SAN DIEGO STATE UNIVERSITY
UNIVERSITY OF CALIFORNIA, SAN DIEGO
Mental Health and Quality of Life of Undocumented Latino Immigrants in the CaliforniaMexico Border: Risks and Protective Factors
A dissertation proposal submitted in partial satisfaction of the
Requirements for the degree Doctor of Philosophy
in
Clinical Psychology
by
Luz M. Garcini
Committee in charge:
San Diego State University
Professor Elizabeth A. Klonoff, Chair
Professor John P. Elder
Professor Vanessa L. Malcarne
University of California, San Diego
Professor Neil Doran
Professor Mark G. Myers
Professor Monica D. Ulibarri
2013
The Dissertation Proposal of Luz M. Garcini is approved, and it is acceptable
in quality and form:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Chair
San Diego State University
University of California, San Diego
2013
iii
TABLE OF CONTENTS
Signature Page …........................................................................................................... iii
Table of Contents ….......................................................................................................
iv
List of Abbreviations ….................................................................................................. vii
Acknowledgements …....................................................................................................
ix
Abstract …......................................................................................................................
11
Introduction …................................................................................................................
14
The Foreign-Born Latino Population .................................................................
15
Undocumented Latino Immigrants ..................................................................... 17
Background ..................................................................................................................... 20
Mental Health of Undocumented Immigrants .................................................... 20
Immigration-Related Risk Factors .....................................................................
22
Protective Factors ...............................................................................................
26
Culture and Context Sensitive Mental Health Assessment with Latinos .......................
28
Cultural Concepts of Distress ............................................................................
28
Nervios and Ataque de Nervios among Latino Immigrants....................
30
Contextual Concepts of Distress among Immigrants .........................................
33
Ulysses Syndrome ...................................................................................
34
Theoretical Framework and Significance .......................................................................
36
New Contribution ...............................................................................................
36
General Aims ......................................................................................................
37
Phase One: Formative Study ..........................................................................................
38
Specific Aims .....................................................................................................
38
iv
Method ............................................................................................................... 38
Participants ............................................................................................ 38
Inclusion/Exclusion Criteria ................................................................. 39
Protection of Research Participants ...................................................... 39
Design ................................................................................................... 40
Measures ............................................................................................... 41
Translation ............................................................................................ 41
Analyses ...............................................................................................
42
Phase Two: Clinical Study ...........................................................................................
44
Specific Aims ...................................................................................................
44
Method .............................................................................................................
46
Participants ..........................................................................................
46
Targeted Sampling ..............................................................................
47
Respondent Driven Sampling .............................................................
47
Inclusion/Exclusion Criteria ...............................................................
49
Power Analyses ...................................................................................
50
Protection of Research Participants ....................................................
52
Design .................................................................................................
53
Measures .............................................................................................
53
Translation ..........................................................................................
67
Analyses .............................................................................................
68
Hypotheses .........................................................................................
68
Table 1. Demographic and socio-economic characteristics by immigration legal
v
status categories .............................................................................................................. 73
Table 2. Lifetime prevalence of mental health disorders among Latinos ...................... 74
Table 3. Assessment of Cultural and Contextual Concepts of Distress ........................ 75
Figure 1. Dahlgreen & Whitehead (1991) Socioecological Model ............................... 78
Appendix A: Screening Questions for Participation in Focus Groups .......................... 79
Appendix B: Mental Health Services Contact List .......................................................
80
Appendix C: Demographic Questionnaire: Focus Groups ...........................................
81
Appendix D: Focus Groups Guided Discussion Questions .........................................
83
Appendix E: Translation Forms ...................................................................................
84
Appendix F: Screener for Participation Eligibility in Quantitative Study ...................
91
Appendix G; Questionnaire and Measures for Quantitative Study ..............................
92
References .................................................................................................................... 114
vi
List of Abbreviations
ACS
American Community Survey
PA
American Psychological Association
BSI-18
Brief Symptom Inventory-Brief
BSI-46
Bradford Somatic Inventory
CIDI
Composite International Diagnostic Interview
CDCPAR
Cancer Disparities Community Partners and Research
CFI
Cultural Formulation Interview
DREAMers
Development, Relief, and Education for Alien Minors Act
DSM
Diagnostic and Statistical Manual of Mental Disorders
EMIC
Explanatory Model Interview Catalogue
GAD
Generalized Anxiety Disorder
HTQ
Harvard Trauma Questionnaire
ICD
International Classification of Diseases
INS
Immigration and Naturalization Services
IRB
Institutional Review Board for the Protection of Human Subjects
M.I.N.I.
Mini International Neuropsychiatric Interview
MDD
Major Depressive Disorder
MLS
Multidimensional Loss Scale
NIMH
National Institute of Mental Health
NLAAS
National Latino and Asian American Study
PI
Principal investigator
vii
PMLD
Post-Migration Living Difficulties Questionnaire
PTSD
Post-traumatic Stress Disorder
QOL
Quality of life
RDS
Respondent Driven Sampling
SCI-2
Sense of Community Index Version 2
SCID
Structured Clinical Interview for DSM diagnosis
SDPRC
San Diego Prevention Research Center
SDSU
San Diego State University
SPSS
Statistical Package for the Social Sciences Software
UCSD
University of California, San Diego
UIs
Undocumented immigrants
US
United States
WHO
World Health Organization
WHOQOL-BREF
World Health Organization Quality of Life Questionnaire-Brief
viii
Acknowledgements
Con infinito agradecimiento a mis mentores y profesores Elizabeth Klonoff, Vanessa
Malcarne, Guadalupe Ayala, John Elder, Monica Ulibarri, Neil Doran, Mark Myers, Ana
Navarro and Kate Murray, por sus valiosas enseñanzas, guia, y apoyo durante los pasados cinco
años en el programa. Este trabajo no seria posible sin todos ustedes. Gracias tambien a mi
mentor Jeff Baker por haber creido en mi y por ser un modelo ejemplar de dedicacion en este
bello campo.
Mi agradecimiento tambien va para mis companeros y amigos, Luis Medina y Sheeva
Mostoufi, por ayudarme, aconsejarme y guiarme en el proceso de esta propuesta. Gracias por
tomarme de la mano y caminar conmigo.
Tambien me gustaria reconocer el apoyo financiero de Humberto B. Galvan durante mi
desarrollo academico, asi como a Ford Fellowship Foundation y a UCSD San Diego Fellowship
program por haber invertido en mi. Este trabajo es parte del resultado.
A mis hijos, Thania y Baruch Galvan, no tengo palabras suficientes que puedan expresar
lo mucho que agradezco su presencia en mi vida. Ustedes son mi motor y mi empuje. Mi trabajo
y mi vida entera estan dedicados a ustedes. A mis hermanos, Carlos y Ana, gracias por existir, y
a mis padres Luz y Carlos, gracias por darme el ser. Sin ello, este trabajo no existiria! Gracias
tambien a mis cachorros, Benito y Clarita, por su constante compania durante largas horas de
trabajo. Nunca han dejado que me sienta sola.
Especial agradecimiento es para los millones de immigrantes indocumentados que luchan
dia a dia en este pais por salir adelante. Gracias por producir y servirnos la comida que
comemos, por mantener y cuidar las casas en las que vivimos, por atender y velar por nuestros
ix
hijos y familias como si fueran propias, pero sobre todo, gracias por ser un vivo ejemplo de que
“Si se puede!” Gloria, te recurdo y tu muerte no fue en vano. Te llevo a ti y a tu familia en mi
pensamiento y este trabajo es el resultado. Gracias por darme un proposito.
Tambien, gracias a Margaret Kahn, Susan Wooley, Marina Plon, Issac Plon, Richard
Alter, Karina Miranda, Lorena Nuno, Abel Gomez, Carlos Mendez y Rosa Zepeda, porque cada
uno de ustedes me ayuda a levantar cuando me cuesta trabajo caminar. Gracias por estar
presentes en mi vida.
Sobre todas las cosas, gracias a Dios por ser mi roca, mi fortaleza y mi guia en todo
momento. “Porque yo sé muy bien los planes que tengo para ustedes —afirma el Señor—,
planes de bienestar y no de calamidad, a fin de darles un futuro y una esperanza” (Jeremias,
29:11)
x
11
ABSTRACT OF THE DISSERTATION
Mental Health and Quality of Life of Undocumented Latino Immigrants in the
California-Mexico Border: Risks and Protective Factors
by
Luz M. Garcini
Doctor of Philosophy in Clinical Psychology
San Diego State University, 2013
University of California, San Diego, 2013
Professor Elizabeth A. Klonoff, Chair
Background: Undocumented Latino immigrants (UIs) and their families make up a
considerable proportion of the US population at-risk for mental health distress. Yet,
research to inform the mental health and quality of life (QOL) of UIs is scant and
existing studies often lack scientific rigor. Objective: This study aims to use the socioecologic framework and context-sensitive methodology to study risk and protective
factors associated with mental health outcomes among UIs living in San Diego and
surrounding areas. Design: This study has two phases. In phase one, focus groups with
30 Latino immigrants knowledgeable about the undocumented population in San
Diego will be conducted to gather qualitative data to: (1) assess the perceived
12
relevance of mental health as a concern among UIs; and (2) obtain feedback on the
proposed methodology for the clinical mental health assessments to be undertaken in
phase two. Phase two is a cross-sectional study aimed to: (1) assess the prevalence of
mental health disorders among UI Latinos and compare it to rates for other US
populations; (2) evaluate the QOL of UIs and identify its association with mental
health; (3) identify demographic, socioeconomic and immigration-related risk factors
associated with mental health disorders among UIs; and (4) identify moderators of the
association between immigration-related loss/trauma and mental health among UI
Latinos. The cross-sectional study will use semi-structured clinical interviews to
assess the mental health and QOL of approximately 200 UIs Latino adults.
Recruitment will utilize Respondent Driven Sampling (RDS) with the collaboration of
networks-based referrals from the SDSU/UCSD Disparities Community Partners and
Research (CDCPAR) Resource. Measures: Mental health disorders will be assessed
primarily using the Spanish version of the M.I.N.I. International Neuropsychiatric
Interview, as well as adapted versions of the Diagnostic and Statistical Manual for
Mental Disorders 5th Edition (DSM-V) Cultural Formulation Interview (CFI) for the
assessment of Cultural and Contextual Concepts of Distress. Analysis: Qualitative
data will be analyzed using systematic methods outlined by Miles and Huberman
(1994), whereas multivariate sequential regression analyses will be used to assess
quantitative associations of interest. Significance levels will be set at p ≤ .05.
Conclusion: Results will increase understanding of the mental health needs of UI
Latinos, which is important to decrease inappropriate use of healthcare services, and
13
ensure a healthier workforce and community, as well as to inform the development of
interventions and policies.
