Abstract
Objectives. We assessed access to and use of health services among Mexican-born undocumented immigrants living in New York City in 2004.
Methods. We used venue-based sampling to recruit participants from locations where undocumented immigrants were likely to congregate. Participants were 18 years or older, born in Mexico, and current residents of New York City. The main outcome measures were health insurance coverage, access to a regular health care provider, and emergency department care.
Results. In multivariable models, living in a residence with fewer other adults, linguistic acculturation, higher levels of formal income, higher levels of social support, and poor health were associated with health insurance coverage. Female gender, fewer children, arrival before 1997, higher levels of formal income, health insurance coverage, greater social support, and not reporting discrimination were associated with access to a regular health care provider. Higher levels of education, higher levels of formal income, and poor health were associated with emergency department care.
Conclusions. Absent large-scale political solutions to the challenges of undocumented immigrants, policies that address factors shown to limit access to care may improve health among this growing population.
Between 1990 and 2000, the United States attracted almost one third of the world's immigrants, and the total number of foreign-born residents in the United States increased by 57%.1,2 Contributing to the overall increase in the foreign-born population has been a rapid rise in the number of undocumented immigrants living in the United States. Since the mid-1990s, more undocumented than legal immigrants have arrived each year.3 These trends hold true for people arriving from Mexico, the leading country of birth among foreign-born residents of the United States. As of March 2004, approximately one half of Mexicans living in the United States were undocumented, accounting for 5.9 million (57%) of the 10.3 million undocumented immigrants estimated to be living in the United States.3
Identifying and studying undocumented immigrants is so challenging that a paucity of evidence exists about the health status of undocumented immigrants in the United States.4 The best available evidence suggests that undocumented immigrants may represent a vulnerable population at higher risk for disease and injury than either documented immigrants or native-born US citizens.1,5–16 Yet, despite early recognition of the potential vulnerability of undocumented immigrants and their rapidly increasing prevalence in the United States, the determinants of access to and use of health services in this group remain poorly understood.17,18 Most research about access to health services among undocumented immigrants has used samples of immigrants of diverse origins and of varying immigration status; although these studies generally find that the legal status of undocumented immigrants is an important barrier to accessing health services,6,17,19,20 little is known about the demographic, economic, social, and health-related determinants of access to and use of health services by undocumented immigrants.
We assessed the determinants of access to and use of health services among undocumented Mexican immigrants living in New York City, where the Mexican foreign-born population increased by 275% between 1990 and 2000.21 The Behavioral Model for Vulnerable Populations22 was used as a theoretical framework for our hypothesis that the likelihood of health insurance coverage, access to a regular health care provider, and emergency department care among undocumented immigrants living in New York City is shaped by a hierarchy of predisposing characteristics. These characteristics include temporally distal determinants such as sociodemographic factors (e.g., education) and immigration factors (e.g., year of entry into the United States) and are likely to influence access to health services through more proximal enabling (e.g., income) and health-need characteristics.
METHODS
Sample
The sampling frame consisted of adults (18 years or older) from all 5 boroughs of New York City who reported being born in Mexico. Participants were recruited in communities with large populations of Mexican immigrants. Venues were selected by a 2-step procedure. First, we used US Census data to identify the 12 neighborhoods in the city, as defined by the New York City Department of City Planning, with the highest concentrations of Mexican immigrants.2,21 Second, we conducted at least 2 walk-throughs of all streets in each of the 12 neighborhoods on different days and at different times of day to identify neighborhood venues with heavy volumes of foot traffic that might prove amenable to conducting interviews.
Outreach workers trained in data collection recruited participants between October 8 and December 5, 2004, with street outreach techniques common in research involving immigrant populations6,23–25 and other hard-to-reach populations.26,27 Participants qualified for the study if they reported being 18 years or older, born in Mexico, and current residents of New York City. Twenty-minute interviews were conducted in either English or Spanish by trained and supervised interviewers who used translated and back-translated structured questionnaires. Fewer than 2% of interviews were conducted in English.
Measures
Predisposing factors, defined as characteristics that incline people to use health services, included sociodemographic characteristics and immigration factors. Sociodemographic characteristics included age, gender, educational attainment, marital status, number of children, and number of other adults living at the current residence. We inquired about the respondents' legal status and the year they first entered the United States and dichotomized year of entry as before or after January 1, 1997, to reflect relevant changes in US legislation.10 We assessed levels of acculturation with a modified version of the 12-item Welfare Reform Baseline Interview acculturation module, developed for use among Hispanic populations.28 Linguistic acculturation was assessed by 7 of the 8 items that asked about the preference for other languages as compared with English (e.g., “What language do you usually speak with friends?”). The item on “language spoken” was excluded because it lacked variability. We assessed social acculturation with the 4 items that asked about preference for Mexican, Latino, or Hispanic groups as compared with other groups in a variety of social contexts (e.g., “Your close friends are …?”). The Cronbach alpha for items used in both scales was 0.92. The linguistic and social acculturation scores were summed and divided into thirds for analysis.
Enabling factors, defined as characteristics that enable or impede use of health services, were measured by asking respondents about their economic and social resources. Respondents reported income earned in the formal economy (i.e., reported and taxed income, including public assistance) and in the informal economy (i.e., nonreported and nontaxed income). For the analysis, we categorized both formal and informal income as none, $1 to $10 000, $10 001 to $20 000, more than $20 000, or missing (not reported). We also asked respondents if they had access to health insurance of any sort in the past 6 months, if they had worked as day laborers in the past 6 months, and if they sent money to family or friends in Mexico. To evaluate social support, we asked about emotional (e.g., “someone to love you and make you feel wanted”), instrumental (e.g., “someone to help you if you were confined to bed”), and appraisal (e.g., “someone to give you good advice in a crisis”) support in the past 6 months.29 We summed responses and divided the combined social support score into thirds for analysis. Respondents were asked if they had ever been discriminated against, prevented from doing something, hassled, or made to feel inferior because of age, race, language, immigrant status, gender, sexual orientation, poverty, drug use, having been in jail or prison, religion, mental illness, physical illness or disability, or other reason. We asked respondents to identify the form of discrimination that most affected their life and categorized this as either none or discrimination relating to race, language, immigrant status, or other.
Need factors were used to evaluate respondents' health. We assessed respondents' health status by asking about the number of days that poor physical or mental health limited usual activities in the past 30 days.30–32 Health status was categorized as 0 days, 1 to 5 days, or more than 5 days for the analysis.
