensive

knowledge

Herbal remedies 9 1

Traditional healers

(curandero, sobador, etc)

1 8 1

Alternative therapies

(acupuncture, chiropractic, etc)

8 2

Prayer, rituals, other spiritual

practices

1 6 3

Over-the-counter medications 6 4

Non-prescribed prescription drugs 7 3

Knowledge of Latino folk illnesses (n = 10)

Folk illnesses No

knowledge

Some

knowledge

Extensive

knowledge

Ataque de nervios (Nervous attack) 6 4

Empacho (Blocked bowel) 4 3 3


28

Caída de mollera (Fallen fontanel) 6 2 2

Mal de ojo (Evil eye) 2 4 4

Susto (Fright) 6 4

Caída de matríz (Fallen uterus) 2 4 4

20 Each physician provided a unique list of herbs, supplements, OTC, and/or non-prescribed

prescription drugs commonly used by their Latino patients (Table 2). The most frequently

mentioned herbs were manzanilla (Matricaria recutita), yerba buena (Mentha spp.), and sábila

(Aloe vera). Types of preparations included teas, shakes (with nopal), and alcoholic extracts

for internal or external use. Not all of the herbs or herbal products listed were considered

“traditional”; St. Johnswort (Hypericum perforatum) was considered a “Western” herbal

remedy that more acculturated Latinos learned about while living in the U.S. Similarly,

physicians believed that dietary supplements were more common among more

acculturated Latinos; these included chondroitin/glucosamine products, erectile

dysfunction products, Vitamin B12 injections, grapeseed oil, and multivitamins.

Table 2. Commonly used herbs among Latino patients listed by physicians.

Common name Latin Binomial Use (according to physician) # times

mentioned

Manzanilla/chamomile Matricaria recutita

3

Yerba buena/

spearmint

Mentha spicata

3

Sábila, aloe Aloe vera

3

Gengibre/ginger Zingiber officinalis Upper respiratory infections 2

Miel/honey

Upper respiratory infections 2

Limón/Lemon Citrus x limon Colds/flu 2

Linaza/flax seed Linus utisatissimum

2


29

Nopal/prickly pear

cactus

Opuntia spp. Diabetes 2

Tilia/linden flower Tilia spp.

2

Canela/cinnamon Cinnamomum verum Diabetes 1

Marijuana Cannabis sativa External rub for arthritis/

joint pain

1

Eucalypto/eucalyptus Eucaluptus spp. Upper respiratory infections 1

St. Johnswort Hypericum

perforatum

Depression 1

Ruda/rue Ruta graveolens

1

Cola de caballo/

horsetail

Equisetum spp. Diabetes, kidney pain 1

Arnica Arnica spp.

1

Uña de gato/cat’s claw Uncaria tomentosa

1

21 Physicians did not automatically consider OTC medications to be part of traditional

Latino health practices, but when asked about which OTC medications were common

among their Latino patients they mentioned. Vick’s Vapo-rub, cough syrups and non-

steroidal anti-inflammatory drugs (NSAIDs). When considering prescription drugs that

patients use without a prescription, five physicians mentioned antibiotics, three reported

oral and/or injected corticosteroids, and one said that some diabetic patients share

hypoglycemic medications with family members.

22 Physicians expressed different opinions about the safety and efficacy of traditional

remedies and therapies. One physician stated that she did not “think of acupuncture or

[a] chiropractor (sobador) as dangerous.” Two physicians expressed concern about the

safety of Chinese herbal medicines. Two physicians believed that honey, mint and ginger

were very effective for treating the common cold and recommended these to their

patients on a regular basis. Another felt that nopal and other herbs may not have

measurable physiologic effects, but patients who use natural remedies are often more


30

willing to make significant changes to their diet and lifestyle, which makes a difference

for patients with chronic diseases, such as diabetes. On the other hand, another physician

had experience with diabetic patients who used sweetened fruit smoothies containing

nopal, resulting in elevated blood glucose from the extra sugar, the opposite of the

intended therapeutic effect.

23 Physicians were more concerned with the misuse or mislabeling of pharmaceuticals. Six

of the participants considered the use of non-prescribed antibiotics to be a major problem

among Latinos (especially for viral infections), due to increased bacterial resistance and

the danger of home-administered injections. Four of the ten physicians mentioned

corticosteroids as a problem, either as injections for pain or allergies, or as an unlisted

ingredient in “natural” pain relief formulas obtained in Mexico. These products, said two

physicians, may also contain unlabeled NSAIDs, which posed a risk of gastric, hepatic or

renal damage. One also considered weight-loss products being sold in Latino communities

to be dangerous.

24 Six physicians could not think of any significant herb-drug interactions that they knew of

or had encountered in clinical practice. One mentioned the potential for reactions

between warfarin and ginkgo or between chondroitin-glucosamine and cholesterol

medications. Another physician mentioned St. Johnswort as posing a risk, as well as herbs

that interact with statin drugs. Two felt that the lack of regulation of herbal products and

supplements made it difficult to assess their safety or the risk of herb-drug interactions.

Attitudes and Communication Skills

25 All of the physicians described their way of communicating with their Latino patients

about their health beliefs and practices as open-minded and/or nonjudgmental. They

agreed that asking point-blank “what they think is going on” and “what they’re doing for

the problem,” including “anything natural,” was the best way to elicit information about

the patient’s explanatory model and use of TCAM. They reported that patients are usually

quite forthcoming with this information. “That’s where the ‘mal de ojo’ comes up. It’s not

usually their chief complaint, but it comes out when I ask them what’s going on.”

26 Three physicians emphasized the importance of understanding how patients understand

their illness, in part because the patient population is very diverse and health literacy

varies from person to person. One physician stated the following:

I always ask patients about how they understand their illness. Then we can tailor or

customize how much time I have to spend on health education. Because of time

issues, ‘tell me what you know about hypertension or diabetes’ is a good starting

point, to determine how much do they need to know.

27 Besides tailoring health education during initial patient visits, asking how the patient

understands his or her illness at follow-up visits was seen as important “because things

can get lost in translation and over time people develop their own understanding of their

own health.” One physician felt that asking about the patient’s perspective was most

important for psychosocial issues, where the problem was less clear-cut than physical

complaints.

28 Responding to patients’ information about TCAM in a nonjudgmental way was seen as the

best way to build trust with patients and keep the lines of communication open. A

participant reported:


31

I’ve learned that it’s important for me not to be critical. I usually let it roll by.

Unless I feel there’s a reason for me to tell them it’s dangerous, I usually don’t. If I

challenge what they use or the person they saw, it is counterproductive for me—it

reduces my credibility.

29 As long as the patient was not using something harmful, physicians usually did not

recommend that patients stop using TCAM:

I try and respond positively because in general it doesn’t help to come down on

them about it. I try to make sure it’s not dangerous and then say they can drink

their ‘whatever’ unless it’s something I know is directly harmful; a diabetic taking

fruit shake they have to stop, but if its nopales that’s ok. I try to let them continue

and incorporate that.

30 Physicians mentioned using online resources, such as Natural Standard, to look up the

evidence base on the safety and efficacy of herbal remedies. ”If there’s no evidence, my

usual spiel is that if you think it’s helpful, go ahead. But I tend to be an empiricist; I don’t

recommend unless there’s evidence.” Others were more open to the possibility that

traditional medicine may be effective: “I believe that 100s or 1000s of years of traditions

has some truth to the healing process.”

31 The frequency with which physicians asked about specific TCAM and conventional

therapies varied. Half of the participants rarely asked about herbal remedies or

traditional healers, while all of the physicians almost always asked about OTC and

prescription medications (Table 3).

Table 3. Self-reported physician frequency of asking about Latino patients’ TCAM and conventionaltherapies (n = 10)

Type of therapy or perception Rarely Sometimes Always

Herbal remedies 5 3 2

Supplements 1 5 4

Traditional healers 4 3 3

Alternative practitioners 3 4 3

Spiritual practices 7 2 1

Over-the-counter medications 10

Non-prescribed prescription drugs 1 9

Medication dosage 1 2 7

Side-effects related to drugs oralternative treatments

3 4 2

How the patient understands their illness 2 6 1

32 Providers differed in their frequency of incorporating TCAM into treatment plans. All of

the participants recommended diet and exercise sometimes or always However, half of


32

the participants had never recommended herbal remedies. Two sometimes recommended

herbs but only with patients who were already using natural products or who were

unwilling to use pharmaceuticals. “I throw in soothing things … if they don’t like

medications, or if they’re skeptical about Western medicine, or I know that it’s important

for their healing practice.” More common was referring to acupuncturists within the

Kaiser Permanente network or recommended relaxation techniques. No physicians had

ever recommended that a patient consult a traditional Latino healer (Table 4).

Table 4. Self-reported physician frequency of integrating preventive health practices and/or TCAMtherapies to the treatment plan (n = 10)

Practice/therapy Rarely Sometimes Always

Diet 2 8

Exercise 1 9

Herbal remedies 8 2

Supplements 3 4 3

Spiritual practices 4 4 1

Relaxation techniques 2 4 4

Referrals to traditional healers 10

Referrals to alternative practitioners 2 4 2

Discussion

33 All of the physicians described their attitude toward Latino patients regarding TCAM as

non-judgmental. The physicians believed that unbiased, direct questioning during

medical encounters resulted in open, honest responses from patients that allowed

physicians to make good medical decisions and offer appropriate patient education. Many

of the physicians reported having a fairly good to excellent understanding of Latino

health beliefs and folk illnesses, although others were less familiar. As a group, they

reported the least knowledge about herbal medicine. This indicates that although

physicians’ “cultural knowledge” was not always extensive, they considered their open-

minded attitude and direct communication style to be effective in working with Latino

patients. Research indicates that in addition to racial/ethnic concordance, good

communication skills between patients and physicians lead to better patient satisfaction

and treatment plan adherence 31.

34 Although the herbal remedies that physicians listed included many of the herbs

mentioned in research on Latino TCAM, 17,23,24,32,33, each physician mentioned a different

list, indicating a limited amount of knowledge spread over a wide spectrum. Some of their

familiarity with certain herbs may arise from clinical practice. For example, internists

who treat type 2 diabetic adults talked more about nopal (used as a hypoglycemic agent)


33

than other physicians. The pediatrician and family medicine doctors were more familiar

with folk illnesses that affect children, such as empacho and caída de mollera. A lack of

formal training or evidence-base for herbal remedies or supplements prevented some

physicians from recommending them to patients.

35 Physicians may have reported asking more about OTC and prescription medications and

having a better understanding of how Latino patients used these products because they

are more familiar with pharmaceuticals than with herbal medications. Similarly, while

physicians did not volunteer much knowledge about herb-drug interactions or dangerous

herbal remedies, they were worried about the misuse of antibiotics, corticosteroids,

NSAIDs, and weight-loss drugs. This concern may stem not only from the potency and

potential danger of these medications over herbs, but also from more physician

knowledge about these drugs.

36 While all of the physician participants identified somehow as Latino or Hispanic, they

have experienced multiple processes of acculturation that may have limited their

understanding and use of Latino health beliefs and practices. They all grew up and

attended medical school in the U.S., and for all but two, English was their first language.

37 Medical education in the US inculcates physicians with a scientific culture that

emphasizes objectivity and excludes many TCAM modalities 34. Although they had all

participated in some type of cultural competency training, none of the physicians had

extensive education in herbal medicine or other TCAM modalities. Increasing physician

knowledge about the safety, efficacy, and potential interactions of herbs may raise their

rate of asking about these remedies 35.

38 Physicians’ concerns with their Latino patients’ use of non-prescribed medications

highlight the importance of including these therapies in studies of Latino TCAM use.

Ethnopharmacology encompasses more than herbal remedies and traditional healing

practices by including studies of why and how people use and understand the mechanism

of modern pharmaceuticals 23. Socioeconomic barriers to health care, as well as cultural

beliefs about efficacy, and greater comfort using familiar medications from one’s native

country, are all factors that contribute to the self-prescription of antibiotics and other

drugs 36. In regards to antibiotics, besides their inefficacy against viral infections,

infectious disease specialists and public health officials are concerned with the rise in

antibiotic resistance resulting from inappropriate antibiotic use and point to the need for

culturally-appropriate interventions that target consumers as well as vendors of these

antibiotics 37. The literature does not include a discussion of problems with Latinos’

misuse of corticosteroids or NSAIDS for pain management, but physicians’ concerns point

to a need to research this issue.

39 The physicians’ open, nonjudgmental approach may help patients feel more comfortable

volunteering information about TCAM. While a physician’s attitude is important for

increasing patient comfort, studies indicate that physicians may also need to ask more

explicitly about TCAM and other health issues in order to elicit information 30,38. Some

physicians mentioned that unlike community-based clinics serving mostly recent, low-

income immigrants, Kaiser Permanente Latino members are more educated and

acculturated, and thus less likely to use TCAM. However, providers’ assumptions that

their patients do not use much TCAM may prevent them from asking regularly 30. Patient

data gathered in the second stage of this study will demonstrate if providers’ assumption

that Latino Kaiser Permanente members use less TCAM than lower-income Latino

patients matches patients’ actual rates of use.


34

Limitations

40 This research was limited by the questionnaire format; more open-ended questions and

audio recording of responses may have helped to capture physicians’ knowledge and

attitudes. The questions asked physicians to generalize about all Latinos, which did not

effectively capture the diversity of the patients they serve. Furthermore, the data is based

on self-reporting, rather than observations of physician behavior in clinical encounters,

so it is difficult to know if what providers say they do actually happens in clinical

practice.

41 Because these physicians all identify as Latino/a and work with a primarily Latino patient

population within a bilingual module, their cultural knowledge, communication skills,

and attitudes toward TCAM may not be representative of other groups of physicians

within Kaiser Permanente. As employees of a managed care organization, they may have

different clinical guidelines or time constraints than physicians working in other medical

contexts.

Conclusions

42 This study demonstrated that in regards to Latino patients’ health beliefs and TCAM,

physicians at Kaiser Permanente’s Salud en Español module consider their

communication style to be direct and their attitude open-minded. Their level of

knowledge about specific health beliefs and TCAM modalities varies from very low to

quite extensive, with the least amount of knowledge falling in the realm of herbal

remedies. The physicians’ primary safety concerns are not about herbs or traditional

healers, but about the misuse of non-prescribed prescription drugs, such as

corticosteroids and antibiotics. Rather than understanding and communicating more

about TCAM, physicians felt that developing skills to quickly assess the educational level

and health literacy of their patients would improve patient-provider communication and

lead to better health outcomes.

Acknowledgements

43 The authors would like to acknowledge the UC Global Health Institute (UCGHI) for

providing partial funding for the presentation and review of this work.