14
I. INTRODUCTION
A current important issues in the global policy agenda is that of international
migration, that is, the movement of people across international boundaries, given its
enormous impact on the economy, society, culture and health indicators of countries
of origin, transit and destination. According to the World Health Organization (WHO)
(2010), international migration is at its all-time-high with more than 230 million
people or approximately 3% of the world’s population being international migrants.
This estimate represents an approximate 34% increase in the international migrant
population over the past two decades, with the greatest flow of migration taking place
from less developed to more industrialized countries, as migrants cross borders in
search of better economic and social opportunities (WHO, 2010). For more than two
decades, the United States (US) has been identified as the most popular destination for
international migrants, with an average annual immigration growth of 2.8% (WHO,
2010). Recent estimates show that approximately 13% of the US population is foreignborn, with immigrants from Latin America comprising the majority of the US foreignborn population (53%) (US Census Bureau, 2012). If population trends remain
unchanged, it is estimated that nearly one in five Americans will be foreign-born by
2050, with a large proportion being Latinos (Pew Research Center, 2013). The
increase in global mobility, advances in communication infrastructure, demand-pull
factors in the US (e.g., family unification, economic opportunity) and supply-push
factors in sending countries (e.g., poverty, violence), make it likely that Latinos will
continue to migrate to the US at a fast rate. Thus, it is in the best interest of this
15
country to increase knowledge about the complex needs and health status of Latino
immigrants by putting it at the forefront of national policy, public health initiatives,
economic planning, and research agendas.
The foreign-born Latino population in the United States
Foreign-born Latinos in the US vary widely in terms of country of origin,
geographic distribution, demographics, socio-economic position, health status, and
immigration-related characteristics. For example, of the approximately 21 million
foreign-born Latinos in the US, 11.7 million or more than half (55%) are of Mexicanorigin (US Census Bureau, 2012). This means that of the total US foreign-born
population, more than 29% were born in Mexico (US Census Bureau, 2012). Also,
despite recent increases in foreign-born Latino populations across various US states,
California continues to be the state with the largest number of foreign-born Latinos,
including housing the majority of UIs (Brown & Lopez, 2013). Several counties in
Southern California, including those near the California-Mexico border, have been
identified as having a rapid growth in their foreign-born Latino population,
particularly of Mexican origin (Brown & Lopez, 2013). If these population trends
continue, the Latino immigrant population in this region will grow at a faster rate than
the population as a whole, in both the US and Mexico (Immigration Policy Center,
2012).
When compared to the US-born population, foreign-born Latinos differ
considerably in demographic and socioeconomic characteristics. According to the
American Community Survey (ACS) (2012), the majority of foreign-born Latinos
(55%) is between the ages of 18-44 years, whereas only 35% of the US-born
16
population is within such age range. Disparities in educational attainment are also
evident with a greater proportion of foreign-born Latinos reporting lower levels of
education when compared to the US-born general population. The aforementioned
disparities in age and education highlight the important contribution of foreign-born
Latinos to a productive workforce in secondary job markets, which is essential to
foster economic growth in the US. Unfortunately, disparities in poverty rates are also
evident between foreign-born Latinos and the US-born population, with a greater
number of foreign-born Latinos living in poverty (18 versus 10% respectively).
Important to note is that the aforementioned estimates are based on national data not
likely to be inclusive of UIs; thus, it is possible that the previously mentioned socioeconomic disparities may be even larger than reported for certain foreign-born Latino
subgroups, specifically UIs.
Health disparities have also been documented between foreign-born Latinos
and their US-born counterparts, with greater advantage found among the foreign-born
(Cunningham, Ruben, & Narayan, 2008). Some potential explanations to the health
advantage observed among foreign-born Latinos have been attributed to: (a) better
lifestyles before and immediately following migration to the US; (b) extensive social
support, and (c) health selection through immigration screening (Cunningham, et al.,
2008). Although it is possible that these explanations may be valid for some foreignborn subgroups, it is also likely that these assumptions may not hold truth for most
disadvantaged immigrants (e.g., UIs). Unfortunately, foreign-born Latinos are often
studied as a homogeneous group, without much attention given to within group
differences, including variations among those differing in immigration legal status.
17
UIs, who often immigrate to the US as a result of harsh living conditions in their
country of origin, must face distressing and marginalized lifestyles while residing in
the US (Garcini, Murray, Zhoe, Klonoff, Myers, & Elder, under review). Faced with
restricted opportunities for legalization and family reunification, the distress
experienced by UIs often becomes chronic and more severe. Extensive research shows
that the health advantage of foreign-born Latinos, often dissipates over time, with
longer time of residence in the US associated with significant deterioration in health
status (Cunningham, et al., 2008). Research to inform on the health status of
disadvantaged foreign-born Latinos, including UIs, is needed to elucidate on existing
health disparities so that effective prevention and treatment alternatives may be
developed (Vega, Rodriguez, & Gruskin, 2009).
Undocumented Latino immigrants in the United States
A current national political debate is the issue of defining a path towards
legalization to address the millions of UIs in the US. It is estimated that only about
29% of foreign-born Latinos are naturalized citizens, with the rest being non-citizens
(71%), including legal residents and UIs (American Immigration Council, 2012). UIs
and individuals living in “mixed-status” families, that is, families in which at least one
member is undocumented, make up a considerable proportion of the US population. It
is estimated that in 2011 there were approximately 11 million UI Latinos in the US;
approximately 4% of the total US population (Pew Research Center, 2013). UIs
comprise about 30% of the US foreign-born population, with the majority being of
Mexican-origin (Pew Research Center, 2013). Also, there are approximately 4.5
million US-born children whose parents are unauthorized (Passel & Cohn, 2009;
18
2010; 2012), and at least 9 million Latinos living in “mixed-status” families (Taylor,
Lopez, Passel, & Motel, 2011). Moreover, estimates show that UIs comprise 5.4% of
the US workforce, accounting for up to 10% of the labor force in states such as
California (Passel & Cohn, 2009). Also, it is estimated that one in four farmworkers is
an UI, and that UIs comprise a large proportion of jobs in the construction, food,
transportation and maintenance industries. Unfortunately, most UIs and their families
experience socioeconomic disadvantage. When compared to the general foreign-born
Latino population, UIs have lower educational attainment and higher poverty rates.
These socioeconomic disparities become even greater when UIs are compared to the
general US-born population. Table 1 summarizes some of the aforementioned
disparities by immigration legal status.
Although some UIs eventually return to their country of origin, a good
proportion decides to stay and establish permanent residence in the US. Most UIs that
make the US their permanent residence include those able to reunite with their
families in the US, as well as those with US-born children. Estimates show that
approximately 43% of UIs have resided in the US for more than 10 years (Passel &
Cohn, 2008). The negative effects on health of socioeconomic disadvantage,
marginalization, and demanding work conditions over time are widely documented
(Commission on Social Determinants of Health, 2008), as is the economic impact of
poor health on the healthcare system. Yet, there is growing proportion of foreign-born
Latinos, particularly UIs and their US-born children, for whom such negative health
effects may become reality over time. Identifying protective factors to ameliorate the
negative health effects of poverty, marginalization and harsh living environments in
19
this population is necessary to develop prevention interventions, reduce healthcare
cost, and inform policy.
20
II. BACKGROUND
Immigrant health has been a seriously neglected area of research, although this
is gradually changing with a recent increase in studies focusing in quality and use of
healthcare among at-risk immigrants, including UIs. Unfortunately, research to
understand the effects of immigration legal status, particularly undocumented status,
on physical and mental health is limited. Given that UIs make up a considerable
proportion of the US population and its workforce, facilitating understanding of their
wellbeing and mental health challenges is important to decrease inappropriate use of
healthcare services, and ensure a healthier workforce and community, as well as to
inform the development of interventions and policies.
Mental health of undocumented immigrants in the United States
According to Healthy People 2020, mental health is 1 of 12 leading health
indicators given it is essential to a person’s wellbeing, quality of life, physical
functioning, interpersonal relationships, and productivity (US Department of Health
and Human Services). The association between mental health and quality of life is
widely documented, with better mental health associated to increased wellbeing. In a
study of UI Latinos from the 2009 San Diego Prevention Research Center (SDPRC)
Community survey, depression was found to be the only factor significantly associated
with poor quality of wellbeing scores (β =-13.34, 95% CI = -22.32, -4.36, p = 0.01),
after controlling for demographic, socioeconomic and migration-related factors,
including length of time in the US and language acculturation (Garcini, Renzaho,
Molina, & Ayala, in preparation). The immigration path to the US often presents with
21
multiple stressors and complex challenges at different stages of the migration process,
which increase risk for emotional disturbance and may compromise mental health
(Chung, Bernak, Ortiz, & Sandoval-Perez, 2008; Sluzki, 1979; Ornelas & Perreira,
2011). UIs are a population at increased risk for mental health distress given the
additional complex stressors that these population face above and beyond those of
documented immigrants (Sullivan & Rehm, 2005).
Research to explore determinants of health among UIs has increased
considerably within the past decade; however, a recent systematic review of 23 studies
showed that there is very little research to inform the wellbeing and mental health of
UIs, and that existing studies often lack scientific rigor and are limited in providing
prevalence data for mental health disorders and associated risk factors (Garcini, et al.,
under review). The use of self-report, imprecise measurement, and the limited
analysis of mental health outcomes by immigration legal status also make it
challenging to identify the prevalence of mental health disorders among UIs. Among
the few studies reporting on prevalence of mental health disorders in this population,
only one provided actual Diagnostic and Statistical Manual for Mental Disorders 4th
Edition (DSM-IV) diagnosis. This study explored the prevalence and predictors of
PTSD among 212 UIs at their point of entry to the US (Rasmussen, Rosenfeld,
Reeves, & Keller, 2007). Results from this study showed that 11% of UIs (95% CI =
0.07, 0.16) met criteria for PTSD, with at least 82% of participants reporting having
experienced previous trauma. When compared to national estimates using data from
the National Latino and Asian American Study (NLAAS) for US-born and foreignborn Latinos, the prevalence of PTSD among UIs was considerably higher (5.9%, 95%
22
CI = 0.04, 0.07 and 4.0%, 95% CI = 0.03, 0.05, respectively) (Alegria, Canido, Shrout,
Woo, Duan, Vila, et al., 2008). The aforementioned disparities in the prevalence of
PTSD across Latino subgroups suggests that the mental health advantage often
reported among foreign-born Latinos, may not accurately reflect that of UIs,
particularly in regards to trauma and stress related disorders.