Access to and use of health services was measured by 3 variables. We assessed respondents' insurance coverage by asking if they had health insurance coverage of any sort during the past 6 months. We assessed access to a regular health care provider by asking respondents if they usually went to a doctor's office or clinic, Medicaid or health maintenance organization (HMO), emergency department in a hospital, drug treatment center, nowhere, or other location for medical care. We considered respondents as having access to a regular health care provider if they reported going to a doctor's office or clinic, Medicaid or HMO, emergency department in a hospital, or drug treatment center and seeing the same doctor, nurse, or physician's assistant more than 90% of the time. Respondents were also asked if they had been seen or received care in an emergency department during the past 6 months.
Statistical Analyses
We calculated the overall prevalence and the prevalence according to the covariates of interest of our outcome measures (i.e., insurance coverage in the past 6 months, access to a regular provider, and emergency department care in the past 6 months) and used the 2-tailed χ2 test to test for bivariate associations.
In multivariable analyses, we developed a series of 3 multivariable logistic regression models for each outcome variable. In the first model, we regressed the outcome variable on predisposing characteristics, in the second model we regressed the dependent variable on predisposing and enabling characteristics, and in the third model we regressed the dependent variable on predisposing, enabling, and need characteristics. This modeling approach allowed for the estimation of overall, adjusted, and direct associations between predisposing, enabling, and need characteristics and our measures of access to and use of health services.33 For parsimony and to avoid unstable estimates, only variables statistically associated (P ≤ .10) with a particular outcome variable were retained in subsequent models.33
RESULTS
Sample Characteristics
We recruited 505 persons for this study. All analyses were restricted to the 431 respondents who were undocumented immigrants (based on self-report of legal status); their characteristics are shown in Table 1. The mean age was 31.7 years, 30.3% were women, 83.1% reported “less than high school” as the highest level of education completed, 50.5% were married, 66.8% had at least 1 child, and 76.4% reported that they lived in a residence with more than 2 other adults. The median year of entry into the United States was 1999.
TABLE 1.
Sample Characteristics and Bivariate Associations Between Covariates of Interest and Prevalence of Access to Insurance and Regular Providers and Receipt of Care in an Emergency Department Among Undocumented Immigrants Born in Mexico: New York City, 2004
| Access to Health Insurance |
Access to a Regular Provider |
Receipt of Care in an Emergency
Department |
|||||
| Total Sample, No. (%) | % | P | % | P | % | P | |
| Total | 431 (100.0) | 10.5 | 36.5 | 13.0 | |||
| Age, y | .22 | .24 | .37 | ||||
| 18–24 | 104 (24.2) | 12.8 | 36.9 | 13.9 | |||
| 25–34 | 177 (41.2) | 9.1 | 38.9 | 9.7 | |||
| 35–44 | 112 (26.0) | 8.0 | 29.4 | 16.4 | |||
| >44 | 37 (8.6) | 18.9 | 46.0 | 16.2 | |||
| Gender | <.01 | <.01 | .04 | ||||
| Men | 299 (69.7) | 7.7 | 28.4 | 10.9 | |||
| Women | 130 (30.3) | 17.5 | 54.3 | 18.1 | |||
| Education | .84 | .90 | <.01 | ||||
| Less than high school | 358 (83.1) | 10.2 | 36.9 | 12.5 | |||
| High school or GED | 43 (10.0) | 11.6 | 34.9 | 4.9 | |||
| At least some college | 30 (7.0) | 13.3 | 33.3 | 30.0 | |||
| Marital status | .60 | .76 | .90 | ||||
| Single | 177 (41.1) | 10.9 | 38.5 | 12.1 | |||
| Married | 218 (50.6) | 11.1 | 34.9 | 13.6 | |||
| Divorced/separated/widowed/other | 36 (8.4) | 5.6 | 36.1 | 13.9 | |||
| Children, no. | .17 | .11 | .71 | ||||
| None | 141 (33.2) | 11.3 | 38.6 | 15.0 | |||
| 1 | 64 (15.1) | 17.5 | 48.4 | 14.8 | |||
| 2 | 95 (22.4) | 7.4 | 35.1 | 11.7 | |||
| 3 | 63 (14.8) | 11.3 | 25.8 | 14.5 | |||
| > 3 | 62 (14.6) | 4.9 | 32.8 | 8.2 | |||
| Other adults in the residence, no. | <.01 | .01 | .73 | ||||
| 1–2 | 100 (23.6) | 21.0 | 52.0 | 15.0 | |||
| 3 | 80 (18.9) | 8.9 | 60.8 | 15.2 | |||
| 4 | 96 (22.7) | 8.4 | 61.7 | 11.7 | |||
| > 4 | 147 (34.8) | 5.5 | 72.6 | 11.1 | |||
| Year immigrated to United States | .01 | <.01 | .02 | ||||
| 1997–2004 | 276 (66.0) | 8.1 | 29.2 | 10.0 | |||
| 1970–1996 | 142 (34.0) | 16.2 | 48.6 | 18.3 | |||
| Linguistic acculturation/preference levela | <.01 | .76 | .80 | ||||
| Low | 106 (26.8) | 16.4 | 36.9 | 13.7 | |||
| Moderate | 160 (40.5) | 4.4 | 34.2 | 14.5 | |||
| High | 129 (32.7) | 13.2 | 38.3 | 11.8 | |||
| Social acculturation/preference levela | .74 | .52 | .57 | ||||
| Low | 172 (43.7) | 9.4 | 34.1 | 11.8 | |||
| Moderate | 106 (26.9) | 11.4 | 41.0 | 15.7 | |||
| High | 116 (29.4) | 12.2 | 36.0 | 15.5 | |||
| Total formal income in past year,b $ | <.01 | .01 | .12 | ||||
| None | 246 (57.1) | 7.0 | 29.6 | 11.5 | |||
| 1–10 000 | 70 (16.2) | 15.9 | 49.3 | 9.0 | |||
| 10 001–20 000 | 34 (7.9) | 17.7 | 50.0 | 26.5 | |||
| > 20 000 | 17 (3.9) | 29.4 | 41.2 | 17.7 | |||
| Legal income not reported | 64 (14.8) | 9.4 | 40.3 | 14.3 | |||