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ABSTRACTS

Understanding Latinos’ health beliefs and traditional, complementary and alternative medicine

(TCAM) practices, and improving cross-cultural communication skills may improve quality of

care and reduce health disparities. Although studies have examined the health beliefs and

practices of Latino patients, few have examined the knowledge, attitudes, and communication

skills of health care providers in regards to Latino TCAM use. This paper discusses the results

from 10 physician questionnaires, which form part of a larger mixed-methods study of patients

and physicians at a bilingual clinic at Kaiser Permanente in Oakland, California. Physicians had a

range of knowledge regarding health beliefs and practices common among Latinos, but all

reported an open and non-judgmental attitude during patient interactions and were permissive

of TCAM therapies they considered safe. Physicians believed that TCAM use decreased with

acculturation and varied by ethnicity, education and income. Physicians were more concerned

with the misuse of prescription drugs among Latino patients than the potential for herbal

toxicity or herb-drug interactions. The results indicate a need to include questions about

pharmaceuticals in future research on Latino health practices, and also point to the need for

research on how education, income and acculturation affect health beliefs and TCAM practices

within different Latino subgroups.

La compréhension des croyances des Latinos en matière de santé et de leur recours aux

médecines traditionnelle, complémentaire et alternative, et l'amélioration des compétences en

matière de communication interculturelle peut faire progresser la qualité des soins et réduire les

disparités dans le domaine de la santé. Plusieurs études se sont penchées sur les croyances et les

pratiques des Latinos en matière de santé mais peu se sont intéressées aux connaissances, aux

attitudes et aux aptitudes en communication des professionnels de santé à l'égard des médecines

TCA utilisées par les Latinos. Cette étude discute des résultats de 10 questionnaires complétés par

des médecins, qui font partie d'une étude à méthodologie mixte à grande échelle portant sur des

patients et des médecins d’une clinique bilingue du Kaiser Permanente à Oakland en Californie.

Les médecins ont montré qu’ils avaient un large éventail de connaissances concernant les

croyances et les pratiques liées à la santé répandues dans la communauté latino, et tous ont

rapporté une attitude ouverte et sans jugement pendant les entretiens avec les patients et se sont

montrés tolérants vis-à-vis des traitements traditionnels, complémentaires et alternatifs qu'ils

considéraient comme sans danger. Les résultats montrent que les médecins estiment que le

recours aux médecines TCA diminue avec l'acculturation et varie en fonction de l'ethnicité, de

l'éducation et du revenu. Les médecins sont davantage préoccupés par le mauvais usage que font

les patients latinos des médicaments prescrits que par le risque de toxicité des plantes ou des

interactions plantes-médicaments. Les résultats indiquent le besoin d'inclure des questions sur

les produits pharmaceutiques dans les futurs travaux de recherche sur les pratiques de santé des


38

Latinos, et pointent sur la nécessité d'étudier la manière dont l'éducation, le revenu et

l'acculturation affectent les croyances en matière de santé et le recours aux médecines TCA dans

les différents sous-groupes de Latinos.

Entender las creencias respecto a la salud, y las prácticas de medicina tradicional,

complementaria y alternativa entre los latinos, así como mejorar las habilidades de

comunicación interculturales, podrían mejorar la calidad de la atención y reducir las

desigualdades de salud. Aunque se han realizado estudios que han examinado las creencias y

prácticas relacionadas a la salud de los pacientes latinos, pocos se han centrado en el

conocimiento, las actitudes y las habilidades de los profesionales de la salud para comunicarse

respecto al uso de la medicina tradicional, complementaria y alternativa entre los latinos. Este

trabajo analiza los resultados de 10 cuestionarios médicos que forman parte de un estudio más

amplio (que utiliza distintos métodos) de pacientes y profesionales médicos en una clínica

bilingüe de Kaiser Permanente en Oakland (California). Los médicos contaban con conocimientos

sobre las creencias y prácticas de salud habituales entre los latinos, aunque todos ellos

manifestaban mantener una actitud abierta sin prejuicios durante las interacciones con los

pacientes y eran permisivos con las terapias de medicina tradicional, complementaria y

alternativa que consideraban seguras. Los profesionales médicos consideraban que dichas

prácticas disminuían con la asimilación cultural y variaban según la etnia, el nivel educativo y el

nivel de ingresos. A los facultativos les preocupaba más la mala utilización de las recetas de

medicamentos entre los pacientes latinos que la posible toxicidad de las hierbas o la interacción

entre medicamentos y hierbas. Los resultados indican que es necesario incluir preguntas sobre

productos farmacéuticos en futuros estudios sobre prácticas de salud entre los latinos, así como

resaltar la necesidad de investigar cómo la educación, el nivel de ingresos y la asimilación

cultural afectan a las creencias de salud y las prácticas de medicina tradicional, complementaria

y alternativa en los distintos subgrupos latinos.

INDEX

Mots-clés: Attitudes des médecins, Communication interculturelle, Compétences culturelles,

Disparités en matière de santé, Femmes latinos, Médecine complémentaire et alternative,

Médecine traditionnelle

Keywords: Complementary and alternative medicine, Cross-cultural communication, Cultural

competence, Health disparities, Latinas, Physician attitudes, Traditional medicine

Palabras claves: Actitudes de los médicos, Competencia cultural, Comunicación intercultural,

Disparidades de salud latinas, Medicina complementaria y alternativa, Medicina tradicional

AUTHORS

INGRID BAUER

BS, University of California, San Francisco, School of Medicine, 5441 Broadway, Oakland, CA

94618, [email protected]

JUAN J. GUERRA

MD, Kaiser Permanente Medical Center, Oakland, California


39


Does Intergenerational SolidarityBuffer the Negative Effects ofResidential Mobility?Evidence for U.S. Children

La solidarité intergénérationnelle atténue-t-elle les effets négatifs de de la

mobilité résidentielle ?Étude sur des enfants américains

¿La solidaridad intergeneracional neutraliza los efectos negativos de los cambios

de residencia?Pruebas sobre niños estadounidenses

Brian Joseph Gillespie

Introduction

1 The recent economic downturn has destabilized housing for low and middle-class

populations with the harmful effects of tighter housing budgets, refinancing, foreclosure,

etc. In addition to this, evictions and relocations are occurring with greater frequency

and forcing individuals to move. According to the Current Population Survey, about 37.1

million Americans (12.5% of the population) moved between 2008 and 2009 (U.S. Census

Bureau 2010). Among these movers, 67.3% relocated within the same county, 17.2%

moved to another county and 12.6% relocated across state lines.1 The relatively high

percentage of Americans (and particularly families with children) that relocates annually

continues to raise concerns for researchers and practitioners (Jelleyman and Spencer

2008; Ersing, Sutphen, and Loeffler 2009).

2 Especially in trying economic times, it is important to better understand the effects of

residential mobility on individuals and families. For the most part, research has shown

negative outcomes for residentially mobile children, yet to date, few studies have

advanced to help understand what factors might serve to cushion the negative effects


40

associated with residential mobility. For instance, to what extent can intergenerational

solidarity (i.e., parent-child closeness) offset the negative effects of moving for children?

3 Intergenerational solidarity has long been a major focus in the study of the family. The

parent-adolescent relationship, specifically closeness between parent and child, occupies

a central place in most conceptions of the socialization process. This is because the family

is one of, if not the primary, focus of emotional energy during adolescence. The main

focus of this paper is whether or not intergenerational solidarity helps to offset the

negative effects of moving on children.

Prior Research and Theory

Residential Mobility and Child Outcomes

4 Research widely focuses on two specific outcomes of mobility on children: academic

achievement and behavior problems. Scholars have consistently found that compared

with non-mobile children, mobile children experience significantly more behavior

problems, (Simpson and Fowler 1994; Haynie, South, and Bose 2006; Gillespie 2013),

poorer health outcomes (Gillespie and Bostean, 2013), as well as negative academic

outcomes, such as dropping out (Coleman 1988; Haveman, Wolfe, and Spaulding 1991;

South, Haynie, and Bose 2005), decreased academic performance (Ingersoll, Scamman,

and Eckerling 1989; Tucker, Marx, and Long 1998), and grade retention (Simpson and

Fowler 1994).

5 One possible reason given for the differences in outcomes between mobile and non-

mobile children is the loss of social capital experienced by both the child and the parents

in the move (Coleman 1988; Stack 1994; Pribesh and Downey 1999; Pettit and McLanahan

2003). Household characteristics that predict selection into migration can complicate the

picture, as moves can be instigated by family disruptions, such as divorce, that negatively

affect child outcomes (Astone and McLanahan 1994; Tucker, Marx, and Long 1998;

Norford and Medway 2002). At the same time, long-distance moves are more common for

families with higher levels of education and household income (Tucker, Marx, and Long

1998; Fischer 2002), which are positively related to child outcomes (Davis-Kean 2005).

6 Outside of individual and household predictors, such as marital disruption (Madigan and

Hogan 1991), the major debates on residential mobility and child outcomes have centered

largely on community and family support.

Community and Family Protective Factors

7 The most well-known way of measuring community and family protective factors is

through the transmission and maintenance of social capital, a concept that has been

popularized by James Coleman. Over the past two decades, Coleman’s (1988) work on

social capital has inspired scholars to view where a person lives as promoting the

formation and maintenance of social ties that are paramount in forming a child’s ability

to excel in educational settings. Coleman’s key point is that interactions between

individuals and institutions (i.e., parents, teachers, schools, and community) are

resources that provide children with assets that increase their abilities, achievement-

levels, and general welfare. These social and community ties are broken when a family

relocates, resulting in a loss of social capital. Negative effects may be even worse when


41

families relocate repeatedly: e.g., “…for families that have moved often, the social

relations that constitute social capital are broken at each move” (Coleman 1988: 113).

8 Coleman argues that the concentration of social interactions among parents, between

parent and child, and between parents and community institutions (e.g., school) close

intergenerational relations and, in turn, create pathways to the attainment of social

capital. He charges that moving erodes family and community ties to social capital and

that this has important and negative effects on child outcomes. However, it has not been

considered whether or not the parent-child bond (arguably the social capital dimension

least affected by a move) can serve to buffer the negative effects of broken social and

community-level ties after relocation.

Intergenerational Solidarity

9 Research on the effects of the parent-child relationship on child outcomes has, for the

most part, shown that high quality intergenerational relationships are beneficial for

children. For instance, Aseltine, Gore, and Colten (1998) found a significant relationship

between parent-child closeness and decreased depression and externalizing behavior

problems in children. Others (Conger, Ge, Elder, Lorenz, and Simons 1994) found that

positive parent-child relationships buffer the negative emotional and behavioral effects

of divorce on children. In a longitudinal study, Hair, Moore, Garrett, Ling, and Cleveland

(2008) found that adolescent intergenerational cohesion was associated with greater

young adult mental well-being. However, little is known about whether parent-child

closure can offset the negative effects of moving associated with loss of community-level

social capital.

10 Few people question the value of a strong parent-child relationship. Close

intergenerational bonding during adolescence has been linked to a number of positive

outcomes, such as fewer behavior problems (Aseltine, Gore, and Colten 1998; Hair, Moore,

Garrett, Ling, and Cleveland 2008) and higher educational attainment (Bronte-Tinkew,

Scott, and Lilia 2010). Again, it should stand that the parent-child relationship (ostensibly

the dimension of social capital left most intact after a move) will help to buffer the

negative effects of moving on children over and above parent-community and child-

community social capital.

11 The act of moving is a decision made almost completely by parents, albeit sometimes with

children’s interests a major concern. Further, the decision to move (and where to move)

is made almost completely by parents, and this decision is expected to have consequences

on children’s behavior and achievement. However, in the same respect, a strong parent-

child relationship might buffer the negative effects of community-based social capital

loss for parents and children alike.

Research Question and Hypothesis

12 Following from the research discussed in the previous section, the main research

question being considered is: does intergenerational solidarity moderate the relationship

between residential mobility and child academic and behavioral outcomes? It is expected

that since the parent-child relationship remains relatively intact it will offset the loss of

community-based social capital and negative behavioral and achievement effects after a


42

move. This research question linking mobility and child outcomes is tested with measures

for an extensive set of child and family characteristics and community-based social

capital.

Data and Methods

National Longitudinal Survey of Youth (NLSY) Information and

Sampling

13 The National Longitudinal Survey of Youth (NLSY79) is a longitudinal study of a

representative sample of 12,696 American men and women aged 14 to 21 in 1979. The

children of the female NLSY79 respondents are also surveyed biennially starting in 1986

and these NLSY79 Child and Young Adult data files can be linked with the original NLSY79

to assess intergenerational phenomena and outcomes. The present study utilizes data

only from the 2000, 2002, 2004, and 2006 survey waves because respondents’ residential

mobility was not assessed in the NLSY until 2000.The age ranges for children during the

2000 wave of interviews is from 5.83 – 15.17, and the ages of the mothers in the study

ranged from 36-40 at the time of the 2000 interview.

14 Multiple children are surveyed in each household, giving the NLSY a useful hierarchical

design. High response rates (between 85 – 90%) also contribute to the validity of the

analysis. This rate has been maintained because data are primarily collected in the

respondent’s home through face-to-face interviews. This study utilizes the records of

3,168 adolescent respondents.

Variables and Measures

Child Outcomes

15 Academic achievement was measured using the NLSY79 Child and Youth respondent’s 2000,

2002, 2004, and 2006 Peabody Individual Achievement Test (PIAT) scores. The PIAT is a

widely used measure of academic achievement for children. Since 1986, the children in

this study have been assessed biennially between ages five and 15. Each assessment

begins with five age-appropriate questions and progresses to more advanced concepts.

The reading recognition test measures word recognition and pronunciation ability, and

the math test measures basic math skills and concepts.

16 The behavioral problems measure was measured using Peterson and Zill’s (1986) Behavior

Problems Index (BPI). This index consists of 28 questions, drawn primarily from the

widely used Child Behavior Checklist (Achenbach and Edelbrock 1981) along with other

widely used child behavior scales. The respondent’s mother indicates whether a

statement about the child’s behavior is “often true,” “sometimes true,” or “never true.”

17 Because the purpose of this analysis is to assess the effects of moving and several other

theoretical predictor variables on changes in educational achievement and behavior

problems, it is important to use longitudinal data which includes measures of the

predictors and outcomes in a person-year format. This allows for consideration of social

capital for each survey wave in the analysis. Adequately controlling for past behaviors

before a move occurs is crucial; otherwise, associating changes in child outcomes after

moving cannot be done confidently. The sample consists of children who completed the


43

PIAT and BPI for the 1998 (baseline), 2000, 2002, 2004, and 2006 survey rounds. The PIAT is

administered starting at age five, and the behavior problems assessment begins at age

four; neither examination is recorded after age 15.

Control Variables

Individual and Household Characteristics

18 Individual and household characteristics include time variant variables, such as annual

household income, age, and whether or not a family change (e.g., marital disruption)

occurred between any of the survey waves. Dummy variables for marital status marked

whether or not a respondent’s parent was married, never married, divorced, remarried,

separated, or widowed across each survey wave. Time-invariant variables include the

child’s sex, birth order, mother’s age at child’s birth, mother’s highest year of education

completed (measured once in 2000), family structure (father in household or not), and the

number of children in the respondent’s household. Children were assigned to racial

groups based on the primary racial identification of their mothers as Black, Hispanic, or

Non-Black/Non-Hispanic. All other variables in the analysis vary across survey waves.