Moreover, although not specifically reported based on DSM-IV diagnosis,
research shows that depression is also prevalent among UIs. A preliminary study using
data from the 2009 SDPRC Community survey on 397 Latino immigrants (15%
undocumented) showed that 12% of UIs reported moderate to severe levels of
depression, with depression identified as a significant predictor of wellbeing after
controlling for relevant covariates (Garcini, et al., in preparation). Likewise, in a study
of 90 Mexican-origin immigrant women (67% undocumented), results showed
undocumented women not qualifying for amnesty to have significantly higher levels
of depression when compared to UIs qualifying for amnesty and legal residents
(Rodriguez & DeWolfe, 1990). Various qualitative studies have also render support
for depression as a relevant concern among UIs, along with anxiety, somatization, and
substance use/abuse disorders (Garcini, et al., under review). Additional studies to
provide background data on the prevalence of the aforementioned mental health
disorders among UIs that is based on DSM-V or ICD-10 diagnosis are needed to
inform decision-making and the provision of health services.
Immigration-related risk factors
Psychological distress has been identified as common to the undocumented
experience with stressors varying across different stages of the immigration process
23
(Garcini, et al., under review). Salient stressors identified as common among UIs premigration include having a sense of failure related to the inability to succeed in the
country of origin, as well as history of political/war trauma (Horton, 2009; Paris,
2008; Walter, Bourgois, & Loinaz, 2004). Dangerous border crossing, including
exposure to environmental hazards, violence and extortion from immigration
authorities and organized crime, witnessing death of others while crossing, and
abandonment by border crossing guides or “coyotes,” have also been identified as
salient stressors experienced in-transit (DeLuca, McEwen, & Keim, 2010; Infante,
Idrovo, Sanchez-Dominguez, Vinhas, & Gonzalesz-Vazquez, 2012; McGuire &
Georges, 2003; Paris, 2008).
Additionally, multiple post-migration stressors are faced by UIs upon their
arrival to the US, which often become chronic stressors over time. A salient
contextual stressor often experienced among UIs is marginalization and isolation. This
includes experiencing a restricted existence due to a limited social sphere of activity,
isolation from the larger community, separation from family and friends, inability to
travel internationally to visit family or during emergencies, and experiencing a sense
of voicelessness, invisibility, and “loss of all rights” (Abrego, 2006; Aroian, 1993;
Ellis & Chen, 2013; Hass, Dutton, & Orloff, 2000; Hondagnew-Sotelo & Avila, 1997;
Horton, 2009; Infante, et al., 2012; Joseph, 2011; McGuire & Georges, 2003; Paris,
2008; Walter, et al., 2004). Fear of deportation and limited resources, including
trouble getting employment, financial difficulties, limited access to healthcare, poor
housing and unsafe neighborhoods, have also been identified as relevant concerns in
this population (Abrego, 2006; Aroian, 1993; Ellis & Chen, 2013; Hass, et al., 2000;
24
Infante, et al., 2012; Joseph, 2011; McGuire & Georges, 2003; Paris, 2008; Walter, et
al., 2004). One study identified food insecurity/hunger as a stressor among UIs (28%),
and a significant predictor of poor mental (p = .04) and physical health (p < .0001)
(Hadley, et al., 2008). Exploitability and victimization, including working strenuous
jobs and demanding work schedules, low wages, working without benefits and
enduring silent physical, psychological, and sexual abuse associated to domestic
violence for fear of deportation, have also been identified as stressors commonly
experience by UIs post-migration (Aroian, 1993; Hass, et al., 2000; HondagnewSotelo & Avila, 1997; McGuire & Georges, 2003; Sabina, Cuevas, & Sebally, 2013).
Acculturation, that is difficulties transcending cultural differences in terms of
beliefs, values, and behaviors, as well as difficulties communicating due to limited
English proficiency, have also has been identified as salient difficulties for UIs postmigration. UIs with limited English proficiency have been identified as most at-risk
for experiencing acculturative stress, as well as those with deficits in stress-coping
resources and strong attachments to their families in the country of origin (Miranda &
Matheny, 2000; Sanchez, Dillon, Ruffin, & De La Rosa, 2012). Regarding the
association between length of time in the US and mental health outcomes, studies have
found that longer time lived in the US was associated with increased mental health
distress among UI adults (Hadley, et al., 2008; Santos, Bohon, & Sanchez-Sosa,
1998).
In addition to the aforementioned contextual stressors, UIs experience various
intrapersonal and interpersonal stressors post-migration. Intrapersonal stressors
commonly experienced by UIs include: (a) identity shift related to changes in gender
25
and family roles/expectations, which differ from the immigrant’s culture (e.g., from
mother/wife in country of origin to laborer/provider in the US) (Hondagnew-Sotelo &
Avila, 1997; Horton, 2009; Paris, 2008; Walter, et al., 2004); (b) variation in selfperception associated with changes in racial classification (e.g., from being perceived
as “White” in country of origin (Brazil) to “Latino” in the US) (Joseph, 2011); (c)
internalization of the undocumented stereotype, which may be associated to decreased
self-esteem, a sense of being burdensome, guilt/shame, and a loss of motivation
(Abrego, 2006; Ellis & Chen, 2013); (d) distressing emotions associated with a sense
of moral failing for leaving family behind, as well as resentment or guilt among UIs
living in mixed-status families in which some members have documentation and
greater access to resources/opportunities not available to undocumented family
members (Horton, 2009; Walter, et al., 2004); and (e) deception associated with
downward social mobility and limited opportunities, primarily among UIs with higher
educational attainment in their country of origin who settle for jobs in the US
secondary markets, as well as for DREAMers who despite excellence in their early
academic achievements may not have opportunities to further their studies (Abrego,
2006; Aroian, 1993; Ellis & Chen, 2013; Joseph, 2011). Interpersonal stressors are
also common to the undocumented experience. For example, strained family
relationships and conflicts resulting from displacement of negative emotions onto
others, specifically jealousy and anger toward those with a documented status or
towards other UIs who may represent competition for jobs/resources, have been
reported as prevalent (Aroian, 1993; Ellis & Chen, 2013; Hondagnew-Sotelo & Avila,
1997; Horton, 2009; McGuire & Georges, 2003; Paris, 2008; Walter, et al., 2004).
26
Discrimination and stigmatization on the basis of race, language proficiency, and antiimmigrant sentiments are also common (Chavez, 1994; Ellis & Chen, 2013; Infante, et
al., 2012; Joseph, 2011).
UIs are clearly an at-risk population for emotional and mental health distress
given the many stressors that they faced, which are often experienced over time and
endured under harsh living conditions. UIs represent a marginalized group, for whom
access to health services, including mental health services, is restricted and limited;
thus, increasing risk for the progression towards more severe psychopathology over
time. Identifying protective factors that may reduce the negative effect of migrationrelated stress on the mental health of UIs is important to inform prevention efforts,
public health action and policy development.
Protective factors
Research to identify protective factors likely to ameliorate the effect of
migrant-related stressors on the mental health of UIs is extremely limited, and most
studies that exist are qualitative (Garcini, et al., under review). Some protective factors
previously identified in the qualitative literature include: (1) building and maintaining
adequate social support and sense of community, which includes maintaining close
family ties with those left in the country of origin; (2) resourcefulness and creativity to
find viable solutions to social challenges, which includes becoming proficient in
English and development of job skills; (3) religiosity and/or spirituality; (4) having an
optimistic view of the future, which includes reframing the undocumented experience
in a more positive way; and (5) experiencing increased empathy for marginalized
others (Aroian, 1993; Chavez, 1994; Ellis & Chen, 2013; McGuire & Georges, 2003;
27
Paris, 2008). Among the few quantitative studies that exist, most have focused
exclusively on social support as a protective factor, with one study reporting higher
levels of social support to be associated with lower symptoms of depression and
anxiety (Potochnick & Perreira, 2010). Additional research is needed to better
understand the effect of the aforementioned protective factors as moderators to the
association between migration-related stress and mental health outcomes in this
population.
28
III. CULTURE AND CONTEXT-SENSITIVE MENTAL HEALTH
ASSESSMENT WITH LATINO UNDOCUMENTED IMMIGRANTS
According to the American Psychological Association Multicultural Guidelines,
investigators should aim to “apply culturally-appropriate skills [and measures] in their
research and clinical practice” (APA, 2002, p. 43). This includes incorporating the use
of culture and context-sensitive methodologies, as well as assessment measures that
are relevant and adapted for use with the target population. The use of culture and
context-sensitive assessments is essential to acquire an understanding of the ways in
which relevant experiences relate to presenting psychological distress, as well as to
avoid misdiagnosis. Thus, additional attention must be given to the study and
assessment of Cultural Concepts of Distress, previously referred to as Culture-Bound
Syndromes (American Psychiatric Association, 2013), and their patterns of association
to more traditional DSM-V diagnosis. Likewise, the study of contextual concepts of
distress, such as that experienced among marginalized immigrants, including UIs, is
necessary for the development and provision of context-sensitive interventions
(Achotegui, 2005).
Cultural Concepts of Distress
According to the DSM-V, Cultural Concepts of Distress refer to “ways that
cultural groups experience, understand, and communicate suffering, behavioral
problems, or troubling thoughts and emotions” (American Psychiatric Association,
2013, p. 758). The DSM-V identifies three different types of cultural concepts needed
29
to better understand distress among diverse populations (American Psychiatric
Association, 2013). These include:
a. Cultural syndromes, which represent “clusters of symptoms and attributions
that tend to co-occur among individuals in specific cultural groups,
communities, and contexts and that are recognized locally as coherent patterns
of experience” (American Psychiatric Associatino, 2013, p. 758).
b. Cultural idioms of distress, which are “ways of expressing distress that may
not involve specific symptoms or syndromes, but that provide collective,
shared ways of experiencing and talking about personal or social concerns
(e.g., everyday talk about “Nervios”) (American Psychiatric Association, 2013,
p. 758).
c. Cultural explanations or perceived causes, which are “labels, attributions, or
features of an explanatory model that indicate culturally recognized meaning
or etiology for symptoms, illness, or distress” (American Psychiatric
Association, 2013, p. 758).
Research on Cultural Concepts of Distress is helpful to integrate cultural and
clinical knowledge in a way that it may be feasible to provide “diagnostic
universality” and “cultural specificity” (Guarnaccia & Martizen-Pincay, 2005).
Nevertheless, although some associations have been suggested between certain
psychiatric diagnosis and some Cultural Concepts of Distress (e.g., Ataque de Nervios
and its association to Panic Attacks), no clear one-to-one relationships have been
established. Additional studies are needed to better understand potential associations
and/or differences between Cultural Concepts of Distress and traditional mental health
30
disorders based on DSM-V diagnosis. As previously mentioned, this information is
necessary for the development of more appropriate and effective interventions among
diverse populations.