| Total informal income in past year,c $ | .03 | .01 | .44 | ||||
| None | 112 (26.0) | 12.6 | 47.3 | 10.8 | |||
| 1–10 000 | 135 (31.3) | 13.5 | 34.6 | 14.6 | |||
| 10 001–20 000 | 69 (16.0) | 2.9 | 21.7 | 8.7 | |||
| > 20 000 | 22 (5.1) | 22.7 | 40.9 | 9.1 | |||
| Informal income not reported | 93 (21.6) | 6.5 | 36.3 | 17.4 | |||
| Health insurance coverage in past 6 months | <.01 | .05 | |||||
| No | 382 (89.5) | 32.5 | 11.9 | ||||
| Yes | 45 (10.5) | 68.9 | 22.2 | ||||
| Day labor employment in past 6 months | .01 | <.01 | .45 | ||||
| Yes | 103 (23.9) | 3.9 | 18.6 | 10.8 | |||
| No | 328 (76.1) | 12.7 | 42.1 | 13.7 | |||
| Money sent to family/friends in Mexico | <.01 | .03 | .74 | ||||
| No | 64 (14.9) | 20.6 | 49.2 | 14.3 | |||
| Yes | 366 (85.1) | 8.8 | 39.5 | 12.8 | |||
| Social support | .02 | .01 | <.01 | ||||
| Low | 150 (36.7) | 6.1 | 30.6 | 10.3 | |||
| Medium | 137 (33.5) | 8.9 | 33.6 | 8.8 | |||
| High | 122 (29.8) | 16.4 | 47.5 | 20.7 | |||
| Discrimination experiencedd | .48 | .02 | .64 | ||||
| No discrimination | 171 (40.6) | 13.0 | 42.9 | 13.0 | |||
| Race | 52 (12.4) | 9.6 | 35.3 | 9.8 | |||
| Language | 106 (25.2) | 7.6 | 24.8 | 11.5 | |||
| Immigrant status | 67 (15.9) | 7.6 | 43.3 | 16.9 | |||
| Other | 25 (5.9) | 16.0 | 24.0 | 20.0 | |||
| No. of days activities were limited by poor health in past 30 days | .06 | .55 | <.01 | ||||
| 0 | 333 (78.7) | 9.1 | 35.1 | 10.7 | |||
| 1–5 | 47 (11.1) | 10.6 | 42.6 | 10.9 | |||
| > 5 | 43 (10.2) | 20.9 | 39.5 | 32.6 | |||
Note. GED = general educational development.
Assessed with a modified version of the 12-item Welfare Reform Baseline Interview acculturation module.28
Formal income is all reported and taxed income, including public assistance.
Informal income is all nonreported and nontaxed income.
Respondents were asked whether they experienced discrimination and, if so, what form most affected their lives.
A majority of respondents (57.1%) reported that they earned no formal income in the past year, 52.4% earned informal income in the past year, 23.9% worked as a day laborer in the past 6 months, and 85.1% sent money to family or friends in Mexico. A majority (59.4%) also reported that they experienced some form of discrimination, with 25.2% identifying language discrimination as most affecting their life. Approximately one tenth of respondents reported that poor physical or mental health limited their usual activities for more than 5 of the past 30 days (10.2%) or that they had health insurance coverage in the past 6 months (10.5%). Slightly more than one third of respondents (36.5%) reported access to a regular provider, and 13.0% received emergency department care in the past 6 months.
Bivariate Analyses
In bivariate analyses (Table 1), health insurance coverage in the past 6 months was associated with being a woman (P < .01), living in a residence with fewer other adults (P < .01), earlier year of entry to the United States (P = .01), levels of linguistic acculturation (P < .01), higher levels of formal (P < .01) and informal (P = .03) income in the past year, not working as a day laborer in the past 6 months (P = .01), not sending money to family or friends in Mexico (P < .01), and higher levels of social support (P = .02).
Women (P < .01) and respondents who reported living in a residence with more other adults (P = .01), an earlier year of entry to the United States (P < .01), moderate levels of formal income in the past year (P = .01), no informal income in the past year (P = .01), health insurance coverage in the past 6 months (P < .01), not working as a day laborer in the past 6 months (P < .01), not sending money home to family or friends in Mexico (P = .03), a high level of social support (P = .01), and not experiencing discrimination or experiencing discrimination relating to immigrant status (P = .02) were more likely to report access to a regular health care provider (Table 1).
Emergency department care during the past 6 months was more common among women (P = .04) and those who reported a higher level of educational attainment (P < .01), an earlier year of entry into the United States (P = .02), health insurance coverage in the past 6 months (P = .05), higher levels of social support (P < .01), and poor physical or mental health that limited their usual activities for more than 5 of the past 30 days (P < .01).
Multivariable Analyses
In multivariable models (Table 2), health insurance coverage during the past 6 months was associated with living in a residence with fewer other adults (odds ratio [OR] = 0.29 for more than 4 adults compared with 1–2 adults; 95% confidence interval [CI] = 0.10, 0.82), linguistic acculturation (OR = 0.20 for moderate levels compared with the lowest levels; 95% CI = 0.07, 0.58), high levels of formal income earned in the past year (OR = 6.20 for more than $20 000 compared with no formal income; 95% CI = 1.27, 30.38), not sending money to family or friends in Mexico (OR = 0.40 for those who sent money; 95% CI = 0.16, 1.01), higher levels of social support (OR = 3.57 compared with the lowest levels; 95% CI = 1.25, 10.21), and more days in which health limited usual activities in the past 30 days (OR = 4.54 comparing more than 5 days with 0 days; 95% CI = 1.50, 13.74).
TABLE 2.