Social Capital

19 Interaction between parents and community institutions was measured using two variables:

how often a child’s parent volunteers at the child’s school reported as never or almost

never (0), once or twice a term (1), once a month (2), once or twice a month (3),or once a

week or more (4) (Morgan and Sørensen 1999), and, following Coleman (1988), a

dichotomous variable marking whether or not a child attends Catholic school.2

20 Interaction between child and community institutions was measured by whether or not the

child participates in extracurricular activities (White and Gager 2007); how often he/she

attends religious services as coded as about once a week (1), about once a month (2), a few

times a year (3), or never (4) (Parcel and Dufur 2001); and how often the child feels lonely

or wishes he or she has more friends as measured as being never or hardly ever (1),

sometimes (2), or often (3).

Key Independent Variables

21 The potentially disruptive act of residential mobility is captured by a variable marking

whether a respondent did not move (0), moved locally (1), or moved across city, county,

or state boundaries.

22 Intergenerational solidarity was measured by the level of closeness the respondent reported

feeling to his/her mother, reported as being not very close (1), fairly close (2), quite close

(3), or extremely close (4).

Analytic Strategy

23 Linear Mixed Modeling (LMM) was used to examine the moderation effects of

intergenerational solidarity on the relationship between moving and child academic and

behavioral outcomes. Models were run separately for each of these two child outcomes.


44

24 This study applied an upward two-step preliminary modeling procedure employed by

Singer and Willett (2003): (a) an unconditional means model, and (b) and unconditional

growth model.3 First, the unconditional means model is the preliminary verification for

whether LMM is appropriate for this analysis by partitioning the total variation in the

outcome variable (BPI or PIAT). The intra-class correlation coefficient (ICC) measures the

proportion of variance in the outcome variable that is due to between-children

differences rather than differences within children over time.

25 LMM is a flexible and powerful method for the analysis of longitudinal data. In LMM,

independent observations are not assumed, meaning that between-subject and within-

subject effects are both considered. This modeling structure is also flexible in its use of

missing information. Other models use listwise deletion of cases if a complete trajectory

is not available for an individual. LMM, on the other hand, accounts for all respondents in

the data set and is, therefore, arguably a better model for unbalanced panel data sets like

the NLSY where not every respondent is observed in every year. Lastly, LMM allows for

the analysis of hierarchically organized data. In this study, four models (A through D)

were tested on three levels using an LMM structure. The first of these three levels

consisted of households, the second was the individual child nested in each household

and the last level, time, was measured by interview round and nested within each child.

26 The Hausman specification test validated these models (results not shown). LMM assumes

that the dependent variable be conditionally normal. Shapiro-Wilkins, and Skewness/

Kurtosis testing (not shown), indicate that both dependent variables were distributed

reasonably normally. Stata estimated the fixed and random effects as well as the

reliability and correlation coefficients. Variance inflation factors were checked in order

to assess for severe multicollinearity in the model (average VIF: 1.24).Analysis of the

correlation matrix (not shown) indicates that none of the observed relationships between

the independent variables in the models were very strong.

Results

Sample Characteristics in 2000 (Valid N=3,168)

27 The average household income for families in the sample from the 2000 wave was

approximately $55,000 per year. The majority of the children in the sample (52%) were

boys, only a slightly larger percent than the entire NLSY population sample (51%). The

mean age of children in the sample at the time of the 2000 wave was 10.8 (SD= 2.45). Half

of the sample mothers identified as Non-Black, Non-Hispanic (50.44), 28.6% identified as

Black, and 20.9% identified as Hispanic.

28 About three-fourths of the sample (75.82%) did not move while 15.27% moved locally and

8.91% moved across city, county, or state lines. The sample statistics on mobility are

reasonably consistent with recent reported rates of residential mobility in the United

States (U.S. Census Bureau, 2010).


45

Academic Achievement

29 For each dependent variable, four models were tested on three levels using a LMM

structure. Table 1 presents a summary of the series of theoretically important variable

cluster models fitted to the data on academic achievement.

Table 1. Intergenerational Solidarity, Residential Mobility, and Child Academic Achievement.

+ p <.10, * p <.05, ** p <.01, *** p < .001.

30 Model A in Table 1 shows a test of the main effects on achievement. The results suggest

that there is a significant positive relationship between the child’s reported closeness to

mother and his/her achievement. There is also a significant association between

residential mobility and achievement. Sex is not a significant predictor of achievement at

this level of the model.

31 In Model B, the main effects included in Model A are being tested with the inclusion of

interaction terms between residential mobility and intergenerational solidarity as well as

a triple interaction effect for residential mobility, intergenerational solidarity, and sex.

The only significant interaction term in this model is the three-way interaction term

with gender. This indicates that the relationship between parent-child closeness and

residential mobility is conditioned by the child’s sex.

32 Model C was the first theoretical model in which household and individual-level

characteristics were added to the model that includes the interaction effects. In Model B,

the added variables include age, Black, Hispanic, household income, family structure

(father in household), number of children in the household, birth order, mother’s age at

birth of child, mother’s education, whether or not a marital disruption (divorce or

separation) took place between survey waves, and a dummy variable for never married.


46

33 The results of this model also imply that mother’s age at child’s birth and her education

level are positively associated with the respondent’s academic achievement score when

all other modeled variables are controlled. As expected, the baseline PIAT score is a

significant and positively associated predictor of later academic achievement. The linear

age term remains significant, indicating that academic achievement scores decrease over

time. The triple interaction term also remains significant in this model.

34 The full and final model, Model D, includes measures of individual and household

characteristics as well as controls for community-level social capital. The added variables

are for parents’ classroom volunteering frequency and the respondent child’s Catholic

school attendance (parent/child-community connectivity); the child’s participation in

extracurricular activities, religious service attendance, and child’s self-reported level of

loneliness (child-community connectivity). When included in the model, only

participation in extracurricular activities significantly predicts academic achievement

levels above and beyond the effects of individual and household characteristics. However,

the three-way interaction among residential mobility, intergenerational solidarity, and

child’s sex is significant at the .05 level. The considerable decrease in information

criterion fit statistics (Table 2) clearly indicates that the final model is a significantly

better fit than all prior models.

Table 2. Fit Statistics of Linear Mixed Models

Notes: When analyzing fit of nested models, the test of significance for likelihood ratio testing is a X2

test with degrees of freedom equal to the difference in the number of parameters between themodels. If two models are not nested they can be compared using Akaike Information Criterion (AIC)and/or the Bayesian Information Criterion (BIC). Only the preliminary models were compared usingLRT. A decrease in AIC and BIC scores between non-nested models is an indication of better fit.


47

Behavior Problems

35 Similar to academic achievement, analysis was run using the BPI as a dependent variable

in four models on three hierarchical levels (time within children and children within

households). Table 3 shows the prediction of behavior problems in these four steps:

Model A shows only the main effects modeled against behavior problems, Model B then

adds the key interaction terms of interest, Model C adds adjustment for individual and

household characteristics, and Model D adds the series of controls for community-based

social capital.

Table 3: Intergenerational Solidarity, Residential Mobility, and Child Behavior Problems

36 With regard to the nature of the relationship between the main effects and behavior

problems, Model A in Table 3 shows only a marginally significant positive relationship

between residential mobility and the respondent child’s BPI score with the lagged BPI

baseline in the model (.059). The respondent’s reported closeness to his/her mother is

negatively associated with behavior problems. Being a male is shown to be a positively

associated significant predictor of child behavior problems.

37 Model B in Table 3 adds relevant interaction terms into the model. The coefficient for

residential mobility x intergenerational solidarity is significant at the .05 level. Model C

includes measures for individual and household characteristics. Intergenerational

solidarity is the only significant predictor of behavior problems in this model. No

interaction terms between solidarity and mobility are significant in this model. The final

behavior problems model, Model D, includes individual- and household-level predictors

as well as controls for community-based social capital (in order to isolate the effects of

intergenerational social capital). This model shows significant negative effects for


48

intergenerational solidarity and also the interaction between intergenerational solidarity

and residential mobility on behavior problems. Therefore, closeness to mother is a

significant predictor of behavior problems and these effects increase after a residential

move takes place (locally or across distance).

38 Residual plotting for both behavior problems and academic achievement models revealed

constant variance and indicated that neither model’s residual errors deviate from a

normal distribution. Additional diagnostics plotting the best linear unbiased predicted

values (BLUPs) for random effects did not provide evidence of extremely unusual random

child or household effects in either model.

Discussion

39 The current study tested the moderation of intergenerational solidarity on the

relationship between residential mobility and adolescent outcomes. It was hypothesized

that intergenerational solidarity and residential mobility would interact to significantly

affect adolescent behavior and achievement above and beyond other theoretically

important variables (including measures for other dimensions of social capital).

40 To test these hypotheses with the greatest rigor, a longitudinal analysis was conducted

that involved four conditional growth models incorporating clustered theoretically

important variables (i.e., individual/household characteristics and community-based

social capital). In light of mixed research on the relationship between social capital and

residential mobility effects for children, it was important to analyze how the parent-child

relationship might cushion the effects of mobility and attendant loss community-based

social capital.

41 It was expected that the parent-child relationship would significantly buffer the negative

academic and behavioral effects of moving on children. This is because the

intergenerational form of social capital is arguably the one dimension of capital to remain

relatively intact once a move takes place. This hypothesis is supported by this research.

42 The effect in Model D, Table 3, shows a significant positive association between behavior

problems and an interaction between residential mobility and intergenerational

solidarity. Controlling for all other theoretically important variables, intergenerational

solidarity is a significant predictor of behavior problems, and this is especially so after a

residential relocation takes place. For academic achievement, this association holds but

only when conditioned by gender.

43 These analyses are subject to several caveats. Measuring child outcomes across only four

waves of this longitudinal survey does not allow for analysis of behavior and achievement

to the extent that the relationship between residential mobility and academic

achievement and/or behavior problems takes longer than two, four, or six years to

develop.Reverse causation may also be present in the models above. For instance,

problem behavior may cause children to have distant relationships with their parents.

Also, because only the children of NLSY female respondents are surveyed, father-child

and father-community interaction (other than what is reported by the mother) cannot be

assessed as a component of intergenerational solidarity or community-based social

capital. The information available for a child’s mother is not necessarily available for the

child’s father. Moreover, because of the NLSY design, children raised in single-father

homes are not included in the sample. With the rise of joint custody arrangements, this is


49

an important limitation to this study, if only because this study’s main focus is on the

parent-child relationship.

Conclusion

44 The effect of moving on child outcomes was successfully modeled with a hierarchical

design to compensate for time as it is nested within children and children nested within

households. Intergenerational solidarity significantly interacts with residential mobility

to predict adolescent behavior and achievement outcomes. As such, intergenerational

solidarity is one dimension of social capital that needs purposeful consideration in

residential mobility research because it appreciably offsets negative child academic and

behavioral outcomes.

45 The findings of the current study are important in a number of ways. First, the data show

that intergenerational solidarity does significantly offset the negative behavioral and

achievement effects of residential mobility, even when controlling for the effects of

individual/household-level variables and community-level social capital. Second, the

research indicates that in a study of child outcomes, generally, there are different

significant predictors and interactions for behavior problems than there are for academic

achievement in adolescence even though prior researchers had posited similarly negative

effects of moving on a range of child outcomes (Coleman 1988; Hendershott 1989; Hagan,

MacMillan, and Wheaton 1996; Norford and Medway 2002).

46 Moving is difficult—it is arguably one of life’s most stressful commonly occurring events.

Residentially mobile children, especially those who move frequently, are at a risk for a

host of negative behavioral and academic outcomes. However, these potentially harmful

effects may be forestalled by social services and policy commitment to help mobile

children and families adjust to their new schools and communities. These approaches to

intervention are based on a multidisciplinary effort that would include social workers,

educators, school administrators, and the community at large.

47 In other words, community leaders and other practitioners ought to be mindful of these

effects and help to improve parent-community and child-community social capital,

especially among mobile and hypermobile families. For instance, community health

practitioners might facilitate community-based functions that provide opportunities for

recent “transplants” to network—this would be especially beneficial for high-mobility

communities.

48 At the same time, community and school involvement for residentially mobile families

relies, at least in part, on whether or not the school community reaches out to involve

them and help them adjust. Thus, school-based services focused on residentially mobile

individuals and families would help encourage parental involvement in school activities

and functions. People will never stop moving—but helping integrate mobile families into

their destination communities is a good start at alleviating the negative social,

behavioral, and academic effects of residential mobility on children.


50

Acknowledgments

49 The author would like to thank the Center of Expertise on Migration and Health, Michael

Rodriguez, and David Lopez-Carr for their advice and comments on earlier drafts of this

manuscript.

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NOTES

1. A large portion of the mobility rate in America can be accounted for by a subpopulation of

hypermobile households (Clark and Davies-Withers 2007). Therefore, these CPS figures might

underestimate rates of residential mobility because these figures do not reflect multiple moves

made by those who moved more than once within a year.

2. Coleman argues that Catholic school is indicative of social ties in the larger community that

are based on members’ religious affiliation.

3. The preliminary models confirmed significance for each dependent variable and are not

presented in the tables.

ABSTRACTS

This longitudinal study examines the moderation effects of parent-child closeness on residential

mobility and two important adolescent outcomes. Children’s behavior problems and academic

achievement test scores were compared across four survey waves of the National Longitudinal

Survey of Youth (2000, 2002, 2004, and 2006) and matched to data from their mothers' reports

from the National Longitudinal Survey of Youth 1979. The results suggest that controlling for

other dimensions of social capital (i.e., child-community and parent-community), the negative

behavioral effects of moving are buffered by the reported level of emotional closeness to one’s

parent. That is, the closer a child reports being to his/her parent, the fewer behavior problems

this child will experience following relocation. Furthermore, the negative academic effects of

moving are moderated by intergenerational solidarity and conditioned by sex. This indicates

that the reported level of parent-child closeness (vis-à-vis residential mobility) is significantly

altered by sex for achievement outcomes.

Cette étude longitudinale examine les effets de modération de la proximité parent-enfant sur la

mobilité résidentielle et deux résultats importants liés aux adolescents. Les problèmes

comportementaux des enfants et leurs performances scolaires ont été comparés d'après les

résultats de quatre vagues d'enquête du National Longitudinal Survey of Youth (2000, 2002, 2004,

et 2006), et appariés aux résultats d’une enquête conduite auprès de leurs mères, le National

Longitudinal Survey of Youth 1979. Selon les résultats, et en tenant compte des autres

dimensions du capital social (à savoir communauté des enfants et communauté des parents), les

effets comportementaux négatifs de la mobilité sont atténués par le degré rapporté de proximité

affective avec un parent. En effet, plus un enfant se dit proche de son père/sa mère, moins il aura

de problèmes comportementaux après un déménagement. De plus, les effets négatifs de la

mobilité sur les résultats scolaires sont pondérés par la solidarité intergénérationnelle et


53

conditionnés par le sexe. Cela indique que le degré de proximité parent-enfant rapporté (vis-à-

vis de la mobilité résidentielle) est considérablement influencé par le sexe en ce qui concerne les

résultats scolaires.