Nervios and Ataque de Nervios among Latino Immigrants. Among Latino
immigrants, two specific Cultural Concepts of Distress that have recently received
attention include “Nervios” and “Ataque de Nervios.” According to DSM-V, Nervios
refers to “a general state of vulnerability to stressful life experiences and to difficult
life circumstances . . . [which is characterized by] a wide range of symptoms of
emotional distress, somatic disturbance, and inability to function” (American
Psychiatric Association, 2013, p. 835). Some DSM-V conditions that appear to be
related to Nervios include Major Depressive Disorder (MDD), dysthymia, Generalized
Anxiety Disorder (GAD), Social Anxiety Disorder, and Somatic Symptom Disorder
(American Psychiatric Association, 2013). According to DSM-V, Ataque de Nervios
may be considered as “normative expressions of acute distress” that are characterized
by “symptoms of intense emotional upset, including acute anxiety, anger, or grief;
screaming and shouting uncontrollably; attacks of crying; trembling; heat in the chest
rising to the head; becoming verbally and physically aggressive [among other
symptoms]” (American Psychiatric Association, 2013, p. 833). A generalized feature
of Ataque de Nervios is a sense of being out of control, and the Ataques are often
related to a stressful life event, mostly involving the family (e.g., death, family
conflict, accidents). Some DSM-V disorders that have been related to Ataque de
Nervios include Panic Attack, Panic Disorder, Conversion Disorder, unspecified or
specified forms of Dissociative Disorders, and Intermittent Explosive Disorder
31
(American Psychiatric Association, 2013). Research has shown that Latinos are likely
to define mental illness as Nervios and Ataque de Nervios, which are usually
contextualized as transitory diffuse idioms of distress, which may not require
traditional clinical treatment (Gonzales & Gonzales-Ramos, 2005). Similarly, research
shows that Latinos are more likely to somatize psychological distress when compared
to non-Latino Whites (Gonzales & Gonzales-Ramos, 2005), and that in many cases
symptoms differ from those traditionally reported by the general population (e.g.,
feeling pins and needles in your hands or feet, feeling heat inside the body, sensations
of fluttering in the stomach). Thus, somatic disturbance is an important characteristic
of Nervios and Ataque de Nervios that merits further study.
Among Latino immigrants, Nervios and Ataque de Nervios have been identified as
prevalent conditions. In a recent study of 422 Latino migrant farmworkers the
prevalence of Nervios was 22%, with lower income, drug use, higher acculturation and
poor housing conditions more likely to be associated with a Nervios diagnosis
(O’Connor, Stoecklin-Marois, & Schenker, 2013). In addition, Nervios has also been
found to be significantly associated with poor or fair self-reported health, symptoms of
depression, and high-perceived stress (O’Connor, et al., 2013). In regards to Ataque de
Nervios, a study using data of 2554 Latinos from the NLAAS found the prevalence of
Ataque de Nervios among Latinos to range between 7-15% varying by Latino
subgroups, with Puerto Ricans reporting the highest prevalence (14.9%) and Mexican
immigrants the lowest (6.0%) (Guarnnacia, Lewis-Fernandez, Martinez-Pincay,
Shrout, Guo, Torres, et al., 2010). In that study, Ataque de Nervios was found to be
more prevalent among women, those with disrupted marital status, and those with
32
higher acculturation to the US. Ataque de Nervios was also prevalent among those
meeting criteria for anxiety and substance use disorders. Given the association of
Nervios/Ataque de Nervios and distress, the high prevalence of Nervios among Latino
immigrants, and the multiple and complex distressing events often faced by UIs,
studies are needed to identify the prevalence of Nervios and Ataque de Nervios among
UIs, as well identify patterns of comorbidity with more traditional DSM-V diagnosis.
Most information on the clinical description of Nervios and Ataque de Nervios has
been gathered from qualitative data, with fewer studies using quantitative data to
define the disorder and identify severity. The use of combined methodologies to the
study of Cultural Concepts of Distress among at-risk Latino immigrants, including
UIs, is essential to better contextualize the experience of Nervios and Ataque de
Nervios from multiple cultural and contextual perspectives. While quantitative
methods may provide a measure for the pervasiveness and severity of Nervios and
Ataque de Nervios, as well as to identify patterns of association to specific risk and
protective factors, qualitative information would facilitate an understanding as to why
and/or how such associations exist and the range of their effects (Creswell, Klassen,
Plano, Clark & Smith, 2011). Additionally, the use of qualitative information to
supplement quantitative data is particularly valuable to use with this population given
possible variations in the meaning and presentation of clinical symptoms. UI Latinos
vary widely in their ethnic composition (e.g., indigenous versus mestizo); thus, it is
possible that variations in symptoms meaning and expression may exist. Consistent
with the use of culture and context sensitive methodology (Creswell, Klassen, Plano,
Clark & Smith, 2011), this study will assess the prevalence of Nervios and Ataque de
33
Nervios by using a combination of qualitative open-ended questions, as well as
previously validated clinical measures of perceived distress and somatic symptoms. In
doing so, this study aims to provide not only prevalence data, but also descriptive
information on the clinical manifestation, severity, and specifiers (e.g., lifetime
prevalence, trait, current) of Nervios and Ataque de Nervios based on DSM-V
description. Table 3 summarizes the measures and criteria to be used in this study to
identify the prevalence and clinical manifestation of Nervios and Ataque de Nervios.
The measures included in Table 3 are described in detail in the measures section of
“Phase Two: Quantitative Study” of the present proposal.
Contextual Concepts of Distress among Immigrants
For certain immigrant subgroups, such as UIs, the immigration experience
presents with multiple and chronic stressors, which over time, exceed the immigrant’s
capacity for adaptation and increase risk for mental health disorders (Achiotegui,
2005). Among UIs, the distress associated with the undocumented experience is not
only chronic, but also complex and in excess to that attributed to typical acculturative
stress (Achiotegui, 2002). Unfortunately, there is yet to be a classification within
DSD-V diagnosis, which may best describe and categorize the distress experienced by
UIs from a cultural and contextual perspective. Providing a diagnosis for Adjustment
Disorder to this immigrant population is inaccurate and lacking of contextual
sensitivity given that Adjustment Disorder is contextualized as a transitional state to
life events in which symptoms disappear with removal of the stressor, whereas the
distress experienced by UIs is chronic and unlikely to lead to adaptation, unless the
immigrant returns to his/her country of origin. Thus, developing a culture and context
34
sensitive approach to the study of distress among unique immigrant populations (i.e.,
UIs), is needed to: (1) avoid misdiagnosis; (2) reduce stigma associated to mental
health problems rooted in contextual influences and for which the immigrant may
have little control over (e.g., fear of deportation, restricted access to resources); (3)
validate the distress and somatic symptoms experienced by the immigrant as to reduce
marginalization; and (4) develop effective treatments and prevention alternatives by
considering the effect of relevant contextual influences.
Ulysses Syndrome. For over a decade, and given the large inflow of UIs into
Europe, researchers overseas have worked diligently to contextualize the distress
experienced by different at-risk immigrant subgroups. Among such efforts has been
the study of the Immigrant Syndrome with Chronic and Multiple Stress or Ulysses
Syndrome, named as such in reference to the Greek hero Ulysses, who endured
countless adversities and dangers away from his homeland (Achiotegui, 2002). The
Ulysses Syndrome is defined as a behavioral and emotional “response [experienced by
immigrants] when faced with a situation of [chronic and severe] stress, [which] is
superior to the adaptation capacities of the [immigrant]” (Achiotegui, 2002). From this
perspective, the Ulysses Syndrome is a cluster of emotional and somatic symptoms, as
well as a prodromal for more severe forms of mental health distress if experienced
over time and without access to treatment, support systems or coping strategies.
Specifically, the clinical expression of Ulysses Syndrome involves: (1) symptoms of
depression, particularly sadness, crying spells and difficulty concentrating, but not
necessarily apathy, low self-esteem or thoughts or death/dying as often characterized
in depressive disorders; (2) symptoms of anxiety, for example tension, worry,
35
irritability, and nervousness; (3) somatic symptoms (e.g., headaches, fatigue, body
aches); (4) migration-related grief in one or more of seven identified areas including:
(a) family and friends left in country of origin; (b) language difficulties; (c)
loss/change of cultural values; (d) missing of cultural practices (i.e., food, landscapes);
(e) loss of/change in social status; (f) marginalization/discrimination; and (g) threat to
physical and mental health. Similar to the research on Nervios and Ataque de Nervios,
most information regarding the conceptualization of Ulysses Syndrome comes from
qualitative data and assessments. Consistent with the use of culture and context
sensitive methodology, and as previously illustrated for the assessment of Nervios and
Ataque de Nervios, this study will assess the prevalence of Ulysses Syndrome by using
a combination of qualitative open-ended questions, as well as previously validated
clinical measures of perceived distress, somatic symptoms and migration-related
stressors. As previously mentioned, in using combined assessment measures, this
study aims to provide not only prevalence data for Ulysses Syndrome, but also a
preliminary categorization for the clinical conceptualization of Ulysses Syndrome
using a cultural and contextual formulation of distress consistent with the CFI of the
DSM-V (American Psychiatric Association, 2013). Table 3 summarizes the measures
and criteria to be used in this study to identify the prevalence and clinical
manifestation of Ulysses Syndrome.
36
IV. THEORETICAL FRAMEWORK AND SIGNIFICANCE
From a socio-ecological perspective, “the human experience results from
reciprocal interactions between individuals and their environments, varying as a
function of the individual, his or her context and culture, and over time” (APA, 2012,
p. 4) (Bronfenbrenner & Morris, 2006; Dahlgren & Whitehead, 1991; Serdarevic &
Chronister, 2005). Figure 1 depicts Dahlgren and Whitehead’s (1991) socio-ecological
model of health, which will be used as theoretical framework in this study. Thus, this
study focuses on the influences of context and culture, in particular risk and protective
factors, which may undermine or protect the mental health of UI Latinos.
New Contribution
Despite the identification of relevant stressors, there is limited information on
the prevalence for specific mental health disorders among UIs, and existing studies
often lack scientific rigor (Garcini, et al., under review). Additionally, an assessment
of methodology and findings of existing studies showed that there are salient selection
and information biases in this area of research, and that culture and context-sensitive
studies are needed to inform the mental health of UIs. Equally important to identifying
salient mental health disorders among UIs is the identification of Cultural and
Contextual Concepts of Distress, as well as protective factors that may reduce risk and
facilitate coping and adjustment to the migration process. Only few studies, mostly
qualitative, have reported on factors useful to ameliorate or cope with distress among
UIs (Aroian, 1993; Chavez, 1994; Ellis & Chen, 2013; McGuire & Georges, 2003;
Paris, 2008). Unfortunately, the aforementioned studies were often limited in
37
providing clarification of construct definitions for the identified protective factors,
quantitative assessment of such factors and/or a description of the quantitative
association of protective factors to specific mental health outcomes.
General Aims
Given limited research and existing limitations on studies to inform the mental
health of UIs, this dissertation will use the socio-ecologic framework, a contextsensitive approach and a mix-methods design to study the prevalence of mental health
disorders and Cultural and Contextual Concepts of Distress among UI Latinos in San
Diego and nearby areas, as well as to identify risk and protective factors associated
with mental health disorders in this population. Thus, this study includes two phases: a
formative phase and a clinical study.