Multivariable Associations Between Variables of Interest and Access to Insurance Among Undocumented Immigrants Born in Mexico: New York City, 2004
| Model 1, OR (95% CI) | Model 2, OR (95% CI) | Model 3, OR (95% CI) | |
| Predisposing characteristics | |||
| Age, y | |||
| 18–24 (Ref) | 1.00 | … | … |
| 25–34 | 0.73 (0.24, 2.16) | … | … |
| 35–44 | 0.52 (0.14, 1.96) | … | … |
| > 44 | 1.35 (0.28, 6.60) | … | … |
| Gender | |||
| Men (Ref) | 1.00 | … | … |
| Women | 1.97 (0.83, 4.70) | … | … |
| Education | |||
| Less then high school (Ref) | 1.00 | … | … |
| High school or GED | 0.54 (0.13, 2.34) | … | … |
| At least some college | 1.25 (0.32, 4.87) | … | … |
| Marital status | |||
| Single (Ref) | 1.00 | … | … |
| Married | 1.69 (0.66, 4.31) | … | … |
| Divorced/separated/widowed/other | 0.89 (0.16, 5.17) | … | |
| Children, no. | |||
| None (Ref) | 1.00 | 1.00 | 1.00 |
| 1 | 0.86 (0.26, 2.79) | 0.79 (0.24, 2.62) | 0.83 (0.26, 2.70) |
| 2 | 0.28 (0.07, 1.10) | 0.35 (0.11, 1.18) | 0.44 (0.13, 1.46) |
| 3 | 0.44 (0.11, 1.76) | 0.55 (0.16, 1.93) | 0.77 (0.24, 2.44) |
| > 3 | 0.27 (0.05, 1.40) | 0.22 (0.05, 1.08) | 0.41 (0.10, 1.67) |
| Other adults in the residence, no. | |||
| 1–2 (Ref) | 1.00 | 1.00 | 1.00 |
| 3 | 0.32 (0.10, 1.05) | 0.41 (0.13, 1.30) | 0.44 (0.15, 1.30) |
| 4 | 0.35 (0.12, 1.04) | 0.28 (0.08, 0.94) | 0.38 (0.12, 1.20) |
| > 4 | 0.31 (0.11, 0.86) | 0.40 (0.13, 1.20) | 0.29 (0.10, 0.82) |
| Year immigrated to United States | |||
| 1997–2004 (Ref) | 1.00 | 1.00 | … |
| 1970–1996 | 2.88 (1.18, 7.03) | 2.02 (0.79, 5.19) | … |
| Linguistic acculturation/preference levela | |||
| Low (Ref) | 1.00 | 1.00 | 1.00 |
| Moderate | 0.22 (0.08, 0.64) | 0.20 (0.06, 0.60) | 0.20 (0.07, 0.58) |
| High | 0.58 (0.22, 1.56) | 0.55 (0.19, 1.59) | 0.53 (0.20, 1.4) |
| Social acculturation/preference levela | |||
| Low (Ref) | 1.00 | … | … |
| Moderate | 1.24 (0.44, 3.49) | … | … |
| High | 1.09 (0.42, 2.81) | … | … |
| Enabling characteristics | |||
| Total formal income in past year,b $ | |||
| None (Ref) | … | 1.00 | 1.00 |
| 1–10 000 | … | 2.21 (0.66, 7.43) | 2.33 (0.76, 7.18) |
| 10 001–20 000 | … | 3.25 (0.91, 11.64) | 4.51 (1.30, 15.67) |
| > 20 000 | … | 3.82 (0.69, 21.25) | 6.20 (1.27, 30.38) |
| Legal income not reported | … | 4.58 (1.11, 18.96) | 2.43 (0.73, 8.06) |
| Total informal income past year,c $ | |||
| None (Ref) | … | 1.00 | … |
| 1–10 000 | … | 1.38 (0.48, 4.00) | … |
| 10 001–20 000 | … | 0.35 (0.06, 1.97) | … |
| > 20 000 | … | 0.96 (0.15, 6.36) | … |
| Informal income not reported | … | 0.59 (0.14, 2.42) | … |
| Day labor employment in past 6 months | |||
| Yes (Ref) | … | 1.00 | … |
| No | … | 2.27 (0.57, 9.04) | … |
| Money sent to family/friends in Mexico | |||
| No (Ref) | … | 1.00 | 1.00 |
| Yes | … | 0.39 (0.15, 1.05) | 0.40 (0.16, 1.01) |
| Social support | |||
| Low (Ref) | … | 1.00 | 1.00 |
| Medium | … | 2.20 (0.69, 7.05) | 2.26 (0.77, 6.66) |
| High | … | 2.68 (0.88, 8.11) | 3.57 (1.25, 10.21) |
| Discrimination experiencedd | |||
| No discrimination (Ref) | … | 1.00 | … |
| Race | … | 0.72 (0.18, 2.86) | … |
| Language | … | 0.92 (0.30, 2.82) | … |
| Immigrant status | … | 0.58 (0.15, 2.24) | … |
| Other | … | 0.92 (0.14, 5.89) | … |
| Health need | |||
| No. of days activities were limited by poor health in past 30 days | |||
| 0 (Ref) | … | … | 1.00 |
| 1–5 | … | … | 1.05 (0.27, 4.19) |
| > 5 | … | … | 4.54 (1.50, 13.74) |
Note. OR = odds ratio; CI = confidence interval; GED = general educational development. Model 1 regressed the outcome variable on predisposing characteristics. Model 2 regressed the depend variable on predisposing and enabling characteristics. Model 3 regressed the dependent variable on predisposing, enabling, and need characteristics. Predisposing characteristics incline people to use health services, enabling characteristics enable or impede use of health services, and need characteristics identify need for health care.
Assessed with a modified version of the 12-item Welfare Reform Baseline Interview acculturation module.28
Formal income is all reported and taxed income, including public assistance.
Informal income is all nonreported and nontaxed income.
Respondents were asked whether they experienced discrimination and, if so, what form most affected their lives.
In multivariable models (Table 3), having a regular health care provider was associated with being a woman (OR = 2.96; 95% CI = 1.69, 5.16), having fewer children (OR = 0.37 for 3 children compared with none; 95% CI = 0.16, 0.82), entering the United States to live before 1997 (OR = 2.35; 95% CI = 1.33, 4.13), low levels of formal income in the past year (OR = 2.18 for $1–$10 000 compared with no formal income; 95% CI = 1.07, 4.45), health insurance coverage in the past 6 months (OR = 2.96; 95% CI = 1.34, 6.55), and not experiencing discrimination (OR = 0.51 for those who reported discrimination relating to language; 95% CI = 0.27, 0.98).
TABLE 3.