El presente estudio longitudinal examina los efectos de moderación que la cercanía entre padres

e hijos tiene sobre el cambio de residencia y dos importantes resultados entre los adolescentes.

Se han comparado los problemas de comportamiento y las calificaciones académicas de los niños

en cuatro fases del Estudio Longitudinal Nacional de Juventud (2000, 2002, 2004 y 2006) y se han

contrastado los datos con la información que facilitaron las madres en dicho estudio en 1979. Los

resultados sugieren que, si se controlan otras dimensiones del capital social (es decir, comunidad

infantil y comunidad de padres), los efectos negativos sobre el comportamiento que tiene el

mudarse se ven contrarrestados por el nivel de cercanía emocional con los progenitores. De tal

modo, cuanto más cercano admite un niño estar de sus padres, menores serán sus problemas de

comportamiento tras la reubicación. Así mismo, los efectos académicos negativos que conllevan

los traslados se ven aminorados por la solidaridad intergeneracional y además están

condicionados por el sexo. En este aspecto, el nivel de cercanía que se afirma tener entre padres e

hijos (con respecto al cambio de residencia) varía significativamente según el sexo en cuanto a

resultados académicos.

INDEX

Palabras claves: Adolescencia, Cambio de residencia, Capital social, Problemas de

comportamiento, Resultados académicos, Solidaridad intergeneracional

Mots-clés: Adolescence, Capital social, Mobilité résidentielle, Problèmes comportementaux,

Résultats scolaires, Solidarité intergénérationnelle

Keywords: Academic Achievement, Adolescence, Behavior Problems, Intergenerational

Solidarity, Residential Mobility, Social Capital

AUTHOR

BRIAN JOSEPH GILLESPIE

Ph.D., Assistant Professor, Department of Sociology, Sonoma State University, 1801 E. Cotati

Avenue, Rohnert Park, CA 94928, e-mail: [email protected]


54


Demographic and migration-relatedrisk factors for low-level smoking ina farm working sample of Latinos(the MICASA study)Facteurs de risque démographiques et liés à l'immigration d'un échantillon

d’ouvriers agricoles latinos (étude MICASA)

Factores de riesgo relacionados a demográfia y migración en un grupo muestra

de trabajadores agrícolas latinos que fumaban poco (el estudio MICASA)

Erik J. Rodriquez, Maria T. Stoecklin-Marois, Tamara E. Hennessy-Burt,Daniel J. Tancredi and Marc B. Schenker

Background

1 The most preventable cause of death in the U.S. is cigarette smoking (Mokdad, Marks, et

al., 2004, Mokdad, Marks, et al., 2005). In national and regional surveys Latinos have been

found to smoke at a lower rate than non-Latino Whites and non-Latino Blacks. The

national estimate of smoking prevalence among adult Latinos is 14.5% compared to 22.1%

of non-Latino Whites and 21.3% of non-Latino Blacks (Centers for Disease Control and

Prevention, 2010). Rates of smoking among Latinos have been found to differ by sex,

ethnicity, and acculturation level. Nineteen percent of Latino men smoke compared to

only 9.8% of Latino women (Centers for Disease Control and Prevention, 2010). Among

Latino ethnic groups, rates of smoking are highest among Puerto Ricans and lowest

among Central Americans (Perez-Stable, Ramirez, et al., 2001). Among Latino women,

higher levels of acculturation are associated with increased smoking (Markides, Coreil

and Ray, 1987, Marin, Perez-Stable and Marin, 1989, Haynes, Harvey, et al., 1990, Coreil,

Ray and Markides, 1991, Samet, Howard, et al., 1992, Palinkas, Pierce, et al., 1993, Cantero,

Richardson, et al., 1999, Coonrod, Balcazar, et al., 1999, Sundquist and Winkleby, 1999,


55

Acevedo, 2000). However, associations between acculturation and smoking among men is

less consistently reported (Bethel and Schenker, 2005).

2 More recently, studies have examined the phenomenon of low-level smoking, defined as

smoking one to five cigarettes per day (CPD) on average. A daily smoker is someone who

reports smoking every day while a non-daily smoker reports smoking only some days.

Among adult smokers in the U.S., Latinos are much more likely than non-Latinos to be

low-level daily smokers (Trinidad, Perez-Stable, et al., 2009). In California, 70% of Latino

smokers are either low-level or non-daily smokers (Zhu, Pulvers, et al., 2007). Further, the

number of cigarettes smoked per day is lower for Latinos. Nationally, Latino smokers on

average smoke 6.7 CPD compared to 14.9 CPD for non-Latino White smokers and 9.3 CPD

for non-Latino Black smokers (Substance Abuse and Mental Health Services

Administration, 2006). Smoking among Latino farm worker populations has been found to

be predominantly low-level smoking (Gamsky, Schenker, et al., 1992, Garcia, Matheny

Dresser and Zerr, 1996).

3 Research on the prevalence of low-level smoking in the U.S. is limited. Even less data exist

on the characteristics, risk factors, and public health significance of low-level smoking

(Reitzel, Costello, et al., 2009). The purpose of this study was to characterize low-level

smokers and identify demographic, migration-related, and psychosocial risk factors for

low-level smoking in a population of Latino farm workers in California.

Methods

Study Design and Recruitment

4 The Mexican Immigration to California: Agricultural Safety and Acculturation (MICASA)

study is a prospective cohort study conducted among Latino hired farm worker families

(Stoecklin-Marois, Hennessy-Burt and Schenker, 2011). Sampling consisted of households

residing in the town of Mendota, located in the San Joaquin Valley of California. Mendota

was chosen for its large proportion of agricultural workers and Latino immigrants (U.S.

Census Bureau). A two-stage stratified area probability sampling design was used. In the

first step census blocks were randomly selected from a list of all census blocks in Mendota

and enumerators walked door-to-door to map out all dwellings in 62 selected census

blocks. In the second step enumerators acquired demographic information about adult

individuals residing in each dwelling including age, sex, years lived in Mendota, and

involvement in agricultural work. Households that contained at least one hired farm

worker were randomly ordered and contacted sequentially for recruitment. Further

details regarding the sampling design methods and recruitment of participants have been

described previously (Stoecklin-Marois, Hennessy-Burt and Schenker, 2011).

Informed Consent

5 Prior to obtaining written informed consent, a verbal and written description of the study

objectives and procedures were provided to each participant. The study description and

written informed consent were provided in Spanish, the primary language of

participants. All study procedures were approved by the University of California, Davis

Institutional Review Board.


56

Participant Eligibility

6 Men and women were eligible to participate in the study if they were 18 to 55 years of

age, self-identified as Mexican or Central American, resided in Mendota at the time of the

baseline interview, and worked or had a household member who worked in agriculture

for at least 45 days in the last year. Eligibility for the present analysis included

completion of both the baseline and follow-up interviews.

Rates of Participation

7 From these households, 803 participants completed the baseline interview and 620 (77.2%

) subsequently completed the follow-up interview. For individuals who were not

recruited, reported reasons for not participating included distrust, no time or interest,

and unwillingness to disclose personal information.

Data Collection and Questionnaire Instruments

8 The recruitment and baseline interviews of participants were conducted between January

2006 and April 2007. Participant follow-up interviews were conducted between November

2008 and February 2010. Both the baseline and follow-up questionnaires were

interviewer-administered in Spanish and most interviews were conducted in the

participant’s home. Both the baseline and follow-up interviews assessed demographic

characteristics, work history, smoking and psychosocial factors. Migration-related factors

were assessed only at the baseline interview and frequent mental distress was assessed

for the first time at the follow-up interview.

Demographic Characteristics and Migration-Related Factors

9 Demographic characteristics assessed included participant sex, date of birth, marital

status, educational attainment, annual household income, and number of years worked in

agriculture. Migration-related factors included country of birth, age at immigration to

the U.S., number of years lived in the U.S., and acculturation level. In order to better

capture the multi-dimensionality of an individual’s level of acculturation, the revised

version of the Acculturation Rating Scale for Mexican Americans (ARSMA-II) was used

(Cuellar, Arnold and Maldonado, 1995). Two acculturation level categories were

established: low and medium or high (medium/high).

Smoking-Related Outcomes and Low-Level Smoking

10 Questions from the ATS-DLD-78-A were used to assess cigarette smoking (American

Thoracic Society). Participants who reported ever smoking at least 100 cigarettes (5

packs) in the follow-up interview were classified as smokers. Those who reported

smoking a cigarette within the past 30 days of the follow-up interview were identified as

current smokers. Current smokers were then classified as either low-level smokers,

defined as individuals smoking one to five CPD on average since they began smoking, or

individuals smoking 6+ CPD on average according to the follow-up interview. Both

smoking groups included daily and non-daily smokers. Individuals who met the criterion


57

for smoking but had not smoked a cigarette within the past 30 days were categorized as

former smokers.

11 Three participants were excluded from the analysis because their smoking status at the

follow-up interview could not be determined. These three participants reported current

smoking at the baseline interview but never smoking at the follow-up interview. Three

additional participants were missing data for the age that they last smoked cigarettes.

These data were imputed by subtracting the number of years since each participant quit

smoking cigarettes from that participant’s age at the follow-up interview.

Psychosocial and Quality of Life Factors

12 Among the psychosocial factors assessed in the baseline interview were depressive

symptoms, perceived stress, family support, and nervios. Depressive symptoms were

assessed using a validated screening instrument developed from questions on the Center

for Epidemiologic Studies Depression Scale (CES-D) and the Diagnostic Interview Schedule

(DIS) from the National Institutes of Mental Health (Burnam, Wells, et al., 1988). Items

were coded according to the method by Burnam and colleagues later creating a

probability of depressive symptoms. The Perceived Stress Scale questions were rated on a

Likert scale and included the following: “how often have you dealt successfully with daily

problems and hassles?”, “how often have you coped well with important changes that

were taking place in your life?”, “how often have you felt confident about your being able

to handle your personal problems?”, “how often have you been able to control your anger

in your life?”, “how often have you felt that you were on top of things?”, and “how often

did you feel that things were going well?” (Cohen, Kamarck and Mermelstein, 1983).

13 The assessment of family support was based upon seven items from the Provisions of

Social Relations Scale and consisted of the following statements: “no matter what

happens, I know that my family will always be there for me should I need them”, “I’m not

sure if I can completely rely on my family”, “my family lets me know they think I’m a

worthwhile person”, “people in my family have confidence in me”, “people in my family

provide me with help in finding solutions to my problems”, “I know my family will always

stand by me”, and “I know I can count on my family for financial assistance should I need

it” (Turner, Frankel and Levin, 1983). Cronbach’s alpha coefficients for perceived stress

and family support were 0.80 and 0.88, respectively. Scores for both perceived stress and

family support were created by summing responses for each item; with higher scores

indicating higher levels of stress and family support. These scores were then

dichotomized by using the mean and/or median as a cut-off point. Scores above this

established cut-off point were designated as having a “high” level of perceived stress or

family support.

14 A culturally-specific condition known as nervios was assessed. Nervios has been

previously described as a generalized condition of distress that can be expressed with

somatic and psychological symptoms (Salgado de Snyder, Diaz-Perez and Ojeda, 2000).

Participants were classified as having nervios based upon an affirmative response to the

question “sometimes in your life, have you ever suffered from nervios?”. Fair or poor

(fair/poor) self-rated health and frequent mental distress were assessed using the

Healthy Days Core Module of the Health-Related Quality of Life instrument from the

Centers for Disease Control and Prevention (CDC HRQOL – 4) (Centers for Disease Control

and Prevention).


58

Statistical methods

15 Univariate analyses were performed on all variables by calculating means, medians, and

standard deviations for continuous variables and frequencies and proportions for

nominal and ordinal variables. Bivariate analyses examined smoking outcome variables

by each predictor of interest. One-way analysis of variance F-tests and chi-square tests for

association were used to assess statistical significance by smoking group for continuous

and categorical study variables, respectively. Multinomial logistic regression was used to

model low-level smoking and smoking 6+ CPD, separately, against the reference category

of never and former smoking combined (never/former smoking). Survey data analysis

procedures for logistic regression analyses were used to adjust confidence intervals and

hypotheses tests for the probability sampling design. All analyses were performed using

Statistical Analysis Software, Version 9.2 (SAS Institute Inc., Cary, North Carolina).

Results

16 Since patterns of smoking differ between men and women, analyses of demographic

characteristics were stratified by sex. Mean age of participants at the follow-up interview

was 40.8 years, but men tended to be older than women (p<0.01) (Table 1). The cohort

was roughly balanced by sex with 45% men and 55% women. Although 95% of the cohort

was married or living with someone at the follow-up interview, a significantly larger

proportion of women reported being single, divorced, separated, or widowed (p<0.01).

Women were more educated than men; 39% of women versus 29% of men had completed

a higher than primary school education (p=0.03). Average annual incomes were low in the

population with over three fourths of participants reporting household incomes <$30,000.

17 One hundred percent of men versus 83% of women ever worked in agriculture (p<0.0001;

data not shown). Additionally, men had significantly more work experience in agriculture

than women with men reporting an average of 17.7 years compared to 10.5 years for

women (p<0.0001).

18 Sixty-eight percent of participants were born in Mexico and 29% of participants were

born in either El Salvador or another Central American country. Overall, the average

number of years lived in the U.S. was 15.6 and men had a longer residency than women

(18.4 vs. 13.5 years, p<0.0001). Men immigrated to the U.S. 2.5 years earlier, on average,

than women. Despite men immigrating earlier and living in the U.S. longer, men and

women did not differ significantly by acculturation level. The vast majority of both sexes

were classified with a low level of acculturation.


59

Table 1. Description of the study cohort at the follow-up interview (2008-2010).

19 The prevalence of cigarette smoking at follow-up was low; 7% of participants were

current smokers and 12% were former smokers (data not shown). Both current smoking

and former smoking were more prevalent among men than women (12% versus 4% and

21% versus 4%, respectively; p<0.0001). Sixty-one percent of current smokers compared to

38% of former smokers were low-level smokers (p=0.02). Relationships on smoking

behavior among former, low-level, and 6+ CPD smokers showed no differences in the age

individuals began smoking or the number of years smoked prior to immigration to the

U.S. (Table 2). Participants who started smoking after immigrating to the U.S. were coded

as having zero years smoked prior to immigration to the U.S. However, low-level smokers

smoked fewer CPD than either former smokers or those who smoke 6+ CPD (p<0.0001).

Additionally, the number of years smoking and pack years differed significantly across

the groups, with former smokers reporting the shortest number of years smoking and

low-level smokers reporting the smallest number of pack years (p<0.0001). Low-level

smokers also smoked significantly fewer days in the past month than those who smoke 6+

CPD (p=0.04).