38
V. PHASE ONE: FORMATIVE STUDY
Specific Aims
The objectives of this formative phase of the proposed dissertation are explained
by two specific aims of this research.
Aim 1. Use focus groups to assess the perceived relevance of specific mental
health concerns among UIs as reported from Latino immigrants and key experts with
extensive knowledge about the undocumented community in San Diego and nearby
areas.
Aim 2. Obtain feedback and specific recommendations from community members
and key experts on the proposed methodology to be used in a clinical study to assess
the mental health needs of UIs in San Diego and nearby areas. This information will
be used to make culture and context-sensitive modifications to the research protocol to
be used in the clinical mental health assessment to be conducted in phase two of this
proposed dissertation.
METHOD
Participants. Participants will be recruited using networks-based referrals
from the SDSU/UCSD Cancer Disparities Community Partners and Research
(CDCPAR) Resource, as well as from the principal investigator’s social network. The
CDCPAR provides liaisons to academic and community partners to facilitate outreach,
research, and the provision of health-related services for underserved communities and
hard-to-reach populations, including at-risk Latino immigrants. The CDCPAR
represent the Latino communities themselves, and is familiar with health issues
relevant to undocumented Latinos. Approximately 30 Latino immigrant adults (over
39
age 18) knowledgeable about the undocumented population in San Diego will
participate in the focus groups. Participants will receive $20 for their participation.
Inclusion/Exclusion Criteria. Participants must be Latino adults over 18
years of age, be born outside of the US, and report to be knowledgeable about the
undocumented community in San Diego. To determine eligibility for participation, a
brief screener in Spanish will be presented to potential subjects prior to participation in
the focus groups (see Appendix A). To assess eligibility based on knowledge about the
undocumented community, two dichotomous (Yes/No) proxy questions have been
included in the screener: (a) do you think you have a good understanding of the
experiences of undocumented Latino immigrants living in San Diego and surrounding
areas?; and (b) in general, do you have weekly interactions with undocumented Latino
immigrants in San Diego or surrounding areas?. Affirmative responding to both of the
aforementioned questions is required to meet eligibility criteria. There will be no
gender restrictions on enrollment. Given that the focus groups will be conducted in
Spanish, no English language proficiency is required for inclusion. Participants must
also be able to provide written informed consent.
Protection of Research Participants. All participants will sign informed
written consent approved by the Institutional Review Boards (IRB) at both SDSU and
UCSD (SDSU IRB Study Number: Conditionally Approved). There is minimal risk
associated with this study, which may include social stigma associated with
undocumented legal status and mental health problems. The group facilitator will
normalize and validate concerns regarding public discussion of reported issues. Also,
although unlikely, it is possible that participants may experience some emotional
40
discomfort upon discussing mental health issues in their community. For participants
expressing emotional discomfort associated to the discussion, they will be provide
with referral information for accessible, low cost, and Spanish mental health services
in San Diego, where participants may receive needed services regardless of their
immigration legal status (See Appendix B). Additionally, to protect confidentiality,
focus group discussions will emphasize the undocumented experience and mental
health concerns as a whole as opposed to personal, individual experiences. During the
consent process participants will be informed that this study has no association with
the Immigration and Naturalization Service (INS) and none of the information
provided will be reviewed by the INS. Also, participants will be informed during the
consenting process that the proposed study has no foreseeable direct benefits to them.
All study materials and data will be kept confidential and participants’ names and
other identifying information will be removed from the data that is to be analyzed.
Data will be kept in a locked cabinet and digital data will be password-protected.
Only study personnel will have access to research records.
Design. Approximately 4 to 5 focus groups will be conducted. Individuals who
agree to participate and who meet the inclusion criteria will be asked to fill out a brief
demographic questionnaire and to participate in a focus group discussion that will last
approximately 2 hours in duration. The demographic questionnaire will take
approximately 5 minutes to complete, and it will be administered in Spanish prior to
beginning the focus group. For participants unable to read and/or write, the
questionnaire will be read to the participant in private by a bilingual research assistant.
The focus groups will be audio-recorded to facilitate the analyses of data.
41
Measures. The instruments used in this study can be categorized into a demographic
questionnaire and the focus group discussion questions.
Demographic questionnaire. All participants will be given a brief
demographic questionnaire (see Appendix C) to be completed at the beginning of the
focus group. Information to be collected in this questionnaire includes sex, age,
marital status, educational attainment, employment, country of birth, length of
residence in the US, self-reported overall health and mental health, personal and
family mental health history, and social networking with the undocumented
community.
Focus group discussion questions. Focus groups will be conducted using a
semi-structured guide (See Appendix D). This guide includes questions aimed at
fostering discussion pertaining to: (a) perceptions about mental health; (b) perceived
relevance to the study of mental health among UIs and identification of specific
mental health issues relevant to this population; and (c) perceived barriers and
resources that may limit or facilitate participation in health and mental health research
studies among UIs.
Translation. The demographic questionnaire and the focus group discussion
questions will be translated using established methodology (Beaton, Bombardier,
Guillemin, & Ferraz, 2002). The following process will be used in the translation of
the aforementioned measures:
1) Translation. This will involve at least 2 independent forward translations
(English to Spanish) done the principal investigator and bilingual research
42
assistant, which can then compare their versions to identify discrepancies
indicative of ambiguous wording within the questionnaire.
2) Quality control. In this phase, a third bilingual individual, specifically a
community health representative, reviews both Spanish translations and makes
revisions or recommendations as necessary.
3) Back Translation. In this phase, another person blind to the original survey,
back translates the new Spanish questionnaires into English, and compares it to
the original English questionnaire to check the validity of the translation.
4) Expert Committee Review. An expert committee, comprised of the principal
investigator, the research assistant involved in the translation process, the
community member who synthesized both Spanish versions, and staff
members of the SDSU/UCSD CDCPAR resource will meet with the purpose
of consolidating the different versions of the Spanish and English
questionnaires to produce the final forms and ensure equivalence between the
English and the new Spanish version.
5) Pretesting. The translate questionnaire and the focus group questions will be
given to 5 Latino community members using standard cognitive interviewing
techniques to assess for ambiguity in the questions.
Recommended forms developed by Beaton, et al (2002) will be used for the
written documentation of the translations process at all of the different stages (see
Appendix E).
Analyses. Statistical analysis will be a two-part process. The first part will
involve the analysis of quantitative data from the demographic questionnaires.
43
Descriptive statistics (e.g., frequencies, measures of central tendency) will be used to
develop an overall demographic profile for participants in this study, as well as
profiles for participants in the different focus groups. Demographic profiles for
participants in each group will be used to assess for the generalizability or
inconsistency of comments across the groups. All quantitative analysis will be
conducted using SPSS, version 20 (SPSS, Inc., 2013).
The second part will involve the analysis of qualitative data gathered from the
focus groups. The qualitative data will be analyzed through systematic methods
outlined by Miles and Huberman (1994). The focus group audio-recordings will be
transcribed and then analyzed by the principal investigator and bilingual research
assistants in Spanish with collaboration of supervising faculty and staff members from
the SDSU/UCSD CDCPAR Resource. The data will be read and re-read to develop,
revise, and summarize themes within the data through a collaborative and iterative
process. This qualitative approach is particularly beneficial given this study is
exploratory to obtain formative data that will be used to inform phase two of this
dissertation. Qualitative analysis will be conducted using NVivo, version 10 (Nvivo,
Ltd, 2013).
44
VI. PHASE TWO: CLINICAL STUDY
Specific Aims
The objectives of the quantitative phase of the proposed dissertation are explained by five
specific aims of this research.
Aim 1. Assess the prevalence of mental health disorders and perceived psychological distress
in this sample of UIs and compare it to rates for other Latino and non-Latino populations in the
US. More specifically, this includes:
a. Identify the prevalence of perceived psychological distress as measured by the Brief
Symptom Inventory-18 in this sample population.
b. Identify the prevalence of DSM-V depressive disorders (i.e., MDD), anxiety disorders
(i.e., Agoraphobia, Panic Disorder, GAD, and Social Anxiety Disorder), trauma and
stress-related disorders (i.e., Adjustment disorder and PTSD), Somatic Symptom
Disorder, and substance related disorders (ie., Substance Dependence and Addiction).
c. Identify the prevalence of Cultural Concepts of Distress, specifically Nervios and Ataque
de Nervios in this population.
d. Identify the prevalence of Contextual Concepts of Distress, specifically Ulysses
syndrome, in this population.
e. Identify comorbidity and disparities in the prevalence of the aforementioned mental
health disorders between this sample of UIs and other Latino and non-Latino populations
in the US.
Aim 2. Assess the QOL of this sample population using the World Health Organization
Quality of Life-Brief (WHOQOL-BREF), and identify its association to prevalent mental health
45
disorders, after controlling for relevant covariates (i.e., age, gender, and socioeconomic status).
More specifically, this includes:
a. Assess the overall level of QOL in this sample population.
b. Identify the association between QOL and prevalent mental health disorders after
controlling for age, gender, and socioeconomic status.
c. Identify the association between QOL and perceived psychological distress after
controlling for age, gender, and socioeconomic status.
Aim 3. Identify the association between immigration-related risk factors and diagnosis of a
mental health disorder and psychological distress, after controlling for relevant demographic and
socioeconomic factors. Most specifically, this includes:
a. Identify the prevalence of immigration-related loss or trauma, including pre-migration
loss/trauma, in-transit trauma, and post-migration living difficulties in this sample
population.
b. Identify the association between migration-related factors, including age of arrival in the
US, length of residence in the US, migration-related loss/trauma and post-migration
living difficulties, with diagnosis of a mental health disorder, after controlling for
relevant covariates.
c. Identify the association between migration-related factors, including age of arrival in the
US, length of residence in the US, migration-related loss/trauma and post-migration
living difficulties, with perceived psychological distress, after controlling for relevant
covariates.
Aim 4. Identify moderators to the association between immigration-related
loss/trauma/difficulties and diagnosis for a mental health disorder in this sample of UIs, as well
46
as moderators to the association between immigration-related loss/trauma/difficulties and
perceived psychological distress after controlling for relevant covariates. More specifically, this
includes:
a. Identify the effect of family intactness as moderator to the association between
immigration-related loss/trauma/difficulties and diagnosis of a mental health
disorder/perceived psychological distress, after controlling for relevant covariates.
b. Identify the effect of social support as moderator to the association between immigrationrelated loss/trauma/difficulties factors and diagnosis of a mental health
disorder/perceived psychological distress, after controlling for relevant covariates.
c. Identify the effect of sense of community as moderator between the association of
immigration-related loss/trauma/difficulties and diagnosis of a mental health
disorder/perceived psychological distress, after controlling for relevant covariates.
d. Identify the effect of spirituality and religiosity as moderators between the association of
immigration-related loss/trauma/difficulties and diagnosis of a mental health
disorder/perceived psychological distress, after controlling for relevant covariates.
e.