Multivariable Associations Between Variables of Interest and Access to a Regular Provider Among Undocumented Immigrants Born in Mexico in New York City, 2004
| Model 1, OR (95% CI) | Model 2, OR (95% CI) | Model 3, OR (95% CI) | |
| Predisposing characteristics | |||
| Age, y | |||
| 18–24 (Ref) | 1.00 | … | … |
| 25–34 | 0.91 (0.45, 1.80) | … | … |
| 35–44 | 0.66 (0.29, 1.54) | … | … |
| > 44 | 1.02 (0.33, 3.14) | … | … |
| Gender | |||
| Men (Ref) | 1.00 | 1.00 | 1.00 |
| Women | 3.29 (1.85, 5.85) | 3.17 (1.68, 5.97) | 2.96 (1.69, 5.16) |
| Education | |||
| Less then high school (Ref) | 1.00 | … | … |
| High school or GED | 0.61 (0.25, 1.49) | … | … |
| At least some college | 0.46 (0.17, 1.25) | … | … |
| Marital status | |||
| Single (Ref) | 1.00 | … | … |
| Married | 1.02 (0.55, 1.92) | … | … |
| Divorced/separated/widowed/other | 0.86 (0.31, 2.40) | … | … |
| Children, no. | |||
| None (Ref) | 1.00 | 1.00 | 1.00 |
| 1 | 0.94 (0.41, 2.15) | 1.05 (0.48, 2.29) | 1.08 (0.51, 2.30) |
| 2 | 0.46 (0.20, 1.06) | 0.81 (0.41, 1.61) | 0.73 (0.37, 1.43) |
| 3 | 0.21 (0.08, 0.56) | 0.37 (0.16, 0.87) | 0.37 (0.16, 0.82) |
| > 3 | 0.54 (0.21, 1.42) | 0.64 (0.28, 1.48) | 0.60 (0.27, 1.35) |
| Other adults in the residence, no. | |||
| 1–2 (Ref) | 1.00 | 1.00 | 1.00 |
| 3 | 0.66 (0.31, 1.40) | 0.71 (0.33, 1.53) | 0.84 (0.40, 1.79) |
| 4 | 0.62 (0.29, 1.29) | 0.83 (0.40, 1.73) | 0.84 (0.41, 1.71) |
| > 4 | 0.44 (0.23, 0.86) | 0.55 (0.27, 1.10) | 0.65 (0.33, 1.27) |
| Year immigrated to United States | |||
| 1997–2004 (Ref) | 1.00 | 1.00 | 1.00 |
| 1970–1996 | 2.35 (1.30, 4.26) | 2.20 (1.23, 3.93) | 2.35 (1.33, 4.13) |
| Linguistic acculturation/preference levela | |||
| Low (Ref) | 1.00 | … | … |
| Moderate | 1.16 (0.60, 2.24) | … | … |
| High | 1.64 (0.81, 3.35) | … | … |
| Social acculturation/preference levela | … | … | |
| Low (Ref) | 1.00 | … | … |
| Moderate | 1.33 (0.72, 2.45) | … | … |
| High | 0.85 (0.46, 1.57) | … | … |
| Enabling characteristics | |||
| Total formal income in past year,b $ | |||
| None (Ref) | … | 1.00 | 1.00 |
| 1–10 000 | … | 1.83 (0.88, 3.83) | 2.18 (1.07, 4.45) |
| 10 001–20 000 | … | 1.94 (0.79, 4.77) | 2.33 (0.97, 5.58) |
| > 20 000 | … | 0.66 (0.17, 2.61) | 0.76 (0.19, 2.95) |
| Legal income not reported | … | 2.49 (1.05, 5.92) | 2.02 (0.92, 4.43) |
| Total informal income in past year,c $ | |||
| None (Ref) | … | 1.00 | 1.00 |
| 1–10 000 | … | 0.51 (0.26, 1.03) | 0.63 (0.33, 1.21) |
| 10 001–20 000 | … | 0.48 (0.21, 1.14) | 0.61 (0.27, 1.39) |
| > 20 000 | … | 0.60 (0.19, 1.93) | 0.73 (0.24, 2.28) |
| Informal income not reported | … | 0.48 (0.21, 1.12) | 0.56 (0.25, 1.22) |
| Health insurance coverage in past 6 months | |||
| No (Ref) | … | 1.00 | 1.00 |
| Yes | … | 2.34 (1.04, 5.26) | 2.96 (1.34, 6.55) |
| Day labor employment in past 6 months | |||
| Yes (Ref) | … | 1.00 | |
| No | … | 1.61 (0.82, 3.17) | |
| Money sent to family/friends in Mexico | |||
| No (Ref) | … | 1.00 | … |
| Yes | … | 1.39 (0.63, 3.05) | … |
| Social support | |||
| Low (Ref) | … | 1.00 | … |
| Medium | … | 1.02 (0.54, 1.92) | … |
| High | … | 1.56 (0.82, 2.98) | … |
| Discrimination experiencedd | |||
| No discrimination (Ref) | … | 1.00 | 1.00 |
| Race | … | 0.94 (0.43, 2.10) | 0.82 (0.37, 1.81) |
| Language | … | 0.56 (0.29, 1.09) | 0.51 (0.27, 0.98) |
| Immigrant status | … | 1.02 (0.49, 2.12) | 1.01 (0.49, 2.09) |
| Other | … | 0.26 (0.07, 0.93) | 0.46 (0.14, 1.51) |
| Health need | |||
| No. of days activities were limited by poor health in past 30 days | |||
| 0 (Ref) | … | … | 1.00 |
| 1–5 | … | … | 1.48 (0.68, 3.22) |
| > 5 | … | … | 1.16 (0.51, 2.60) |
Note. OR = odds ratio; CI = confidence interval; GED = general educational development. Model 1 regressed the outcome variable on predisposing characteristics. Model 2 regressed the depend variable on predisposing and enabling characteristics. Model 3 regressed the dependent variable on predisposing, enabling, and need characteristics. Predisposing characteristics incline people to use health services, enabling characteristics enable or impede use of health services, and need characteristics identify need for health care.
Assessed with a modified version of the 12-item Welfare Reform Baseline Interview acculturation module.28
Formal income is all reported and taxed income, including public assistance.
Informal income is all nonreported and nontaxed income.
Respondents were asked whether they experienced discrimination and, if so, what form most affected their lives.
In multivariable models (Table 4), emergency department care in the past 6 months was associated with higher educational attainment (OR = 3.01 for those who reported at least some college education compared with those who had less than a high school education; 95% CI = 1.20, 7.53), moderate levels of formal income in the past year (OR = 4.12 for $10 001–$20 000 compared with no formal income; 95% CI = 1.54, 11.00), and more days in which health limited usual activities in the past 30 days (OR = 4.75 for more than 5 days compared with 0 days; 95% CI = 2.14, 10.59).
TABLE 4.