60

Table 2. Smoking behavior among former smokers, low-level smokers, and those who smoke 6+cigarettes per day (CPD).

20 A larger proportion of women were never/former smokers than men (p<0.01) (Table 3).

The proportion of never/former smokers who were foreign born was larger than the

proportion of low-level smokers who were foreign born, which were both larger than the

proportion of those who smoke 6+ CPD who were foreign born (p=0.045).

Table 3. Demographic and migration-related characteristics of never and former smokerscombined, low-level smokers, and those who smoke 6+ cigarettes per day (CPD).

21 Multinomial logistic regression models adjusted for age and sex examined associations

between demographic and quality of life factors with low-level smoking and smoking 6+

CPD compared to never/former smoking (Table 4). Compared to currently married

persons, single, divorced, widowed, or separated participants were relatively more likely

to be low-level smokers than never/former smokers (relative rate ratio = 5.04, 95% CI: 1.43

– 17.70). Additionally, experiencing frequent mental distress was associated with a

greater than threefold higher relative rate of being a low-level smoker (relative rate ratio

= 3.47, 95% CI: 1.03 – 11.64).

22 Medium/high acculturated participants were more than six times relatively more likely

than low acculturation participants to smoke 6+ CPD (relative rate ratio with respect to

never/former smoking prevalence = 6.41, 95% CI: 1.23 – 33.39) (Table 4). Similar to the

results for low-level smokers, those experiencing frequent mental distress were more


61

than four times relatively more likely to smoke 6+ CPD than to be never/former smokers

(relative rate ratio = 4.07, 95% CI: 1.31 – 12.69). Compared to others, individuals with more

than fifteen years residing in the U.S. were more than two and a half times relatively

more likely (with respect to never/former smoking) to be low-level smokers (relative rate

ratio = 2.60, 95% CI: 1.15 – 5.88) and more than three times relatively more likely of

smoking 6+ CPD (relative rate ratio = 3.75, 95% CI: 1.12 – 12.57).

Table 4. Crude and adjusted odds ratios and 95% confidence intervals (CI) for low-level smokingand for smoking 6+ cigarettes per day (CPD) when compared to never and former smokingcombineda

Discussion

23 The present analysis was one of the first to investigate the characteristics and risk factors

of low-level cigarette smoking in a cohort population of Latino farm worker families.

These results illustrate that, among Latino farm workers, low-level smokers can be

described as having different characteristics than other types of smokers. First, current

smokers are more likely to be low-level smokers than smoke 6+ CPD. This is an important

finding with the potential to impact public health education and smoking cessation

programs. Second, low-level smokers do not smoke as many days during the month as

those who smoke 6+ CPD. Third, the number of years a low-level smoker has smoked was

lower than that of those who smoke 6+ CPD and higher than that of former smokers.

These results are noteworthy because it may be an indication that low-level smokers

increase the number of cigarettes they consume over time.

24 Coinciding with previous research, low-level cigarette smoking is very common among

Latino farm workers who currently smoke. A study conducted in Indiana among Latino

farm workers found that over 75% of smokers smoked less than 10 CPD (Garcia, Matheny

Dresser and Zerr, 1996). In California, the median number of cigarettes smoked per day by

male and female farm workers were 5 and 3, respectively (Gamsky, Schenker, et al., 1992).

This finding improves our understanding of the smoking behaviors of Latino farm

workers who smoke--that current smokers are more likely to be low-level smokers than 6

+ CPD smokers, and is useful to designers of public health education and smoking

cessation programs.


62

25 Statewide, representative data in California has shown that the prevalence of daily low-

level smoking among Latinos in the general population is between 16% and 22% (Zhu,

Pulvers, et al., 2007). However, among non-daily Latino smokers the prevalence of low-

level smoking is between 80% and 85%. In the present analysis, we could not clearly

identify daily and non-daily smokers because smokers were not asked whether they

smoke “every day” or “some days”. However, the prevalence of smoking 30 days in the

past month among low-level smokers was 54% and among those who smoke 6+ CPD was

83% (p=0.04). This would indicate that low-level smokers in the present analysis are non-

daily smokers. Not only is the prevalence of low-level smoking high among Latinos, but

Latinos have been found to have increased odds of low-level smoking compared to Blacks

or Asian/Pacific Islanders. Using nationally representative data, from the Tobacco Use

Supplement of the Current Population Survey, Trinidad and colleagues estimated that

Latinos have 4.6 higher odds of being low-level daily smokers compared to Non-Latino

Whites (Trinidad, Perez-Stable, et al., 2009).

26 The characteristics and risk factors of low-level smoking in the Latino population have

not been well established in the literature. One study examining low-level smoking

attempted to understand the associations of demographic characteristics, tobacco

dependence, withdrawal, and cessation with low-level smoking among Latinos from a

randomized clinical control trial (Reitzel, Costello, et al., 2009). Research into the

characteristics and risk factors of low-level smoking among other ethnic groups is limited

to a few studies that examined associations with smoking ≤10 CPD. Among African

Americans, smoking ≤10 CPD in young adulthood has been linked to factors in late

adolescence such as perceived discrimination, peer smoking, and youth maladaptive

characteristics as well as less parental educational attainment and parental smoking

(Fagan, Brook, et al., 2009). Among Asian Americans, being a woman, highly educated, not

Korean (compared to Chinese), and being a bilingual speaker with high English

proficiency compared to being an English-only speaker were factors associated with

smoking ≤9 CPD (Tong, Nguyen, et al., 2009).

27 In the present analysis, being single, divorced, widowed, or separated was found to be

strongly associated with being a low-level smoker. Research has found that low-level

smokers are more likely not to be married (Hyland, Rezaishiraz, et al., 2005). Additionally,

frequent mental distress was associated with a more than threefold higher relative rate of

low-level smoking (with respect to never/former smoking). Reasons why marital status

and mental distress are associated with low-level smoking have not been well

investigated. Being married or living with someone may be protective of social pressures

to smoke from other family members, friends, and coworkers (Coreil, Ray and Markides,

1991).

28 A population-based study using data from the California Tobacco Survey by Zhu and

colleagues found that only 36% of low-level smokers at baseline remained low-level

smokers 20 months later compared to 82% of 6+ CPD daily smokers. Additionally, they

observed that 21% of low-level smokers at baseline increased their cigarette consumption

to that of 6+ CPD daily smokers 20 months later (Zhu, Sun, et al., 2003). These findings

give some context to the results observed in the present analysis regarding the number of

years smoking and smoking group. Low-level smokers were found to smoke for fewer

years than those who smoke 6+ CPD. This may be because low-level smokers are more

likely to change their cigarette consumption over time.


63

29 Conclusions drawn from the present analysis should be interpreted with caution due to

the small numbers of smokers in each group. Other limitations due to the sample size of

current smokers include the inability to identify characteristics and establish risk factors

by sex, Latino ethnicity, or daily/non-daily status. However, strengths of the present

study include its use of data from a representative, random sample of farm worker

families in California, its effort to describe and characterize low-level smokers using

demographic, migration-related, and psychosocial approaches, and its contribution to the

understanding of the high prevalence of low-level smoking among Latinos. These findings

warrant consideration of smoking behaviors, demographic characteristics, and quality of

life factors when targeting current smokers for smoking education and cessation

programs; particularly among Latinos and underserved populations such as farm

workers. Among the recommendations for future research are to investigate the self-

perceptions of low-level smokers as being smokers or non-smokers and to examine the

characteristics and risk factors of daily and non-daily low-level smoking separately.

Acknowledgements

30 The authors of the present analysis give much gratitude and appreciation to the MICASA

study participants and local field staff, with special thanks to Gloria Andrade, Alex

Cervantes, Ana Cervantes, and Giselle Garcia. Funding for the MICASA study was provided

by the National Institute for Occupational Safety and Health (2U500H007550 and

RO1OH009293) and The California Endowment. The authors would also like to

acknowledge the UC Global Health Institute (UCGHI) for providing partial funding for the

presentation and review of this work.

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ABSTRACTS

Cigarette smoking is the most preventable cause of death in the U.S. Research regarding the

phenomenon of low-level smoking, defined as smoking one to five cigarettes per day (CPD) on

average, is increasing as its high prevalence is better recognized. The Mexican Immigration to

California: Agricultural Safety and Acculturation (MICASA) study is a prospective cohort study of

Latino hired farm worker families that assesses respiratory health, including patterns and

behaviors of cigarette smoking. The purpose of the present analysis was to establish

demographic, migration-related, and psychosocial characteristics and risk factors for low-level

smoking. Seven percent of participants were current smokers, 61% of them being low-level

smokers. Low-level smokers did not smoke as many days during the past month as those who

smoke 6+ CPD (p=0.04). Low-level smokers were more likely than never and former smokers

combined not to be married and to experience frequent mental distress. Those who smoke 6+

CPD were also more likely than never and former smokers combined to experience frequent

mental distress and to be more acculturated. Low-level smokers have characteristics and risk

factors that set them apart from other types of smokers. This increased understanding of low-


66

level smokers can enhance public health education and smoking cessation programs targeted at

Latinos.

Le tabagisme est la principale cause de décès évitable aux Etats-Unis. La recherche sur le

tabagisme faible, défini comme la consommation d'une à cinq cigarettes par jour (CPJ) en

moyenne, se développe car la forte prévalence de ce type de tabagisme est de mieux en mieux

reconnue. L'étude MICASA (The Mexican Immigration to California : Agricultural Safety and

Acculturation) est une étude de cohorte prospective portant sur des familles d'ouvriers agricoles

latinos salariés qui évalue la santé respiratoire, y compris les modes et comportements face au

tabagisme. La présente analyse a pour but de déterminer les caractéristiques démographiques,

psychosociales et liées à l'immigration et les facteurs de risque pour le tabagisme faible. Sept

pour cent des participants étaient des fumeurs et 61 % d'entre eux étaient des petits fumeurs. Au

cours du mois précédent, les petits fumeurs n'avaient pas fumé autant de jours que ceux qui

avaient fumé 6+ CPJ (p=0,04). Les petits fumeurs étaient plus susceptibles d'être célibataires et de

connaître des épisodes fréquents de détresse mentale que les personnes n'ayant jamais fumé et

les anciens fumeurs. Ceux qui fumaient 6+ CPJ étaient également plus susceptibles de connaître

des épisodes fréquents de détresse mentale et d'être plus acculturés que les personnes n'ayant

jamais fumé et que les anciens fumeurs. Les petits fumeurs ont des caractéristiques et des

facteurs de risque qui les mettent à part des autres types de fumeurs. Cette meilleure

compréhension des petits fumeurs peut améliorer l'éducation en matière de santé publique et les

programmes de lutte contre le tabagisme destinés aux Latinos.

En los Estados Unidos fumar cigarrillos es la causa de muerte que más puede prevenirse. Las

investigaciones de fumadores con bajos niveles de consumo, definido como el consumo de uno a

cinco cigarrillos por día en promedio (CDP por sus siglas en inglés), están aumentando en cuanto

su alta prevalencia se conoce mejor. El estudio Migración Mexicana a California: Seguridad en la

Agricultura y Aculturación (MICASA por sus siglas en inglés) evaluó la salud pulmonar de una

cohorte de trabajadores del campo y sus familias, incluyendo sus patrones de conducta en

relación a fumar cigarrillos. El propósito del presente análisis fue establecer las características

demográficas y psicológicas, así como las relacionadas a la migración y los factores de riesgo de

los fumadores con bajos niveles de consumo de cigarrillos. Siete por ciento de los participantes

eran fumadores, de ellos 61% lo hacían en un bajo nivel. Los fumadores con bajos niveles de

consumo no fumaron tantos días durante el mes anterior como aquellos que fumaban 6+ (p=0.04).

Los fumadores con bajos niveles tenían más probabilidades de no estar casados y experimentaban

angustia mental con más frecuencia. Aquellos que fumaban 6+ CDP tenían mayor probabilidad

que los que no fumaban nunca y de los que dejaron de fumar combinados a experimentar

angustia mental y estaban más aculturados. Los fumadores con bajos niveles tenían

características y factores de riesgo que los diferenciaba de los otros tipos de fumadores. Este

mejor entendimiento de los fumadores con bajos niveles de consumo puede mejorar la educación

pública y los programas para dejar de fumar que se enfocan en los latinos.

INDEX

Mots-clés: Acculturation, Agriculture, Epidémiologie, Hispaniques/Latinos, Psychosocial,

Tabagisme

Palabras claves: Aculturación, Agricultura, Consumo de tabaco, Epidemiología, Hispanos/

latinos, Psicosocial

Keywords: Acculturation, Agriculture, Epidemiology, Hispanics/Latinos, Psychosocial, Smoking


67

AUTHORS

ERIK J. RODRIQUEZ

Ph.D., M.P.H., University of California, Western Center for Agricultural, Health and Safety Center

for Tobacco Control Research and Education, 530 Parnassus Ave, Ste 366, Box 1390 - San

Francisco, CA 94143-1390, [email protected]

MARIA T. STOECKLIN-MAROIS

Ph.D., M.P.H., University of California, Davis Department of Public Health Sciences, Western

Center for Agricultural Health and Safety

TAMARA E. HENNESSY-BURT

M.S., University of California, Davis Department of Public Health Sciences, Western Center for

Agricultural Health and Safety

DANIEL J. TANCREDI

Ph.D., UC Davis School of Medicine Department of Pediatrics, Western Center for Agricultural

Health and Safety

MARC B. SCHENKER

M.D., M.P.H., University of California, Davis Department of Public Health Sciences, Western

Center for Agricultural Health and Safety


68

Depression, perceived stress andnervios associated with injury in theMICASA Study, a California farmworker populationDépression, stress ressenti et état de nervosité associés à des blessures dans

l'étude MICASA portant sur une population d'ouvriers agricoles en Californie

Depresión, percepcion de estrés y nervios asociados con lesiones según el estudio

MICASA realizado entre la población agrícola de California

Hong Xiao, Maria Stoecklin-Marois, Chin-shang Li, Stephen A. McCurdyand Marc Schenker

Introduction

1 Farming is an arduous occupation (Schenker 1996; Schenker 2010) and produces a high

number of related injuries. Agriculture ranks among the three occupational groups with

the highest occupational fatality rate (Schenker 2010). The occupational fatality rate in

agriculture remained high (22/100,000 workers) during the 1990s (Rautiainen and

Reynolds 2002). The United States Department of Agriculture (USDA) reported a fatality

rate of 28/100,000 workers in 2002. In California, there are more than 20,000 disabling

non-fatal injuries each year among agricultural workers, and it is estimated that the

actual number may be even higher (Villarejo and Baron 1999). National data suggest that

livestock, machinery, and falls are the most important sources for farm worker injury

(Meyers 1998). Strains and sprains are the most common injuries among migrant farm

workers in California (McCurdy, Samuels et al. 2003).