Identify the effect of English language proficiency as moderator between the association
of immigration-related loss/trauma/difficulties and diagnosis of a mental health
disorder/perceived psychological distress, after controlling for relevant covariates.
Aim 5. Outline health and immigration policy implications for the improvement of mental
health outcomes in this population.
METHODS
Participants. Given the hidden nature of the target population, network-based referral is
currently the most effective and safe method to reach UIs as long as these individuals maintain
47
social networks among UIs like themselves (Cornelius, 1982; Nalven, 1982, Zhang, Hong,
Takeuchi, & Mossakowski, 2012). Snowball sampling is the most commonly used recruitment
method based on network-based referrals. However, given that snowball sampling is
accomplished through convenient and haphazard recruitment strategies (e.g., participants
originate mostly from the researcher’s social contacts), there are inherent selection biases in this
recruitment process. Two methodologies developed to reduce some of the inherent biases in
snowball sampling are Targeted Sampling (Watters & Biernacki, 1989) and Respondent Driven
Sampling (RDS) (Heckathorn, 1997). Participants for this study will be recruited using combined
strategies modeled from Targeted Sampling and RDS methodology.
Targeted Sampling. This method uses experienced field researchers to map out areas
where a target population may be found and recruit a pre-determined number of subjects at each
of the identified sites on the map. In this study, information gathered from: (a) expert health
researchers at the SDSU/UCSD Disparities Community Partners and Research (CDCPAR)
Resource; (b) qualitative data gathered from the focus groups completed in phase one of this
dissertation; and (c) key informants with expertise serving the undocumented community, will be
used to map out areas where UIs in San Diego and nearby areas may be found. Then, at each of
the identified sites, a small number of initial subjects (seeds) will be recruited for participation in
this study. In turn, each of the initial seeds will be ask to recruit other UIs for participation using
RDS methodology.
Respondent Driven Sampling. RDS is a methodology based on a mathematical model
of the social networks that connect participants in a study. In other words, RDS uses networkbased methods along with the statistical validity of standard probability sampling methods to
assess hard-to-reach populations. RDS relies on a structured chain referral system that uses
48
successive waves of participant recruitment to achieve diversity and equilibrium so that initial
samples no longer mirror later samples. Key assumptions of the RDS system are: (1) degree
(i.e., participants accurately report their degree in the network); (2) random recruitment (i.e.,
respondents recruit at-random from their personal networks; (3) reciprocity (i.e., network
connection are reciprocal); and (4) convergence (i.e., the sample composition becomes
independent of the initial “seeds” in a short number of steps). As a result, RDS modifies
traditional snowball sampling in three ways. First, to increase the breadth of the social network
captured by the sample, subsequent recruitment is limited by a coupon-based quota system, in
which an interviewee is only allowed a fixed number of referrals. Second, by using referral
coupons, subjects do not have to personally identify referrals to the researcher and the resulting
anonymity encourages participation. Third, since some individual may tend to have more social
connections that others, they are more likely to be recruited into a survey. To make the results of
an RDS-based survey representative of the target population (and not just respondents with large
social networks), a systematic weighting scheme is build into the RDS model. The weighting
scheme is based on the respondent’s social network size; that is, based on their probability of
being captured by this survey technique-as well as other features of the network which can affect
the referral process. As a result, although RDS will start with a convenience sample of UIs, a
structured process will be used in recruitment so that it may be possible to obtain unbiased
estimates of the overall undocumented population in San Diego.
Specific RDS steps that will be used in this study are: (1) a small number of subjects or
“seeds” will be recruited for participation in the study; (2) these seeds will be provided with
referral coupons to recruit other subjects for participation; (3) next wave of recruits will be
provided another set of referral coupons to recruit additional subjects for participation in this
49
study; and (4) sampling will continue until the targeted community is saturated, or until the
desired sample size and “equilibrium” is reached. Equilibrium will be verified empirically
through the use of RDS software (RDSAT, Version 7.1, Volz, Wejnert, Cameron, Spiller,
Barash, Degani, et al., 2012), and it indicates that the final subjects recruited no longer have
identical characteristics to the initial “seeds.” Consistent with RDS methods, each participant
will be limited to a predetermined number of referral coupons (three coupons per study subject);
thus, limiting biasing the sample towards those with large social networks.
Although data requirements for RDS analysis are minimal, there is specific information
needed from each participant in order to conduct the RDS analysis. This information includes:
(1) size of the respondents personal network within the target population (degree); that is,
estimated number of UIs that are personally known by the participant; (2) participant’s serial
number, that is, this is the serial number of the coupon that the participant was recruited with;
and (3) respondent’s recruiting serial numbers; that is, serial numbers from the coupons that the
respondent is given to recruit other participants for the study. In this study, initial participants or
“seeds” for recruitment will be identified in collaboration with networks-based referrals from the
SDSU/UCSD Disparities Community Partners and Research (CDCPAR) Resource, as well as
referrals from the principal investigator’s social network. As previously mentioned in phase one
of this dissertation, the SDSU/UCSD CDCPAR provides liaisons to academic and community
partners to facilitate outreach and research to underserved populations, including UIs.
Inclusion/Exclusion Criteria. Participants must be Latino adults over 18 years of age
with current undocumented immigration legal status. To determine eligibility for participation, a
brief screener in Spanish will be presented to potential subjects prior to participation in the study
(see Appendix F). To assess eligibility based on immigration legal status, a rule-out system will
50
be used which, asks a series of yes-no questions outlining current legal statuses except
undocumented status, so that respondents who answer no to all questions would be coded as UIs.
The use of a rule-out system has been previously used in other studies of undocumented Latino
immigrants, and it is recommended as the preferred method to assess immigration legal status
(Marcelli, Holmes, & Estrella, 2009). In using a rule-out system, respondents are not forced to
blatantly admit to being undocumented, but rather undocumented status is determined by
denying all possible legal ways to be currently residing in the US. There will be no gender
restrictions on enrollment. Given that the interviews will be conducted in Spanish, no English
language proficiency is required for inclusion. Participants must also be able to provide verbal
informed consent.
Power analysis. Mood disorders (i.e., depression and dysthymia), anxiety disorders and
somatic symptom disorders have been identified as the most prevalent disorders among foreignborn Latinos. Although prevalence estimates vary across studies, results from the National
Latino and Asian American Study estimated that approximately 14.8% of foreign-born Latinos
meet criteria for a mood disorder and 15.2% for anxiety disorders (Guarnaccia, Martinez-Pincay,
Alegria, Shrout, Lewis-Fernandez, & Canino, 2004). Similarly estimates for the NLAAS showed
Mexican-origin foreign-born immigrants to have an estimated prevalence of 12.9% for
depressive disorders and 14.2% for anxiety disorders. Unfortunately, estimates for the prevalence
of diagnosed mental health disorders among UIs are unknown. Thus, to assess for the prevalence
of a mental health disorder in this sample population, the estimate for the most prevalent mental
health disorder (Anxiety) among Mexican-origin foreign-born immigrants was selected as
reference. The Mexican-origin foreign-born population was chosen given that the majority of
UIs in California are of Mexican-origin; thus, the chose estimate may most closely resemble true
51
prevalence in this sample population. To estimate the need sample size for this study, an a priori
power analysis was conducted using OpenEpi, Version 3.01 (Dean, Sullivan, & Soe, 2013). In
order to detect prevalence at a historical proportion of .14 within a 95% confidence interval at
7% precision and with a design effect of 1, a sample size of 95 subjects would be needed. This
means that based on the historical proportion of mental health disorders among Mexican-origin
foreign-born immigrants, approximately 14% of the aforementioned sample would meet
diagnosis for a mental health disorder with a 95% confidence that the prevalence estimate will be
within 7% of the true prevalence value. For studies using RDS, it has been recommended the use
of sample size at least twice as large as would be needed under simple random sampling
(Salganik, 2008). Thus, a total of 190 subjects will be recruited for this study.
Additionally, to assess for the adequacy of the aforementioned sample size to perform the
proposed multivariate analysis in this study, two additional power analyses were conducted.
First, an a priori power analysis was performed using G*Power, Version 3.1 (Faul, 2008) to
determine if the sample size would be adequate to conduct sequential linear regression analysis
with ten predictors included in the model. Results showed that in order to detect a medium effect
size for regression analyses (f = 0.15) including 10 predictors that is statistically significant at the
p < 0.05 level and using a desired power of 0.95, a total sample size of 172 individuals would be
necessary. The proposed sample size of 190 subjects exceeds the aforementioned sample size;
thus, this suggests that the proposed sample size will be appropriate for conducting the proposed
linear regression analyses.
Second, an a priori power analysis was performed using G*Power, Version 3.1 (Faul,
2008) to determine if the sample size would be adequate to conduct logistic regression analysis
with ten predictors included in the model. Results showed that in order to detect a change in the
52
dependent variable with an odds ratio of 1.9 that is statistically significant at the p < 0.05 level
using a desired power of 0.95, a total sample size of 171 subjects would be necessary. The
proposed sample size of 190 subjects exceeds the aforementioned sample size; thus, this suggests
that the proposed sample size will be appropriate for conducting the proposed logistic regression
analyses.
Protection of Research Participants. All participants will provide verbal informed
consent as is customary in research studies with undocumented immigrants (Garcini, et al., under
review). Some of the questions in the interview deal with emotional status and migration
experiences; thus, participating subjects may feel some emotional discomfort when reporting
sensitive information (e.g., migration related loss or trauma) or may experience some difficulty
in remembering details of certain events. To reduce potential discomfort, subjects will be fully
informed that they choose how much they want to share their stories, and that they can refuse to
answer any questions at any time during the interview. Subjects can terminate the interview at
anytime without any penalty. In addition, interviews will be conducted in a private location,
identified by the participant as convenient and safe, where the conversation cannot be overheard
by a third party. Also, the PI has considerable experience working with undocumented
immigrants, and most importantly all interviews will be conducted by psychology trainees with
expertise in the clinical assessment and treatment of mental health disorders who will work under
the supervision of a licensed clinical psychologist. Additionally, for participants expressing
emotional discomfort during or after the interview, they will be provide with referral information
for accessible, low cost, and Spanish mental health services in San Diego, including the SDSU
Psychology Clinic, where participants may receive needed services regardless of their
immigration legal status (See Appendix B).
53
To ensure participants of confidentiality, they will be informed during the consent
process that this study has no association with the Immigration and Naturalization Service (INS)
and that none of the information provided will be reviewed by the INS. Participants will be
informed that the proposed study has no foreseeable direct benefits to them, and that all study
materials and data will be kept confidential, with any identifying information removed from the
data that is to be analyzed. Data will be kept in a locked cabinet and digital data will be
password-protected. Only study personnel will have access to research records.