Multivariable Associations Between Variables of Interest and Receipt of Care in an Emergency Department Among Undocumented Immigrants Born in Mexico: New York City, 2004
| Model 1, OR (95% CI) | Model 2, OR (95% CI) | Model 3, OR (95% CI) | |
| Predisposing characteristics | |||
| Age, y | |||
| 18–24 (Ref) | 1.00 | … | … |
| 25–34 | 0.94 (0.37, 2.43) | … | … |
| 35–44 | 1.26 (0.43, 3.70) | … | … |
| > 44 | 1.34 (0.32, 5.60) | … | … |
| Gender | |||
| Men (Ref) | 1.00 | 1.00 | … |
| Women | 1.87 (0.90, 3.87) | 1.79 (0.78, 4.11) | … |
| Education | |||
| Less then high school (Ref) | 1.00 | 1.00 | 1.00 |
| High school or GED | 0.43 (0.09, 1.99) | 0.13 (0.02, 1.03) | 0.35 (0.08, 1.57) |
| At least some college | 2.40 (0.88, 6.50) | 2.03 (0.78, 5.28) | 3.01 (1.20, 7.53) |
| Marital status | |||
| Single (Ref) | 1.00 | … | … |
| Married | 1.36 (0.60, 3.08) | … | … |
| Divorced/separated/widowed/other | 1.35 (0.38, 4.81) | … | … |
| Children, no. | |||
| None (Ref) | 1.00 | 1.00 | 1.00 |
| 1 | 0.69 (0.23, 2.02) | 0.76 (0.27, 2.18) | 0.94 (0.36, 2.45) |
| 2 | 0.50 (0.16, 1.51) | 0.52 (0.20, 1.38) | 0.95 (0.41, 2.22) |
| 3 | 0.56 (0.18, 1.78) | 0.66 (0.24, 1.80) | 0.90 (0.36, 2.24) |
| > 3 | 0.29 (0.07, 1.10) | 0.31 (0.09, 1.08) | 0.55 (0.19, 1.64) |
| Other adults in the residence | |||
| 1–2 (Ref) | 1.00 | … | … |
| 3 | 0.91 (0.34, 2.43) | … | … |
| 4 | 0.94 (0.36, 2.45) | … | … |
| > 4 | 0.93 (0.39, 2.23) | … | … |
| Year immigrated to United States | |||
| 1997–2004 (Ref) | 1.00 | 1.00 | … |
| 1970–1996 | 2.15 (1.01, 4.58) | 1.75 (0.82, 3.73) | … |
| Linguistic acculturation/preference levela | |||
| Low (Ref) | 1.00 | … | … |
| Moderate | 1.18 (2.76) | … | … |
| High | 0.70 (1.86) | … | … |
| Social acculturation/preference levela | |||
| Low (Ref) | 1.00 | … | … |
| Moderate | 1.67 (0.74, 3.77) | … | … |
| High | 1.33 (0.58, 3.03) | … | … |
| Enabling characteristics | |||
| Total formal income in past year,b $ | |||
| None (Ref) | … | 1.00 | 1.00 |
| 1–10 000 | … | 0.82 (0.29, 2.32) | 0.83 (0.30, 2.28) |
| 10 001–20 000 | … | 3.31 (1.17, 9.36) | 4.12 (1.54, 11.00) |
| > 20 000 | … | 2.28 (0.44, 11.77) | 2.61 (0.60, 11.28) |
| Legal income not reported | … | 0.77 (0.23, 2.51) | 1.10 (0.42, 2.86) |
| Total informal income in past year,c $ | |||
| None (Ref) | … | 1.00 | 1.00 |
| 1–10 000 | … | 1.55 (0.59, 4.04) | 1.69 (0.70, 4.10) |
| 10 001–20 000 | … | 0.75 (0.21, 2.63) | 0.96 (0.30, 3.05) |
| > 20 000 | … | 1.09 (0.19, 6.22) | 1.07 (0.19, 5.96) |
| Informal income not reported | … | 2.79 (0.91, 8.49) | 2.44 (0.90, 6.58) |
| Health insurance coverage in past 6 months | |||
| No (Ref) | … | 1.00 | … |
| Yes | … | 1.27 (0.49, 3.29) | … |
| Day laborer employment in past 6 months | |||
| Yes (Ref) | … | 1.00 | … |
| No | … | 0.78 (0.33, 1.85) | … |
| Money sent to family/friends in Mexico | |||
| No (Ref) | … | 1.00 | … |
| Yes | … | 0.86 (0.32, 2.28) | … |
| Social support | |||
| Low (Ref) | … | 1.00 | … |
| Medium | … | 0.61 (0.24, 1.55) | … |
| High | … | 1.90 (0.83, 4.35) | … |
| Discrimination experiencedd | |||
| No discrimination (Ref) | … | 1.00 | … |
| Race | … | 0.87 (0.28, 2.78) | … |
| Language | … | 1.30 (0.53, 3.16) | … |
| Immigrant status | … | 1.45 (0.53, 3.94) | … |
| Other | … | 2.00 (0.58, 6.88) | … |
| Health need | |||
| No. of days activities were limited by poor health in past 30 days | |||
| 0 (Ref) | … | … | 1.00 |
| 1–5 | … | … | 1.02 (0.35, 2.94) |
| > 5 | … | … | 4.75 (2.14, 10.59) |
Note. OR = odds ratio; CI = confidence interval; GED = general educational development. Model 1 regressed the outcome variable on predisposing characteristics. Model 2 regressed the depend variable on predisposing and enabling characteristics. Model 3 regressed the dependent variable on predisposing, enabling, and need characteristics. Predisposing characteristics incline people to use health services, enabling characteristics enable or impede use of health services, and need characteristics identify need for health care.
Assessed with a modified version of the 12-item Welfare Reform Baseline Interview acculturation module.28
Formal income is all reported and taxed income, including public assistance.
Informal income is all nonreported and nontaxed income.
Respondents were asked whether they experienced discrimination and, if so, what form most affected their lives.
DISCUSSION
Predisposing Characteristics
Social and family networks may be key determinants of access to and use of health services among undocumented immigrants living in urban areas. We found that women were almost 3 times as likely as men to report access to a regular health care provider. Although it is possible that women's needs for obstetric and gynecologic services may drive some of their greater likelihood of reporting access to a regular provider,17 evidence suggests that male Mexican immigrants living in New York City are joined by their spouses and children after first establishing themselves,21 a trend that has been observed more generally among Mexican immigrants to the United States.34 Therefore, it is possible that more women than men in our sample had the social and economic resources and the attendant stability that may be important to accessing health services. By contrast, research suggests that Mexican immigrants, particularly men who have recently immigrated to the United States, are more likely to live with extended kin and unrelated persons than are US-born Mexican Americans, possibly as a practical solution to changing levels of acculturation, resources, and the need for privacy over the life course.35,36
Predisposing characteristics predicted access to and use of health services even after accounting for enabling and need characteristics, including financial and social resources, implying that other mechanisms may be operating here. One potential pathway linking predisposing characteristics to access to and use of health services may be the ability to navigate the convoluted US healthcare system. Our finding that respondents arriving in the United States before 1997 were more likely to report access to a regular health care provider is consistent with previous work that showed that access to health services generally improves with increased time of residence in the United States.17
Access to health services among undocumented immigrants may improve with increased time of residence because of increased integration and improved familiarity with the US healthcare system over time. However, our findings may also reflect changes in legislation in the past decade. In 1996, the United States passed legislation that further restricted the provision of many publicly funded services to undocumented immigrants, making it perhaps even more difficult to obtain health services than it was before the legislation.9,10,18
We found that respondents who completed at least some college were more likely to receive care in an emergency department in the past 6 months than were respondents with less than a high school education. This observation may reflect greater knowledge about the US healthcare system and the types of health services available among better-educated undocumented immigrants.10 Previous work suggests that limited English proficiency and lower levels of acculturation may limit access to health services among immigrants.9,37 Our results did not confirm these findings. However, it is important to emphasize that our analysis focused exclusively on undocumented immigrants, among whom there may be substantially less heterogeneity in acculturation levels than in samples that include documented and undocumented immigrants.