2 California’s agriculture industry generates products worth over $36 billion/year, and

relies primarily on hired farm labor in all aspects of production (CDFA 2008). Hired farm

workers are often immigrants with little or no safety training who face language and


69

cultural barriers and may experience additional challenges because of their

undocumented status (Schenker 2010). These characteristics place farm workers at high

risk of injury (Schenker 2010; Villarejo, McCurdy et al. 2010).

3 Psychological hazards have been associated with agricultural work, (Gregoire 2002)

including depression (Sanne, Mykletun et al. 2004), stress (Simkin, Hawton et al. 1998),

and low level of social support (Linn and Husaini 1987). The 12 month prevalence of mood

disorder was 9.5% in US adult population according to Kessler and colleagues’ report

(Kessler, Chiu et al. 2005). Only half of them received minimally adequate treatment

(Wang, Lane et al. 2005). Women are 50 % more likely to experience a mood disorder than

men during their lifetime. Latinos are more likely to experience a mood disorder than

non-Latinos during their lifetime (Kessler, Berglund et al. 2005). Linn and Husaini

reported a 20% prevalence of depression among Tennessee farm residents (Linn and

Husaini 1987). Eight percent of Ohio cash grain farmers screened positive for depressive

symptoms (Elliott, Heaney et al. 1995), and a 9.3% prevalence of depressive symptoms was

reported in Colorado farmers (Stallones, Lefft et al. 1995). Depression has been associated

with occupational injuries in agriculture (Park, Sprince et al. 2001; Tiesman, Peek-Asa et

al. 2006). However, there have been only few studies on mental health outcomes and

injury among Latino farm workers (Alderete, Vega et al. 2000).

4 Compared to non-Hispanic whites and other ethnic groups, a higher prevalence of

depressive symptoms was also observed among a Latino adolescent population, especially

among those living in rural areas and those with low socio-economic status (Mikolajczyk,

Bredehorst et al. 2007). Nervios is a culturally-interpreted syndrome which is expressed

with a variety of somatic symptoms, such as headaches, fatigue, diarrhea, or dizziness;

and psychological symptoms such as feeling sad, irritable, angry, or absent-minded

(Salgado de Snyder, Diaz-Perez et al. 2000). Nervios represents the physical and emotional

pain that may arise from family poverty, legal status, gender roles, rural background and

social isolation and other stresses, and is expressed in anger and powerlessness (Salgado

de Snyder, Diaz-Perez et al. 2000). Nervios has been significantly associated with stress

and depressive symptoms in Latinos (Weller, Baer et al. 2008).

5 The National Institute for Occupational Safety and Health (NIOSH) has identified stress as

a serious occupational health problem in agriculture (Carruth and Logan 2002). More

than 50% of female farmers have reported symptoms of stress (Berkowitz and Perkins

1985). Social support had ameliorating effects on life stress and was more protective of

psychological health among men, compared to women (Falcon, Todorova et al. 2009).

Despite the importance of psychosocial factors, there are few studies examining these in

the context of agricultural injury. The purpose of this study was to assess psychosocial

factors, including depression, nervios, social support and perceived stress, and their

relationship with injury among a population-based sample of Latino hired farm workers

in California.

Methods

Sample description and eligibility

6 The Mexican Immigration to California: Agricultural Safety and Acculturation (MICASA)

study is a population-based cohort study of occupational exposures and health in farm

workers. Data for this analysis were derived from the MICASA baseline interview


70

undertaken in 2006-2007. Eligible participants included men and women, 18-55 years old,

who identified themselves as Mexican, Central American, Hispanic or Latino, with at least

one member of the household engaged in farm work for at least 45 days in the last year

and residing in Mendota, CA at the time of the interview.

Sample and recruitment

7 A stratified area probability design was used with census block as the primary sampling

unit. A two-stage enumeration was employed to obtain information on age, gender,

nationality, farm work, and years living in Mendota for each adult member of the

household. Further details of the procedure are documented elsewhere (Stoecklin-Marois,

T.E.Hennessy-Burt et al. 2011). A random list of eligible, enumerated households was

created, and households were approached and asked to participate in the study. There

were a total of 467 households, comprising 843 adults who were recruited and completed

a baseline interview. Of these, 759 individuals answered “yes” to the question “have you

ever worked in agriculture?” and are included in this analysis.

Data collection

8 All data collection was done by a local field team in Mendota. The interviewer-

administered questionnaire assessed demographic characteristics, smoking status,

acculturation, nutrition, occupational and environmental risk factors, psychosocial

factors such as depression, perceived stress, and nervios, as well as a variety of health

outcomes including injuries. Baseline interviews were conducted with participants

between January 2006 and April 2007. Written consent in Spanish was obtained from each

participant, and trained interviewers conducted all interviews in Spanish. Participants

received $15 gift cards for completing the interview. All study procedures were approved

by the University of California, Davis Institutional Review Board.

Outcome measurement

9 A qualifying injury was defined as bodily damage within the 12 months prior to interview

due to exposure to energy and requiring the need for medical care, loss of consciousness,

at least one-half day of lost work time, or restriction from normal activities. All qualifying

injuries, whether occupationally related or not, were included in the analysis.

Exposure measurement

10 The primary exposure measurements were self-reported assessments of depression,

perceived stress, family support, and nervios. Depression was assessed with an eight-item

screener for depressive disorders developed by Burnam and colleagues, based upon the

Center for Epidemiologic Studies Depression Scale (CES-D) (Burnam, Wells et al. 1988).

These elements are scored and calculate the probability of being depressed using a

regression algorithm. A value of 0.06 was used as the cut-point for possible depression,

according to suggested criteria by Burnam et al.

11 Perceived stress was measured with a six items drawn from the 14-item Perceived Stress

Scale (Cohen, Kamarck et al. 1983). Items assessed included: 1) “how often have you dealt


71

successfully with daily problems and hassles?”; 2) “how often have you coped well with

important changes that were taking place in your life?” 3) “how often have you felt

confident about your being able to handle your personal problems?”; 4) “how often have

you been able to control your anger in your life?”; 5) “how often have you felt that you

were on top of things?” and 6) “how often did you feel that things were going well?”

Responses were assessed on a four-point Likert scale ranging from “never” to “all the

time.” Scores for perceived stress were obtained by summing all items and was included

as a continuous variable in logistic regression models. The internal reliability coefficient,

Cronbach’s alpha for the six items on the Perceived Stress scale was 0.80.

12 Family support was assessed with seven items drawn from the Family Dimension of the

Provision of Social Relations (PSR) Scale (Turner, Grindstaff et al. 1990). Participants rated

each statement on a Likert scale response ranging from strongly disagree to strongly

agree. Items included statements such as: “No matter what happens, I know my family

will always be there for me should I need them,” and, “I am not sure if I can completely

rely on my family.” Responses were summed to create a continuous index for inclusion in

logistic regression models. The internal reliability coefficient, Cronbach’s alpha for the

seven items on the Family Support scale, was 0.88.

13 Nervios was assessed by an affirmative response to the question, “Sometimes in your life

have you suffered from nervios?” (Salgado de Snyder, Diaz-Perez et al. 2000). Symptoms

of nervios assessed were having an idea stuck in your mind, feeling distracted or absent-

minded, feeling sad, down or depressed, and feeling irritable or angry. Participants were

also asked how much their nervios interfered with activities and what they believed

caused their nervios.

Statistical analysis

14 Initial descriptive statistic analyses were conducted for injury and the psychosocial

exposure measures and important covariates. Logistic regression was subsequently

employed to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for assessing

the association between psychosocial exposure variables and injury, with adjustment for

relevant potential confounders, including age, gender, current smoking, and years of

working in agriculture. Although gender and current smoking were not confounders in

this analysis, they were retained in the models because other studies have reported

associations with injury (Ratzlaff, Gillies et al. 2007). “Years of working in agriculture”

was correlated with age and was not a cofounder and thus was not included in models for

analyses. Final models were adjusted for age, gender and current smoking. All analyses

were conducted using SAS 9.1.3 (Cary, North Carolina, USA).

Results

Demographic characteristics

15 Overall, 759 participants, 339 (44.7%) women and 420 (55.3%) men, were included in the

present analysis. Ninety-four percent of participants were married or living with

someone. More than half worked in agriculture 11+ years, and 64% earned less than

$20,000/year. Nearly two-thirds of the subjects were born in Mexico and 27.6% were born


72

in El Salvador, and the majority of participants were classified as low acculturated. Eleven

percent of participants reported they were current smokers (Table1).

Table 1. Demographic characteristics of 759 farm worker participants by injury

note: p-value for differences between injury and non-injury across the demographic variablesis

Characteristics of Injury

16 Sixty-eight (9.0%) subjects reported a qualifying injury within the preceding year. Of

these, 50 (74%) were injured requiring treatment, 60 (88%) went to medical settings for

help, 10 (15%) were unconscious due to injury, 41 (60%) missed at least ½ day of work, and

24 (35%) reduced work load due to the injury. Injured subjects were more likely to be

older than 40 years (55.9% vs. 37.1 %), current smokers (17.7% vs. 10.7%), working in

agriculture more than 11 years (65.7% vs. 52.7%), and long-term U.S. residents (more than

21 years) (58.8% vs. 42.6%) (Table 1).

Characteristics of depression and nervios

17 Women reported a much higher prevalence of depressive symptoms and nervios than

men. Participants who earned less than $20,000/year and those with longer years

working in agriculture reported higher prevalences of depression and nervios (Table 2).

Overall, fifteen percent of participants reported having depressive symptoms, and 29.6%

of participants reported having nervios (Table 3). Nervios was more commonly reported

among injured compared with uninjured subjects (46.3% vs. 28.0%) (Table 3). Feeling sad/

down and irritable/angry were the most frequently reported nervios symptoms (Table 4).


73

Table 2. Demographic characteristics of farm worker participants by depression and nervios

note: p-value for differences between depression and non-depression, nervios and non-nervios acrossthe demographic variables

Table 3. Distribution of psychosocial variables

*: chi-square test, **: two-sided t test

Table 4. Prevalence of psychological symptoms of nervios among men and women


74

Psychosocial factors and injury

18 Logistic regression was used to assess associations between psychosocial factors and

injury. After adjusting for age, sex, and current smoking, depressive symptoms were

significantly associated with injury (OR=5.4, 95% CI: 3.1-9.4) (Figure 1). Participants

reporting nervios had more than twice the odds of injury compared to those without

nervios (OR=2.2, 95% CI: 1.3-3.8). Perceived stress and levels of family support were not

associated with injury.

Figure 1. Adjusted ORs and 95% CI for psychosocial factors associated with injury in Californiafarm workers

Note: models adjusted for age, sex and current smoking

Discussion

19 The goal of this analysis was to assess whether psychosocial factors are associated with

injury among Latino farm workers. Depression and nervios were both associated with

injury, whereas perceived stress and family support showed no association with injury.

20 A consistent association of depression with the risk of injury has been found in previous

studies. Tiesman and colleagues. reported that depressive symptoms predicted injury in a

prospective study of 1493 Iowa farm residents (Tiesman, Peek-Asa et al. 2006). Park and

Sprince reported that depressive symptoms were significantly associated with injury,

with odds ratios up to 3.22 in a cohort study of Iowa farmers (Park, Sprince et al. 2001).

Researchers also found that feeling irritable, feeling depressed and having difficulty

sleeping were associated with an increased risk of injury in a cohort study of Ohio grain

workers (Atrubin, Wilkins et al. 2005). These studies lend support to our finding that

depression is associated with injury.

21 There was a strong association between depression and injury in our study, with the

results suggesting that participants who had depressive symptoms were nearly six times


75

more likely to have been injured at work than those without depressive symptoms. One

possible mechanism is that depression reduces concern about personal protection leading

to injury (Beseler and Stallones 2010). It is also possible that psychological stress impedes

a worker’s perception, assessment, judgment, and ability to respond to short-term

demands on attention and readiness (acute stress reaction) (Schaubroeck and Ganster

1993), degrading safety performance and ultimately leading to injury (Kidd, Scharf et al.

1996).

22 In the Ontario Farm Family Health Study (Simpson, Sebastian et al. 2004), financial

concerns were a prominent source of stress. Financial problems were significantly

associated with depression in Colorado farm workers (Beseler and Stallones 2010), a

population in which depression was associated with injury. In our study, income was also

associated with depression, and injury was more frequent among participants earning

less than $10,000/year. As two-thirds of participants earned $20,000 or less annually in

our study, financial concerns are likely to be important for this population. For example,

financially stressed workers paid piece-rate may work at a rapid and unsafe pace to

maximize income, increasing the risk of injury (McCurdy, Samuels et al. 2003).

23 In the Mexican American Prevalence and Services Survey (MAPSS), Mexican immigrants

had a lower rate of psychiatric symptoms and disorders than did US-born Mexican

Americans migrant farm workers in Fresno County, California (Alderete, Vega et al. 2000).

However, a cross-national study found that migrants were at higher risk than non-

migrants for psychiatric symptoms (Breslau, Borges et al. 2011). The prevalence of

psychiatric symptoms might be more strongly associated with the age at migration rather

than the duration of living in the U.S. based on the finding that Mexican-origin Latinos

who spent their childhood in the U.S. had worse mental health status than those who did

not migrate (Breslau, Borges et al. 2011). In our study, increased age was significantly

associated with depression. No association was observed between depression and

acculturation or years of living in the U.S.

24 Hispanic immigrants are less likely to use mental health services compared to non-

Hispanics, but they do use general practitioners over specialists for mental health care

(Vega, Kolody et al. 1999). They prefer counseling or counseling plus medication over

antidepressant medication alone (Dwight-Johnson, Lagomasino et al. 2010). It has been

suggested that individual education, transportation assistance, family involvement,

providing Spanish-speaking staff, and offering different services in a single community

primary care location could improve attendance and keep them in treatment (Santiago-

Rivera, Kanter et al. 2010) so as to better control depressive symptoms and decrease the

risk of injury.

25 Nervios was strongly associated with injury in our study. Chen et al. reported that many

personality traits are associated with increasing risks of unintentional injuries. One

possible mechanism may be poor judgment and impulsivity leading to injuries (Chen,

Sinclair et al. 2008). We are not aware of any literature reporting nervios associated with

injury among farm workers.

26 In an Ontario farm family health cross-sectional study, a significant association was

observed between perceived stress and farm injury among operators working on farms

(Simpson, Sebastian et al. 2004). However, in our study we did not observe an association

between perceived stress and injury. This may relate to social and cultural differences

between the predominantly White Ontario population and our Hispanic population,

potentially affecting both risk for injury and reporting.


76

27 Social support is viewed as a protective factor according to the stress buffering model of

social support (Cohen and Wills 1985). However, we did not find a significant association

between family support and injury. Social support may not play a key role in preventing

injury although it may indirectly be associated with injury by mediating stress. Since our

population included primarily married subjects, we may also have not included subjects

with the least social support (e.g. single males) and our findings may not be generalizable

to that population.