Design. A cross-sectional survey design will be used. Individuals who agree to
participate and who meet inclusion criteria will be asked to complete an in-person semistructured clinical interview lasting approximately 1 to 1.5 hours in duration depending on the
extent of the psychopathology reported. The clinical interviews will be conducted in Spanish by
Latino psychology trainees, including the principal investigator, working under the supervision
of a licensed clinical psychologist. Participants will be given a choice to complete the clinical
interviews at the SDSU Psychology Clinic or at location identified by the participant as
convenient and safe.
Measures. The instruments used in this study can be categorized into a demographic
questionnaire, immigration history, respondent driven sampling questions, health-related quality
of life assessment, clinical mental health assessment, migration-related loss, trauma and
difficulties, and protective factors. In addition, at the end of each interview, the interviewers will
complete a questionnaire to record clinical and behavioral observations.
Demographic questionnaire. All participants will be asked a series of demographic
questions (see Appendix G). Information to be collected in this questionnaire includes sex, age,
educational attainment, employment, and household income. Demographic questions were
54
modeled from the 2009 San Diego Prevention Research Center (SDPRC) Community Survey,
which assessed various aspects of health and health behaviors among Latinos in the US,
including UIs. These questions are available in Spanish and have been previously used with UIs
in San Diego.
Immigration history. Participants will be asked some questions about their immigration
history (see Appendix H). Immigration history information to be collected includes country and
state of birth, country and state where migrant spent most of his/her life, age of arrival in the US,
and length of time in the US. These questions were modeled from the 2009 SDPRC Community
Survey, as well as from the San Diego Labor Trafficking Survey Questionnaire (Zhang, 2012).
These questions have been previously translated into Spanish and have been used to assess
immigration history among undocumented Latinos.
Respondent driven sampling questions. Four questions will be used exclusively for the
purpose of mapping recruitment location and to calculate RDS estimates (see Appendix I).
These questions include area of residence (town name only), size of the respondent’s personal
network who are UIs, relationships to the referral source (person who provided the coupon to the
participant), and length of time that the participant has known the referral source. These
questions were modeled from the San Diego Labor Trafficking Survey Questionnaire (Zhang,
2012), which are available in Spanish and have been previously used in studies with UIs.
Health-related quality of life assessment. This will be done using two measures. First, a
shortened and adapted version of the World Health Organization (WHO) Composite
International Diagnostic Interview (CIDI) Chronic Conditions Module Version 3.0 will be used
to assess the past (prior to immigration) or present history of commonly occurring chronic health
conditions known to influence QOL including arthritis, chronic pain, heart disease, hypertension,
55
asthma, diabetes, stomach problems and cancer (Haro, Arbabzadeh-Bouchez, Brugha, Girolamo,
Guyer, Lepine, et al, 2006). This shortened version of the CIDI Chronic Conditions takes
approximately a minute to complete. Second the World Health Organization Quality of Life
Scale-Brief (WHOQOL-BREF) will be used to assess subjective overall quality of life across
various domains (Skevington, Lotfy, & O'Connel, 2004). Previous research shows that
subjective assessment of QOL is most appropriate with at-risk immigrant populations, given
objective measures are often limited in considering the potential effects of factors such as trauma
or post-migration living difficulties on quality of life (WHOQOL Group, 1998). For this study
and consistent with the WHO definition, QOL is defined as “an individual’s perception on their
position in life in the context of the culture and value systems in which they live and in relation
to their goals, expectations, standards and concerns” (Skevington, Lotfy, & O'Connel, 2004, p. 8)
The WHOQOL-BREF is an abbreviated 26-item version of the WHOQOL-100, which is a wellestablished measure to assess quality of life worldwide. The WHOOLF-BREF takes
approximately five minutes to complete. The WHOQOL-BREF was found to have comparable
discriminant validity to the WHOQOL-100 in differentiating between ill and well individuals.
The WHOQOL-BREF includes 26 items to assess QOL across four domains:
1. Physical: This domain assesses distress and interference with life functioning in the areas
of pain and discomfort, energy and fatigue, sleep, mobility and activities of daily living,
dependence on medication and/or treatments, and work capacity.
2. Psychological: This domain assesses a person’s experiencing of positive and negative
feelings, a person’s perspective of his/her thinking, self-esteem, perceptions of body
image/appearance, and spirituality.
3. Social relationships: This domain assesses the extent to which individuals experience
56
social and emotional support from others, including family, friends and intimate
relationships.
4. Environment: This domain assesses a person’s sense of safety and security from physical
harm, quality of the home environment, financial stressors, access to health and social
services, opportunity and desire for new knowledge, opportunities for leisure and
recreation, and accessible transportation.
Domain scores for the WHOQOL-BREF are calculated by taking the mean of all items
included in each domain and multiplying by a factor of four. These scores are then transformed
to a 0-100 scale, with higher scores denoting higher quality of life. Cronbach alpha values for
each of the four domains scores range from .66 (for domain 3) to .84 (for domain 1)
demonstrating good internal consistency. It has been recommended that Cronbach alpha values
for domain 3 (social relationships) be read with caution as they were based on three scores,
rather than the minimum recommended of four items for assessing internal reliability. The
WHOQOL-BREF was developed cross-culturally, and it has been validated in field studies in 50
different languages, including Spanish for use in US populations, which facilitates cross-cultural
comparisons worldwide. The WHOQOL-BREF is the most widely used QOL measure in the
world, and has been previously used to assess QOL among at-risk immigrants (e.g., Benner,
Townsend, Kaloi, Htwe, Naranichakul, Hunnangkul, et al., 2010; Kashdan, Morina, & Priebe,
2009; Laban, Komproe, Gernnat, & de Jong, 2008).
Clinical mental health assessment. Mental health outcomes to be assessed in this study
include: (1) Perceived psychological distress, (2) traditional mental health disorders previously
considered within Axis I diagnosis and previously identified as prevalent among Latino
immigrant populations; (3) Cultural Concepts of Distress relevant to Latino immigrants; and (4)
57
Contextual Concepts of Distress to migrant populations. Traditional mental disorders to be
assessed in this study include: Major Depressive Disorder (MDD), Dysthymia, Agoraphobia,
Panic Disorder, Generalized Anxiety Disorder (GAD), Social Anxiety Disorder (Social Phobia),
Post-Traumatic Stress Disorder (PTSD), Adjustment Disorder, Somatic Symptom Disorder,
Alcohol Dependence/Abuse and Substance Dependence/Abuse, as well as suicidality. Cultural
Concepts of Distress to be assessed in this study include Nervios and Ataque de Nervios.
Contextual Concepts of Distress to be assessed in this study include Ulysses Syndrome.
To assess for perceived psychological distress, the Brief Symptom Invetory-18 (BSI-18) will
be used. This 18-item questionnaire is a self- report measure of emotional or psychological
distress in the past week (Derogatis, 2000). The 18-items are rated on a 5-point Likert scale with
0 = not at all to 4 = extremely. The BSI-18 renders a total score, which consists of the sum of the
18 items, and a score for each subscale of 6 items (Anxiety, Depression, and Somatization). For
this study, the Spanish translation published by Derogatis (2000) will be used. This version has
shown adequate construct validity and reliability in previous studies with Latino populations
(Galdón, Dura, Andreu, Ferrando, Murgui, Perez, et al., 2008). In the present study BSI-18
scores will be used in two ways. First, the total score on BSI-18 will be used as a measure of
overall psychosocial distress, which has been showed to have satisfactory internal consistency
(Cronbach’s α = .91). Second, cutoff scores as recommended by Derogatis (2000) will be used to
determine “caseness” of psychological distress in order identify criteria for the assessment of
Cultural and Contextual Concepts of Distress (to be described later in this section). The BSI-18
has been normed for use with clinical and non-clinical populations. Subjects with a T-score of 63
or higher in the general distress scale or at least in two of the BSI-18 dimensions will be
considered as experiencing clinical levels of distress (Derogatis, 2000).
58
To assess for the prevalence of traditional mental health disorders previously specified, two
measures will be used.
1. M.I.N.I. International Neuropsychiatric Interview (V. 6.0) (Sheehan, Lecrubier, HarnettSheehan, Janavs, Weiller, Bonara, et al., 1997; Sheehan, Lecrubier, Harnett-Sheehan,
Amorim, Janavs, Weiller, et. al., 1998). Specific modules of the M.I.N.I. will be used to
assess for MDD, agoraphobia, panic disorder, GAD, social anxiety disorder, PTSD,
Alcohol Dependence/Abuse, Substance Dependence/Abuse and suicidality. The M.I.N.I.
is a short, structured diagnostic interview used widely in clinical and research settings
worldwide to assess for DSM-V and ICD-10 psychiatric disorders. This measure has
been validated against the much longer Structured Clinical Interview for DSM diagnosis
(SCID) and the Composite International Diagnostic Interview for IDC-10 diagnosis
(CIDI) (Lecrubier, Sheehan, Weiller, Amorim, Bonara, Sheehan, et al., 1997; Sheehan, et
al., 1997). The M.I.N.I. has been identified as a more time-efficient alternative to the
SCID-P and CIDI given that the interview can be completed in approximately 15
minutes. The Spanish translations and adaptations of the M.I.N.I. have been conducted in
Spain and in the United States. The sensitivity and specificity of the most common
disorders using the Spanish version of the M.I.N.I. were MDD (94.1 and 62.2,
respectively), GAD (92.3 and 64.6) and social phobia (100 and 84.2) (Bobes, 1998). The
positive and negative predictive values for these disorders were 41.0 and 97.4 for MDD,
34.2 and 97.6 for GAD, and 14.2 and 100 for social phobia. Thus, the Spanish version of
the M.I.N.I. is considered to have adequate psychometric properties and it is
recommended for use with Latino populations (Mestre, Rossi, & Torrens, 2013).
59
2. Structured Clinical Interview-SCID (DSM-VResearch Version). The SCID DSM-V
Research Version is a structured clinical interview used for the diagnosis of DSM
disorders among adults not suffering from severe cognitive impairment, agitation or
severe psychotic symptoms (First, Spitzer, Gibbon, & Williams, 2002). In this study, only
two modules of the SCID will be used: (1) Adjustment Disorder module, and (2) Somatic
Symptom Disorder module. The SCID has been long recognized as "gold standard" in
determining the accuracy of clinical diagnoses for mental health disorders (e.g., Shear,
Greeno, Kang, et al., 2000; Steiner, Tebes, Sledge, et al., 1995). Ratings on the SCID are
based on both patient’s answers and the expertise of the interview/rater, who may add
additional questions to clarify ambiguity in diagnosis and assess the severity of the
symptoms. To score the SCID, interviewers codify the responses of the modules as
1=absent/false, 2=subthreshold, or 3=present/true, indicating a need to continue to
another module when applicable. There is a fourth rating option ? to be used when
information is insufficient. The SCID had demonstrated superior validity over standard
clinical interviews at intake (Kranzler, Kadden, Babor, Tennen, & Rounsaville, 1996),
and reliability coefficients have ranged from fair to excellent varying across disorders.