Enabling Characteristics
Our findings suggest that personal resources, including financial and social resources, are important determinants of health insurance coverage and access to a regular provider among undocumented Mexican immigrants, even after accounting for differences in health need. This finding parallels past studies that showed that socioeconomic factors are important determinants of health care use among immigrants19 and Hispanics38 in general.
We observed a positive dose–response relationship between the total formal income earned in the past year and the likelihood of reporting health insurance coverage in the past 6 months. Those earning more than $20 000 per year in formal income were more than 6 times as likely to report access to health insurance as those earning no formal income in the past year. We also found that health insurance was the most important predictor of reporting access to a regular provider, a finding also consistent with prior work.39 By contrast, respondents sending remittances to family and friends in Mexico were less likely to report health insurance coverage, and those earning more informal income were not any more likely to report health insurance coverage or access to a regular health care provider than were those who earned less informal income. Together, these results suggest that undocumented immigrants' financial resources, and specifically their capacity to obtain formal employment, may be central determinants of their access to health services and likely of their health status overall.
Perhaps not surprisingly, delays in seeking care may be related to fears of discovery by government officials. Thus, undocumented immigrants' anxieties about obtaining care may represent a significant barrier to accessing health services in this group18,40; this previously was shown among undocumented immigrants with tuberculosis.15 Although we did not specifically ask about respondents' fears about obtaining services, we found that those with more social support were more likely to report access to health services. Undocumented immigrants with more social resources may be more attuned to the risks involved in accessing specific health services and more likely to overcome the fear associated with such attempts at access. By contrast, those experiencing social insults, such as discrimination, may be less likely to access health services. In our sample, respondents experiencing discrimination with respect to language were less likely to report access to a regular health care provider than were those who did not experience discrimination, suggesting the profound need for linguistically appropriate health services.
Need Characteristics
Undocumented Mexicans in New York City with more health need were more likely to report health insurance coverage and emergency department care, but not access to a regular health care provider. This is consistent with previous research among Hispanics showing that greater health care need is associated with emergency services use.38
The dependence on emergency services to address health care needs among undocumented Mexicans, although understandable given the barriers to regular-care access, may exacerbate the burden of pathology in this group because care is delayed until illness is severe enough to warrant emergency care.20
Limitations
There were several limitations to this study. We used venue-based sampling to recruit participants and were unable to calculate a response rate. However, our sampling method may have provided a more representative sample than alternative methods such as telephone interviews. The fact that 85% of people recruited for this study were indeed undocumented immigrants suggests that we were successful in identifying areas where undocumented immigrants congregated and in recruiting undocumented immigrants to participate. Furthermore, the demographic profile of our sample was consistent with what is known about undocumented Mexican immigrants living in New York City.21
It is possible that undocumented immigrants may underreport key areas of concern. In anticipation of this possibility, we used in-person anonymous interviews that in past research have been shown to be an effective approach to establish the sort of trust necessary to inquire about sensitive topics, such as legal status, and elicit accurate responses.18 In addition, the cross-sectional design of our survey did not capture temporal changes in the ability of undocumented immigrants to access health services. Prospective data are necessary to elucidate changes in the ability of undocumented immigrants to access health services over time.
Conclusions
There is substantial debate in US public discourse about how best to frame the issue of undocumented immigration and how best to respond to the challenges it entails. We showed that the use of health services in a sample of undocumented Mexican immigrants living in New York City was limited. Our data strongly suggest that greater ability to navigate the US health care system, greater access to social resources, and engagement of undocumented immigrants in the formal economy are associated with greater access to appropriate health services. Irrespective of political positions, the reality of millions of undocumented immigrants living in the United States suggests that it is imperative for us to understand the barriers to health care access among this group so that we may inform public discourse and develop effective interventions.
Acknowledgments
This research was supported in part by a grant from the National Institutes of Health (DA 017642).
Human Participant Protection
The study received institutional review board approval at the New York Academy of Medicine and New York University. All study participants provided oral consent during the interview. To preserve participants' anonymity, no identifying information was collected about participants.
Peer Reviewed
Contributors
A. Nandi performed the data analysis and was the lead author. S. Galea, G. Lopez, S. Strongarone, and D. C. Ompad developed the research topic, designed the study, and supervised data collection. V. Nandi made significant contributions to the analysis. All authors helped to originate ideas, interpret findings, and review drafts of the article.