28 There were some limitations in this study: First, temporality of the association is

uncertain in cross-sectional studies because of potential reciprocal relationship between

depression or nervios and injury. Nervios was assessed at any time in the person’s life.

Therefore, it is not certain if the injury preceded or followed the nervios condition.

Secondly, study data were based on self-report, which is subject to recall bias. Finally, this

study focused on Latino farm workers in California, and results might not be

generalizable to other industries and ethnic groups.

29 On the other hand, there were strengths of this study in the use of a representative

population-based sample of a hard to reach demographic group, large sample size, and

strict data quality control and data management. Although study data are based on self-

report, we used standardized questions from the National Health and Nutrition

Examination Survey. Interviews were conducted in Spanish by trained personnel,

minimizing interview biases. Strict data quality control and management was performed

to minimize information bias and ensured the validity and precision of the study.

Conclusions

30 Psychosocial variables were strongly associated with injury in this sample of California

Hispanic farm workers. These findings may be useful for guiding prevention and

management of injury. For example, persons with psychiatric symptoms, especially

depression and nervios, represent a high-risk group for injury and may benefit from

recognizing this and more intensive educational and other measures for prevention. Also,

persons suffering agricultural injury should be evaluated and monitored for psychiatric

symptoms that may have preceded their injury or resulted from it. Further research is

needed to confirm the temporality of the association between psychosocial variables and

injury and to evaluate the effectiveness of prevention and treatment measures.

Acknowledgments

31 This study is supported by National Institute for Occupational Safety and Health

(Research agreements: 2U50OH007550 and 1R01OH009293). The authors appreciate the

advice and support from Dr. Robert Harrison at the University of California, San

Francisco, Hennessy-Burt T.E. (data management), and MICASA field team. Statistical and

database architect support was derived through Grant Number UL1 RR024146 from the

National Center for Research Resources (NCRR), a component of the National Institutes of

Health (NIH) and NIH Roadmap for Medical Research, and its contents are solely the

responsibility of the authors and do not necessarily represent the official view of NCRR or

NIH. The authors also acknowledge the UC Global Health Institute (UCGHI) for providing

partial funding for the presentation and review of this work.


77

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ABSTRACTS

Introduction: While many studies report on the risks of agricultural injury, few have examined

psychosocial factors associated with injury, especially among Latino farm workers. We examined

psychological factors, including depression, perceived stress, social support and nervios that may

be associated with an increased risk of injury. Methods: MICASA is a population-based study of

occupational exposures and health in farm workers. An interviewer-administered questionnaire

collected data on 759 Latinos, 18-55 years old, engaged in farm work and residing in Mendota, CA.

The questionnaire assessed self-reported psychosocial factors and injury risk. A qualifying injury

was defined as one with the need for medical care, going to a medical setting, loss of

consciousness, >½ day lost work time or restricted from normal activities. Results: Mean age was

37.9 years. 65.0% of participants were born in Mexico and 27.7% were born in El Salvador. The

past-year cumulative incidence of injury was 9.0%. A higher cumulative incidence of past-year

injury was observed among participants older than 40 years (55.9% vs. 37.1 %), current smokers

(17.7% vs. 10.7%), working in agriculture more than 11 years (65.7% vs. 52.7%), and long-term U.S.

residents (more than 21 years) (58.8% vs. 42.6%). After adjusting for age, sex, and current

smoking, depression (OR=5.4, 95% CI: 3.1-9.4) and nervios (OR=2.2, 95% CI: 1.3-3.8) were

significantly associated with injury. Conclusions: The findings may be useful for guiding

prevention and management of injury. Further cohort research to confirm the temporality of the

association between psychosocial variables and injury is needed.

Introduction : De nombreuses études ont examiné les risques de blessures en milieu agricole mais

peu se sont intéressées aux facteurs psychosociaux associés à ces blessures, en particulier parmi

les ouvriers agricoles latinos. Nous avons étudié les facteurs psychologiques, notamment la

dépression, le stress ressenti, le soutien social et l'état de nervosité qui peuvent être liés à un

risque accru de blessures. Méthodes : L'étude MICASA est une étude de population qui porte sur

les expositions professionnelles et la santé des ouvriers agricoles. Un questionnaire rempli par un

enquêteur a permis de recueillir des données sur 759 Latinos, de 18 à 55 ans, ouvriers agricoles et

résidant à Mendota, en Californie. Ce questionnaire a évalué les facteurs psychosociaux auto-

déclarés et le risque de blessure. Une blessure admissible a été définie comme une blessure


80

impliquant des soins médicaux, une visite dans un établissement médical, une perte de

connaissance, >½ journée d'arrêt de travail ou d'activités limitées. Résultats : L'âge moyen était

de 37,9 ans. 65,0 % des participants étaient nés au Mexique et 27,7 % au Salvador. L'incidence

cumulée de blessures l'année précédente était de 9,0 %. Une plus grande incidence cumulée de

blessures l'année précédente a été observée parmi les participants âgés de plus de 40 ans (55,9 %

vs. 37,1 %), les fumeurs (17,7 % vs. 10,7 %), ceux travaillant dans l'agriculture depuis plus de 11

ans (65,7 % vs. 52,7 %), et les résidents américains de longue durée (plus de 21 ans) (58,8 % vs. 42,6

%). Après ajustement en fonction du sexe et du tabagisme, la dépression (OR=5,4, IC à 95 % :

3,1-9,4) et l'état de nervosité (OR=2,2, IC à 95 % : 1,3-3,8) ont été associés de manière significative

à des blessures. Conclusions : Les résultats peuvent être utiles pour orienter la prévention et la

prise en charge des blessures. D'autres études de cohortes sont nécessaires pour confirmer la

temporalité de l'association entre les variables psychosociales et les blessures.

Introducción: Aunque se han realizado numerosos estudios sobre los riesgos de lesiones en la

agricultura, pocos son los que han examinado los factores psicosociales asociados a dichas

lesiones, especialmente entre los trabajadores agrícolas latinos. Hemos estudiado los factores

psicosociales, tales como la depresión, el estrés percibido, el apoyo social y los nervios, que

pueden asociarse a un mayor riesgo de lesiones. Métodos: MICASA es un estudio de población

sobre exposiciones y salud occupacionales en trabajadores agrícolas. Un cuestionario realizado

por entrevistador recogió datos de 759 latinos, de entre 18 y 55 años de edad, que realizaban

labores agrícolas y con residencia en Mendota (California). El cuestionario evaluaba los factores

sociales y el riesgo de lesiones declarados por los encuestados. Las lesiones por las que calificaban

para el estudio eran aquellas que requerían asistencia médica o la visita a un centro médico, que

implicaban pérdida de conciencia o pérdida de más de medio día de trabajo o que restringían la

realización de actividades normales. Resultados: La edad media era de 37.9 años. El 65,0% de los

participantes eran originarios de México y el 27.7% de El Salvador. La incidencia acumulada de

lesiones del año pasado fue del 9.0%. Se observó una mayor incidencia acumulada de lesiones el

año pasado entre participantes de más de 40 años (55.9% contra 37.1 %), fumadores activos (17.7%

contra 10.7%), que llevan trabajando en la agricultura más de 11 años (65.7% contra 52.7%) y los

residentes en Estados Unidos por un largo plazo (más de 21 años) (58.8% contra 42.6%). Tras

ajustar los resultados por edad, sexo, condición de fumador, la depresión (OR=5,4; 95% IC: 3,1-9,4)

y los nervios (OR=2,2, 95% IC: 1.3-3.8) se asociaron de forma importante a las lesiones.

Conclusiones: Las conclusiones extraídas pueden ser de utilidad para guiar la prevención y

manejo de lesiones. Es necesario realizar otros estudios de cohortes para confirmar la

temporalidad de la asociación entre las variables psicosociales y las lesiones.

INDEX

Mots-clés: Agriculture, Blessure, Dépression, Etat de nervosité, Stress ressenti

Palabras claves: Agricultura, Depresión, Estrés percibido, Lesiones, Nervios

Keywords: Agriculture, Depression, Farmworker, Hispanic, Injury, Latino, Nervios, Perceived

Stress, Stress

AUTHORS

HONG XIAO

MD, PHD MPH, University of California, Davis, Department of Public Health Sciences - One Shields

Ave., University of California, Davis; Davis, CA 95616-8638, [email protected]


81

MARIA STOECKLIN-MAROIS

PhD, MPH, University of California, Davis, Department of Public Health Sciences - One Shields

Ave., University of California, Davis; Davis, CA 95616-8638

CHIN-SHANG LI

PhD, University of California, Davis, Department of Public Health Sciences - One Shields Ave.,

University of California, Davis; Davis, CA 95616-8638

STEPHEN A. MCCURDY

MD, MPH, University of California, Davis, Department of Public Health Sciences - One Shields


MARC SCHENKER

MD, MPH, University of California, Davis, Department of Public Health Sciences - One Shields



82

Migration & Self-Rated Health:Comparing Occupational Cohorts inCalifornia & Spain (MICASA andITSAL Projects)Immigration et Santé auto-évaluée : Comparaison de cohortes professionnelles

en Californie et en Espagne (Etudes MICASA et ITSAL)

Migración y autoevaluación del estado de salud: comparación de cohortes

ocupacionales en California y España (proyectos MICASA e ITSAL)

Emily Sousa, Maria Stoecklin-Marois, Jose Miguel Martinez, Fernando G.Benavides and Marc Schenker

Introduction

1 Global migration is a growing phenomenon. In 2010, 214 million people were reported to

be living outside their countries of birth [1]. As an incorporated group, these

international migrants would comprise the 5th largest country in the world [2].

Motivations for leaving one’s country of origin are complex, as are the resulting health

implications. The sheer number of international migrants makes the potential burden of

related public health issues important to consider.

2 Immigration may impact infectious disease, chronic disease, and health care access, as

well as occupational injury and illness. Health implications of migration are commonly

studied from the perspective of receiving nations, with protective outcomes among

newly-arrived foreign-born individuals, followed by declining health with time in the

host country [3-5]. The initial health advantages of immigration are often attributed to

protective cultural factors and selective migration (the healthy immigrant effect) [5, 6]. A

person’s age at the time of migration is also of issue, with the health of those who migrate

as pre-adolescents or adolescents differentiated from that of those who migrate at later


83

stages of development, and more closely resembling the health of native-born individuals

in the host country [4]. Given migration’s magnitude and complicated relationship with

health, research in this area is critical.

3 Migration is often attributed to an imbalance of resources, from land and natural

resources to job opportunities, underemployment and economic strength. This article

utilizes the United Nations definition of migrant workers as people who are paid for

services in states in which they are not nationals [7]. Such migrant workers are abundant,

sending roughly $414 billion in remittances in 2009, $307 billion of which went to

developing countries [8]. This population is especially relevant in a public health context

because of the potential impact of occupational exposures. Differences in work exposures

may exist between host and sending societies, and between foreign-born and native-born

workers within host countries. The volume and diversity of experiences of migrant

workers make public health research in these populations both interesting and

important.

4 Self-rated health is a measure of general health that has been associated with mortality in

various studies across cultures and populations [9-12]. Participants rank their health on a

Likert scale, and responses are dichotomized into good and poor health. The measure is

subjective, and is generally associated with sex and age. Existing literature has found

females and older individuals tend to report higher proportions of poor health than their

male and younger counterparts, respectively [9]. The measure is also valuable because of

its quick and cost-effective collection, making it assessable in a variety of research

settings.

5 Comparative studies of migratory trends provide an opportunity to determine if the

impacts of migration have commonalities across migrant streams, and if so, which factors

are specific to individual country relationships, host and sending societies, and which

factors are observed in multiple settings. Previous studies have looked at the specific

comparison between North Africa-Europe migration and Mexico-USA migration, as well

as migration experiences in host countries across Europe [13, 14]. Guendelman et al.

found similar trends in birth outcomes in North Africa-Europe migration and Mexico-USA

migration. Bollini et al. reported an association between immigrant integration policy

and birth outcomes across Europe. These studies take immigration to be an exposure in

and of itself, and add to existing immigration research by comparing outcomes across

situations. This type of work remains uncommon and is an area of powerful potential in

the field.

6 Spain is of particular interest in migration studies due to the rich migrant history and

transformation in the past decade from a country of net emigration to one of net

immigration [15, 16]. California is also a prime location for immigration research as the

state’s southern border makes up part of the most crossed international border in the

world [17], and one out of every four Californians are foreign-born [18]. In the interest of

parallelism and building on comparative migration research, this analysis compares

Moroccan-born workers in Spain and Mexican-born workers in California.

7 Occupational health is often explored epidemiologically through occupational cohorts,

defined as samples of workers from the same field and/or professional organizations with

similar exposures. Ultimately, experts in the field have noted that, “the choice of

occupational cohort will be influenced by research objectives, and inevitably will be

determined by the availability of data necessary for cohort enumeration, exposure

assessment, and health outcome evaluation” [19]. Migration-related variables are not


84

universally collected in occupational datasets, so the design and analyses conducted in

this study have been guided by the use of available, comparable data to optimize progress

in an emerging field.

8 The goal of this study is to assess self-rated health in occupational cohorts of Moroccan-

born workers in the Immigration, Work and Health (ITSAL) study and Mexican-born

workers in the Mexican Immigration to California: Agricultural Safety and Acculturation

(MICASA) study. Hypotheses tested examine the variability of poor self-rated health by

gender, age, age at migration, and occupation to allow for optimally unbiased comparison

of health status across migratory trends, with the aim of identifying appropriate next

steps in research and optimal public health planning.

Methods

9 This study presents a comparison of two independently collected samples of foreign-born

workers – one of Mexican-born workers in Mendota, California, USA, and the other of

Moroccan-born workers in four cities across Spain (Barcelona, Huelva, Madrid and

Valencia).

Data Collection

10 The MICASA project studies a longitudinal occupational cohort of farm workers in

Mendota, California. Exposures of interest include acculturation, smoking, and other

occupational and environmental health issues potentially relevant to the health of this

population.

11 Stratified area probability sampling was used with census block as the primary sampling

unit [20-22]. A household enumeration procedure identified all dwellings in randomly

selected census blocks and individuals residing in these dwellings. Further details of the

methodology is submitted elsewhere for publication [23]. Eligible individuals were 18-55

years old, residing in Mendota at the time of baseline interviews (2006-2007), living in a

household with at least one person who worked in agriculture a minimum of 45 days in

the previous year, who self-identified as Mexican or Central American, and consented to

participate in the study. Interviews were conducted with a 70% household response rate.

12 Research objectives and methods were explained to potential participants in Spanish.

Individuals choosing to participate in the study provided written consent in Spanish. The

study was approved by the University of California, Davis, Institutional Review Board.

Data presented here were collected as part of the second wave of the study between 2008

and 2010. The survey tool used for the follow-up interview included standardized,

validated scales, focusing on sociodemographics, residential conditions and exposures,

smoking, occupational history and exposures, and a variety of specific and holistic health

measures. At follow-up, 640 individuals were interviewed, of which 424 (66%) were

Mexican-born.