References
- 1.Loue S, Mendez N. Health and health access among urban immigrants. In: Galea S, Vlahov D, eds. Handbook of Urban Health: Populations, Methods, and Practice New York, NY: Springer-Verlag; 2005:103–126 [Google Scholar]
- 2. The Foreign-Born Population: 2000 . Washington, DC: US Census Bureau; 2003 [Google Scholar]
- 3.Passel JS, Van Hook J, Bean FD. Demographic Profile of Unauthorized Migrants and Other Immigrants, Based on Census 2000: Characteristics and Methods . Washington, DC: Urban Institute; 2005 [Google Scholar]
- 4.Rust G. Health status of migrant farmworkers: a literature review and commentary. Am J Public Health 1990;80:1213–1217 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Aday LA. Health status of vulnerable populations. Annu Rev Public Health 1994;15:487–509 [DOI] [PubMed] [Google Scholar]
- 6.Marshall KJ, Urrutia-Rojas X, Mas FS, Coggin C. Health status and access to health care of documented and undocumented immigrant Latino women. Health Care Women Int 2005;26:916–936 [DOI] [PubMed] [Google Scholar]
- 7.Reed MM, Westfall JM, Bublitz C, Battaglia C, Fickenscher A. Birth outcomes in Colorado's undocumented immigrant population. BMC Public Health 2005;5:100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Walter N, Bourgois P, Loinaz HM, Schillinger D. Social context of work injury among undocumented day laborers in San Fransisco. J Gen Intern Med 2002;17:221–229 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Waddell B. United States immigration: a historical perspective. In: Loue S, ed. Handbook of Immigrant Health New York, NY: Plenum; 1998:1–18 [Google Scholar]
- 10.Kullgren JT. Restrictions on undocumented immigrants' access to health services: the public health implications of welfare reform. Am J Public Health 2003;93:1630–1633 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Loue S. Access to healthcare and the undocumented alien. J Leg Med 1992;13:271–332 [DOI] [PubMed] [Google Scholar]
- 12.Institute of Medicine Ending Neglect: The Elimination of Tuberculosis in the United States . Washington, DC: National Academies Press; 2000 [PubMed] [Google Scholar]
- 13.Black PH, Garbutt LD. Stress, inflammation and cardiovascular disease. J Psychosom Res 2002;52:1–23 [DOI] [PubMed] [Google Scholar]
- 14.Galea S, Nandi A, Vlahov D. The social epidemiology of substance use. Epidemiol Rev 2004;26:36–52 [DOI] [PubMed] [Google Scholar]
- 15.Asch S, Leake B, Gelberg L. Does fear of immigration authorities deter tuberculosis patients from seeking care? West J Med 1994;161:373–376 [PMC free article] [PubMed] [Google Scholar]
- 16.Enchautegui ME. Immigration impact on local employment and ethnic minorities. In: Carmon D, ed. Immigrants: Liability or Asset Haifa, Israel: Neaman Books; 1993 [Google Scholar]
- 17.Chavez LR, Cornelius WA, Jones OW. Mexican immigrants and the utilization of US health services: the case of San Diego. Soc Sci Med 1985;21:93–102 [DOI] [PubMed] [Google Scholar]
- 18.Berk ML, Schur CL, Chavez LR, Frankel M. Health care use among undocumented Latino immigrants. Health Aff 2000;19:51–64 [DOI] [PubMed] [Google Scholar]
- 19.Goldman DP, Smith JP, Sood N. Legal status and health insurance among immigrants. Health Aff 2005;24:1640–1653 [DOI] [PubMed] [Google Scholar]
- 20.Law S, Hutton M, Chan D. Clinical, social, and service use characteristics of Fuzhounese undocumented immigrant patients. Psychiatr Serv 2003;54:1034–1037 [DOI] [PubMed] [Google Scholar]
- 21. The Newest New Yorkers 2000 . New York, NY: New York City Department of City Planning; October 2004 [Google Scholar]
- 22.Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: application to medical care use and outcomes for homeless people. Health Serv Res 2000;34:1273–1302 [PMC free article] [PubMed] [Google Scholar]
- 23.Chavez LR, Cornelius WA, Jones OW. Utilization of health services by Mexican immigrant women in San Diego. Women Health 1986;11:3–20 [DOI] [PubMed] [Google Scholar]
- 24.Loue S, Faust M, Bunce A. The effect of immigration and welfare reform legislation on immigrants' access to health care, Cuyahoga, and Lorain counties. J Immigr Health 2000;2:23–30 [DOI] [PubMed] [Google Scholar]
- 25.Salcido RM. Use of services in Los Angeles County by undocumented families: their perceptions of stress and sources of support. Calif Sociol 1982;May:119–132 [Google Scholar]
- 26.Anthony JC, Vlahov D, Celentano DD, et al. Self-report interview data for a study of HIV-1 infection among intravenous drug users: description of methods and preliminary evidence on validity. J Drug Issues 1991;21:735–753 [Google Scholar]
- 27.Vlahov D, Anthony JC, Munoz A, et al. The ALIVE study, a longitudinal study of HIV-1 infection in intravenous drug users: description of methods and characteristics of participants. NIDA Res Monogr 1991;109:75–100 [PubMed] [Google Scholar]
- 28.Marin G, Sabogal F, Marin BVO, Otero-Sabogal R, Perez-Stable EJ. Development of a short acculturation scale for Hispanics. Hisp J Behav Sci 1987;9:183–205 [Google Scholar]
- 29.Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991;32:705–714 [DOI] [PubMed] [Google Scholar]
- 30. Measuring Healthy Days . Atlanta, Ga: Centers for Disease Control and Prevention; 2000 [Google Scholar]
- 31.Hennessy CH, Moriarty DG, Zack MM, Scherr PA, Brackbill R. Measuring health-related quality of life for public health surveillance. Public Health Rep 1999;109:665–672 [PMC free article] [PubMed] [Google Scholar]
- 32.Verbrugge LM, Merrill SS, Liu X. Measuring disability with parsimony. Disabil Rehabil 1999;21:295–306 [DOI] [PubMed] [Google Scholar]
- 33.Victora CG, Huttly SR, Fuchs SC, Olinto MT. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997;26:224–227 [DOI] [PubMed] [Google Scholar]
- 34.Hondagneu-Sotelo P. Gendered Transitions: Mexican Experiences of Immigration . Berkeley: University of California Press; 1994 [Google Scholar]
- 35.Blank S. Hearth and home: the living arrangements of Mexican immigrants and U.S.-born Mexican Americans. Sociol Forum 1998;13:35–59 [Google Scholar]
- 36.Blank S, Torrecilha RS. Understanding the living arrangements of Latino immigrants: a life course approach. Int Migr Rev 1998;32:3–19 [PubMed] [Google Scholar]
- 37.Lara M, Gamboa C, Kahramanian MI, Morales LS, Bautista DE. Acculturation and Latino health in the United States. Annu Rev Public Health 2005;26:367–397 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Wagner TH, Guendelman S. Healthcare utilization among Hispanics: findings from the 1994 minority health survey. Am J Manag Care 2000;6:355–364 [PubMed] [Google Scholar]
- 39.Hubbell FA, Waitzkin H, Mishra SI, Dombrink J, Chavez LR. Access to medical care for documented and undocumented Latinos in a southern California county. West J Med 1991;154:414–417 [PMC free article] [PubMed] [Google Scholar]
- 40.Berk M, Schur C. The effect of fear on access to care among undocumented immigrants. J Immigr Health 2001;3:151–156 [DOI] [PubMed] [Google Scholar]