13 The ITSAL project studies immigration, work and health in Spain. Data presented here are

from a cross-sectional sample taken 2008-2009 (wave 1) that utilized a 74-item

questionnaire to assess sociodemographics, the migration process, occupational and

economic variables, employment conditions, working conditions, occupational risk


85

prevention activities, participation in trade unions, physical and mental health, and

overall evaluation of individuals’ experiences working in Spain.

14 Quota sampling was used to construct a sample of 2,434 foreign-born workers, with

quotas set by nationality, gender, and area of residence in Spain [20-22]. Moroccan-born

individuals (n=625) living in Barcelona, Huelva, Madrid or Valencia (four Spanish cities

with high proportions of foreign-born residents) were interviewed. Inclusion criteria

consisted of living in Spain for at least one year and working in Spain for at least three

months (professional athletes, artists, graduate students and business executives were

excluded), not being a Spanish citizen or married to a native Spaniard, and adequate

Spanish language abilities for interview participation. Interviews were conducted with a

55.8% response rate [24]. All selected individuals within the inclusion criteria were

invited to participate in the study and given an informational letter explaining their

rights and guaranteeing individual confidentiality. Participation was voluntary, with

consent implied by completion of the survey [25].

Measures

15 The following variable definitions were used for both samples: sex, age (categorical – 18

to 30, 31 to 40, 41+ years old), age at migration (categorical – under 13, 13 to 17, 18+ years

old), education (at most primary, secondary, post secondary), and work experience in

agriculture (yes, no).

16 Self-rated health was used as an outcome in both samples. Participants in both studies

were asked to rate their health. Responses were dichotomized into good health or poor

health, as is standard in research with this outcome [6, 9].

17 In the MICASA study, the question read, “Would you say that in general your health is…”

with the following possible responses: excellent, very good, good, fair, and poor.

Excellent, very good, and good were combined to represent good health, and fair and

poor categories were grouped to represent poor health. In the ITSAL study, the question

read, “How would you rate your health right now?” with the following possible responses:

very good, good, fair, poor, and very poor. Very good and good categories were joined to

represent good health, and the fair, poor and very poor were merged to represent poor

health.

Analysis

18 Comparisons were made between the samples overall and with respect to self-rated

health. Variables of interest included sex, age, age at migration, education, and work

experience in agriculture. Chi-square tests were done to assess significant differences.

Log-binomial models [26-29] were constructed to obtain prevalence ratios and respective

95% confidence intervals for poor self-rated health, stratified by sex and adjusted for age.

All analyses were completed with SAS version 9.2 (SAS Institute Inc., Cary, NC, USA).

Results

19 The two samples differ significantly by sex, age, education and experience working in

agriculture (Table 1). The Mexican-born sample was gender balanced, while males


86

comprised 84% of the Moroccan-born sample. Individuals in the Mexican-born sample

were significantly older (41 vs. 31 years old), less educated, and more likely to have

worked in agriculture than their Moroccan-born counterparts (p<0.001). We observed

these same differences among males and females independently. Additionally, among

men, a larger proportion of Mexican-born individuals immigrated before age 18.

Table 1. Sociodemographic profile of Mexican-born and Moroccan-born samples, overall and bygender.

20 Differences also existed between the samples according to self-rated health (Table 2).

Overall, 42% of Mexican-born participants reported poor health compared to 14% of

Moroccan-born participants. This was seen in every stratum by age, age at migration,

education, and agricultural work overall, and remained significant when stratified by

gender, with the exception of age at migration and education in females.


87

Table 2. Poor self-rated health profile of Mexican-born and Moroccan-born samples, overall and bygender.

21 Expected trends in self-rated health by gender (greater proportion of females than males

reporting poor health) [6, 9] are stronger in the Moroccan-born than Mexican-born

participants. Expected trends in self-rated health by age (increased poor health with age)

are observed overall and stratified by gender in both the MICASA and ITSAL samples.

22 Each potential confounder examined above was considered when constructing log-

binomial models to calculate prevalence ratios. Significant differences in poor self-rated

health prevalence between Moroccan-born and Mexican-born were observed by sex and

by age in both sexes separately. Significant differences in poor health prevalence were

not observed between the samples according to age at migration after stratifying by sex.

Poor self-rated health prevalence did vary significantly in males, but the number of

Mexican-born males was small in the post-secondary strata (n=5). Significant poor self-

rated health differences were also observed by experience in agriculture, but the number

of Moroccan-born with agricultural experience was small (n=2 females, n=10 males).

Therefore, age at migration, education and agricultural work were excluded from

consideration in the models. The final model (Figure 1) stratifies by sex and adjusts for

age.


88

Figure 1. Prevalence ratios and 95% CI of poor self-rated health in Mexican-born (MICASA) vs.Moroccan-born (ITSAL) workers, by gender.

*Note: Reference group: Moroccan-Born.

23 In age-adjusted models, Mexican-born women were twice as likely as Moroccan-born

women to report poor self-rated health, and Mexican-born men were more than three-

times as likely to report poor self-rated health as Moroccan-born men (Figure 1).

Discussion

24 The differences in demographics and self-rated health between these two samples are

notable. The higher prevalence of poor self-rated health in the MICASA study may be

accounted for in part by differences in the distribution of sociodemographic

characteristics or agricultural work experience between the two samples, subjectivity of

self-rated health and cultural differences, actual differences in health, or any

combination of these factors.

25 The sociodemographic differences observed may result from distinct sampling and data

collection methods or from actual differences in the source populations. The Mexican-

born sample included higher proportions of women, older individuals, males who

migrated after age 18, individuals with little formal education, and individuals with

agriculture work experience compared to the Moroccan-born sample.

26 Quota sampling was used in Spain across four urban areas. Gender balanced quotas were

the aim, but investigators had difficulty completing sufficient interviews with Moroccan

women to achieve this goal. Cultural issues, as well as potential gender imbalances in the

source population for the sample are possible explanations. Additionally, convenience

sampling limits the generalizability of findings to the source population. However,

sampling across four cities in Spain adds to the knowledge of Moroccan-born workers in

Spain as a whole and is a reasonable trade-off for the less rigorous sampling methods.

27 In contrast, a sampling frame was constructed in Mendota, CA, and a representative

random sample was taken of the town’s population [23]. The representativeness gained

by this approach is advantageous over the ITSAL study, while the specificity of the town’s


89

population limits the generalizability of the results to farm workers living in Mendota or

potentially in other comparable California Central Valley farming communities.

28 Selection bias may have been introduced by language restrictions established as

eligibility criteria in the ITSAL project. It is possible that Moroccan-born workers who

speak Spanish were not representative of the general population of Moroccan-born

workers in Spain.

29 Regardless of the sources of the demographic differences, poor self-rated health is

generally understood to be more prevalent in females than males, with age, and lower

levels of education [9]. However, even when prevalence ratios were calculated and

stratified by gender and adjusted for age, Mexican-born individuals in the MICASA sample

reported poorer general health than Moroccan-born individuals in the ITSAL sample. The

lower education level among Mexican-born participants would be expected to increase

the prevalence of poor self-rated health, so this may account for some of the discrepancy

in the ratios. While models were adjusted for age, ratios adjusted for other possible

confounders could not be calculated due to model convergence concerns.

30 The differences in the prevalence of poor self-rated health between the MICASA and

ITSAL samples may have resulted from the subjectivity of the measure. Latino

populations are understood to somatize emotional issues into physical health concerns,

and such cultural impacts on the concept of health may play a role in the differences seen

between these two samples [30-32]. Research has shown a positive relationship between

poor self-rated health and mortality among US Latinos as a whole, as well as those living

in the US for at least 10 years [33]. At baseline interview in the MICASA study (two to four

years before the data analyzed here were collected), study participants had lived in the

US 15.5 years on average. Thus, it is plausible here that such an association may hold.

31 Self-rated health has been used as an overall health assessment. This construct has been

associated with morbidity and mortality and validated across cultures and communities

[9, 10, 34-36]. However, self-rated health’s associations remain to be researched with

more specific health measures. In addition, self-rated health’s inherent subjectivity

cannot be discounted when considering potential explanations.

32 True differences in health status between the samples may also explain differences

observed in poor self-rated health prevalence in this study. Self-rated health, while

subjective, is a valid health measure with implications for mortality, if not also for

decreased health-related quality of life. The public health implications of such a

difference in health status across populations could be substantial and are important for

policy planning as well as future research.

33 Comparative research would do well to continue exploring health effects across

migrations, distinguishing commonalities as well as factors unique to individual

situations. Such an understanding will be valuable to immigration health research, as

well as public health planning, to ensure optimal health outcomes in our increasingly

mobile world.

Acknowledgments

34 Funding for the MICASA study was provided by the National Institute for Occupational

Safety and Health (2U500H007550 and RO1OH009293) and The California Endowment.

Funding for the ITSAL project was provided by the Fondo de Investigación Sanitaria,


90

Instituto de Salud Carlos III in 2005 (PI050497, PI052202, PI052334), 2006 (PI061701), and

2007 (PI0790470).

35 The authors would like to thank staff at the Western Center for Agriculture & Health and

the Center for Occupational Health Research (CiSal), especially Tamara Hennesy-Burt.

The authors would also like to acknowledge the UC Global Health Institute (UCGHI) for

providing partial funding for the presentation and review of this work. We would also like

to acknowledge the contribution of the MICASA field team, with special thanks to Gloria

Andrade, Alex Cervantes, Ana Cervantes, and Giselle Garcia. Most of all, we thank the

participants for sharing their experiences and making this study possible.

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ABSTRACTS

International migration is a growing global phenomenon. The magnitude of the global

population living outside their countries of origin substantiates the value of considering

potential public health issues and their population-wide burden. As migration has yet to be

generally accepted as an exposure in and of itself, and encompasses a wide range of experiences

and health effects, a measure of overall health is well suited for this research. This study

compares self-rated health between two independently collected occupational cohorts as part of

the ITSAL study in Spain and the MICASA study in Mendota, California, USA. We observed

greater gender balance in the MICASA sample than the ITSAL sample, where there was a

substantial male majority. Mexican-born workers in the MICASA sample tended to be older, less

educated, and more likely to work in agriculture than their Moroccan-born counterparts in the

ITSAL study. We also observed a higher prevalence of poor self-rated health in the MICASA

sample compared to the ITSAL sample. Differences may be due to sampling and data collection

issues, cultural issues and the subjectivity of self-rated health as an outcome, as well as actual

health differences. Further research is needed to determine common and distinct migration-

related public health issues.

L'immigration internationale est un phénomène mondial en plein essor. Le pourcentage élevé de

personnes dans le monde vivant dans un pays autre que son pays d'origine justifie l'intérêt de

prendre en compte les problèmes de santé publique potentiels et le fardeau que cela implique à

l'échelle de la population. Alors que l'immigration n'est pas encore généralement reconnue

comme une exposition en soi, et englobe un large éventail d'expériences et d'effets sur la santé,

une évaluation de la santé globale est tout à fait appropriée pour cette étude. Cette étude

compare la santé auto-évaluée de deux cohortes professionnelles, les donnés ayant été recueillies

indépendamment dans le cadre de l'étude ITSAL en Espagne et de l'étude MICASA à Mendota, en

Californie. Nous avons observé un plus grand équilibre entre les sexes dans l'échantillon MICASA

que dans l'échantillon ITSAL, dans lequel il y avait une majorité considérable d'hommes. Les

ouvriers de l'échantillon MICASA nés au Mexique avaient tendance à être plus âgés, à avoir un

niveau d'instruction moindre, et à être plus susceptibles de travailler dans l'agriculture que leurs

homologues nés au Maroc de l'étude ITSAL. Nous avons également observé une plus forte

prévalence de mauvaise santé auto-évaluée dans l'échantillon MICASA que dans l'échantillon

ITSAL. Les différences peuvent être dues aux méthodes d'échantillonnage et de recueil des

données, à des aspects culturels et à la subjectivité des résultats de la santé auto-déclarée, ainsi

qu'à de réelles différences en matière de santé. D'autres études sont nécessaires pour déterminer

les problèmes de santé publique liées à l'immigration communs et distincts.


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La migración internacional es un fenómeno creciente a nivel mundial. La magnitud de la

población mundial que vive fuera de su país de origen justifica el valor del estudio de los

problemas potenciales para la salud pública y la carga que supone para la población en general.

Debido a que todavía no se ha aceptado de forma generalizada que la migración supone una

exposición por sí misma y al hecho de que abarca una amplia gama de experiencias y efectos para

la salud, una medición de la salud en general parece apropiada para este estudio. En este trabajo

se compara la autoevaluación de la salud entre dos cohortes ocupacionales analizadas

independientemente como parte del estudio ITSAL en España y el estudio MICASA en Mendota

(California, Estados Unidos.). Hemos observado un mayor equilibrio entre sexos en la muestra de

MICASA que en la de ITSAL, donde había una importante mayoría masculina. Los trabajadores de

origen mexicano de la muestra de MICASA tendían a ser mayores, con menor nivel educativo y

con mayor probabilidad de trabajar en la agricultura que los colegas de origen marroquí del

estudio ITSAL. Asimismo, hemos observado una mayor prevalencia de salud deficiente en la

muestra de MICASA en comparación con la muestra de ITSAL. Las diferencias pueden deberse a

problemas de muestreo y de recopilación de datos, a aspectos culturales y a la subjetividad de los

resultados de la autoevaluación de la salud, así como a verdaderas diferencias de salud.

Asimismo, es necesario realizar otros estudios para determinar qué aspectos de salud pública

relacionados con la migración se comparten y cuáles son diferentes.

INDEX

Keywords: Epidemiology, Immigrant Workers, Occupational Health, Self-Reported Health, Spain,

United States

Palabras claves: Autoevaluación de salud, Epidemiología, España, Estados Unidos, Salud

ocupacional, Trabajadores inmigrantes

Mots-clés: Epidemiologie, Espagne, Etats-Unis, Santé au travail, Santé auto-déclarée,

Travailleurs immigrés

AUTHORS

EMILY SOUSA

MPH, University of California, Davis, Department of Public Health Sciences, Western Center for

Agricultural Health and Safety, 1 Shields Ave., Davis, CA 95616, [email protected]

MARIA STOECKLIN-MAROIS

MPH, PhD, University of California, Davis, Department of Public Health Sciences, Western Center

for Agricultural Health and Safety, 1 Shields Ave., Davis, CA 95616

JOSE MIGUEL MARTINEZ

PhD, Universitat Pompeu Fabra, Center for Investigation of Occupational Health

FERNANDO G. BENAVIDES

MD, PhD, Universitat Pompeu Fabra, Center for Investigation of Occupational Health


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MARC SCHENKER

MD, MPH, University of California, Davis, Department of Public Health Sciences, Western Center

for Agricultural Health and Safety, 1 Shields Ave., Davis, CA 95616


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Field Actions Science Reports, Special Issue 10

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