Also, studies have shown to SCID to achieve up to 90% accuracy in diagnosis
(Lobbestael, Leurgans & Arntz, 2011; Ventura, Liberman, Green, Shaner, & Mintz,
1998). Reliability coefficients for the diagnosis of any somatoform disorder using the
SCID-I has been shown to be .84 (Segal, Kabacoff, Hersen, Van Hasselt, & Ryan, 1995),
whereas no report for reliability was found for the diagnosis of adjustment disorder. The
SCID has been translated and validated in Spanish (First, Spitzer, Gibbon, & Williams,
60
1999); thus, it is recommended for use with Latino populations (Mestre, Rossi, &
Torrens, 2013).
To assess for Cultural Concepts of Distress, specifically Nervios and Ataque de Nervios, five
measures will be used.
1.
Explanatory Model Interview Catalogue (EMIC) for the assessment of nervios and
ataque de nervios. The EMIC is a collection of adapted explanatory semi-structured
interviews developed for use in cultural psychiatry to better understand Cultural
Concepts of Distress from an epidemiological and anthropological perspective (Weiss,
1997). An adapted version of the EMIC is available to assess for the experiencing of
Nervios and/or Ataque de Nervios among Latino-origin individuals (Guarnaccia,
Lewis-Fernandez, & Marano, 2003). As recommended by Guarnaccia et al. (2003),
this study will use four modified questions derived from the EMIC approach to assess
for lifetime and current prevalence of “Nervios” and “Ataque de Nervios” among this
sample of undocumented Latino immigrants. Responses to the aforementioned
questions are given in dichotomous format (Yes/No), as well as in a continuous form
to denote the number of Ataque de Nervios that an individual has had in their lifetime
and/or recently (within the past 12 months). These questions are available in Spanish.
2.
Ataque de Nervios Module from the National Latino and Asian American Study
(NLAAS) Questionnaire (Alegría, Vila, Woo, Canino, Takeuchi, Vera, et al., 2004).
The NLAAS is a nationwide study funded by the National Institute of Mental Health
(NIMH) to estimate the lifetime and current prevalence of mental health disorders and
mental health service use among Latino and Asian-origin populations in the US. The
NLAAS Ataque de Nervios Module includes a list of 15 different symptoms that a
61
person may experience during an Ataque de Nervios episode (e.g., get dizzy, fall to the
floor with a “seizure,” shout a lot, become hysterical). Respondents are considered to
meet syndrome criteria if they report having experienced a previous Ataque de Nervios
(as assessed by the EMIC Ataque de Nervios question) and if they responded positively
(Yes) to having experienced four or more symptoms during the attack. The cut-off of
four or more symptoms was derived statistically using tests of distribution of the
responses, as well as previous analysis of reported symptoms in clinical studies
(Guarnaccia, Lewis-Fernandez, & Martinez-Pincay, 2010). This measure is available
in Spanish and has been validated for use with various Latino populations in the US.
3.
The Brief Symptom Inventory (BSI-18), which will be used to assess for clinical level
of psychological distress. As recommended by Derogatis (2000), a T-score of 63 or
higher in the general distress scale or at least in two of the BSI-18 dimensions will be
considered to meet criteria for clinical level of psychological distress.
4.
Bradford Somatic Inventory (BSI), which will be used to assess for somatic
disturbance related to Nervios and Ataque de Nervios. The BSI is a 46-item multiethnic questionnaire used to assess a wide range of somatic symptoms in transcultural
research (Mumford, Bavington, Bhatnagar, Hussain, Mirza, & Naraghi, 1991). The
BSI evaluates whether physical symptoms, including those commonly reported among
subjects suffering from Nervios (e.g., headaches, stomach disturbances, dizziness,
tingling, trembling), have been present in the last month, with possible answers
including: 0 = absent, 1 = present less than 15 days in the past month, and 2 = present
on more than 15 days in the past month. Test-retest reliability of the BSI administered
after a week has been found to be good, with an overall α reliability ranging from 0.86
62
to 0.92 (Chakraborty, Avasthi, Kumar, & Grover, 2010; Mumford, et al, 1991). The
basic construct of the BSI is that the somatic symptoms enlisted are: (1) somewhat
“unusual” compared to symptoms that are usually reported in somatic diseases with
clear pathophysiology (e.g., fluttering or feeling of something moving in the stomach),
or (2) general and/or vague (e.g., headaches), and that the coexistence of a number of
symptoms scoring of at least 14 can be used as an index representing the association of
symptoms of various types that are not likely based on a common pathophysiology.
Consistent with previous research, a cutoff score of 14 discriminates between
psychiatric cases (somatic symptoms related to psychological conditions) and noncases (symptoms due to a medical condition) with 0.75 specificity and 0.87 sensitivity
(Aragona, Catino, Pucci, Carrer, Colosimo, La-Fuente, et al., 2010). The BSI has been
formerly used to assess somatization among different immigrant populations, including
undocumented immigrants (86% of sample was undocumented, of which 46% was of
Latino origin) (Aragona, et al., 2010; Aragona, Monteduro, Colosimo, Maisano, &
Geraci, 2008). The BSI has been previously translated into Spanish following
translation-back translation methodology (Aragona, et al., 2010)
5.
Interference with functional ability due to Nervios and Ataque de Nervios will be
assessed using a question from the NLAAS (Alegria, Vila, Woo, Canino, Takeuchi,
Vega, et al., 2004; Center for Multicultural Mental Health Research, 2013). This
question asks participants to rate on a a scale from 0 = none to 10 = most interference,
how much have “Nervios” and “Ataque De Nervios” interfere with household chores,
quality of work, and social life/relationships. Individuals rate the level of
interference for each of the three identified domains.
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To assess for Contextual Concepts of Distress, specifically Ulysses Syndrome, five
measures will be used:
1. Questions adapted from the DSM-V Cultural Formulation Interview (CFI) (American
Psychiatric Association, 2013), which will be used to assess for: (a) contextual definition
of the undocumented experience as a distressing event, and (b) contextual effect of the
undocumented experience on identity. For this purpose, four open-ended questions will
be used as presented in Appendix G.
2. The Brief Symptom Inventory (BSI-18), which will be used to assess for clinical level of
psychological distress. As recommended by Derogatis (2000), a T-score of 63 or higher
in the general distress scale or at least in two of the BSI-18 dimensions will be considered
to meet criteria for clinical level of psychological distress.
3. Bradford Somatic Inventory-46 (BSI), which will be used to assess for somatic
disturbance as previously described. As previously mentioned and consistent with
previous research in immigrant populations, including Latinos in Europe, a cutoff score
of 14 discriminates between psychiatric and non-psychiatric cases (Aragona, et al., 2008;
2010).
4. Multidimensional Loss Scale (MLS), which will be used to assess for the presence of
migration related losses/mourning and distress associated to the loss. The MLS is a 24item measure used to index experiences of loss and associated distress across multiple
domains (cultural, social, material and interpersonal) relevant to immigrant populations
(Vromans, Schweitzer, & Brough, 2012). The MLS has been shown to have good internal
consistency for the experience of loss events (α = .85) and associated distress (α = .92);
thus, reflecting a unitary construct of multidimensional loss related to the immigration
64
process (Vromans, et al., 2012). Results from factor analysis have provided support for a
five-factor model structure of this measure: (1) loss of symbolic self (e.g., loss of wealth,
traditions, values, language use, life beliefs) (α = .90), (2) loss of interdependency (e.g.,
change in how you are being treated, role or social position) (α = .75), (3) loss of home
(e.g. leaving your country, home, land, possessions) (α = .86), (4) interpersonal loss (e.g.,
separation from family, death of family/friends) (α = .71), and (5) loss of interpersonal
integrity (e.g., loss of freedom and autonomy, sense of wellbeing) (α = .64). Responses to
each loss item are done in two ways: (a) dichotomous answer (Yes/no) depending on
whether the loss has been experienced or not, and (b) rating of perceived stress associated
to each specific loss including not at all or little distressing, quite a bit distressing, and
extremely distressing.
5. Interference with functional ability due to loss, which will be used with the MLS rating of
perceived stress associated to each specific loss as previously described.
Migration-related loss and trauma. This will be done using three measures, which include:
1. Multidimensional Loss Scale (MLS), which will be used to assess for the presence of
migration related losses/mourning and distress associated to the loss as previously
described. A total score will be calculated by adding up all of the loss items reported as
quite distressing or extremely distressing, so that higher scores would denote greater
amount of loss experienced as distressing.
2. Harvard Trauma Questionnaire (HTQ), which will be used to assess for pre-migration
and/or in-transit trauma (Mollica, Mcdonald, Massagli, & Silove, 2004). The HTQ was
designed to assess trauma experiences among at-risk immigrant populations (e.g.,
refugees). The HTQ is composed of two parts. Part one comprises 17 items used to
65
measure participant’s experience and/or witnessing of 17 common forms of human rights
violations that may lead to trauma (e.g., lack of food/water, lost or kidnapped, sexual
abuse), while part two assesses trauma-related symptoms. For the purpose in this study,
only part one of the HTQ will be used given that PTSD symptoms will be assessed using
the M.I.N.I. as previously described. Thus, a total trauma score will be computed by
adding up all trauma events experienced and/or witnessed so that higher scores will
denote greater exposure to traumatic/distressing events related to the migration process.
3. Post-migration Living Difficulties Questionnaire (PMLD) will be used to assess postmigration living difficulties. The PMLD is a 23-item questionnaire used to assess recent
adverse life experiences typical of migration (Silove, Sinnerbrink, Field, Manicavasagar,
& Steel, 1997; Steel, Silove, Bird, McGorry, & Mohan, 1999). The PMLD yields a total
score, as well as five subscale scores which measure: 1) financial, 2) health, 3) family and
relational, 4) discrimination; and 5) immigration stressors. Responses to each living
difficulty were given using a five-point scale from 0 = no problem at all to 3 = very
serious problem.” A high cumulative score indicates a high amount of post-migration
stress.
Protective factors. These will be assessed using 4 measures, which include:
1. Family intactness, which will be assessed using two questions aimed at identifying the
marital and parental status of the respondent, as well as whether his/her spouse or
children immigrated with the respondent to the US or if they continue to live in the
country of origin. Responses to these questions will be used to create a categorical
variable to denote 0 = family intact versus 1 = family not intact. An intact family will be
66
defined as that in which a respondent’s spouse (if any) and his/her children (if any) reside
in the US with the participant.
2. Sense of Community Index Version 2 (SCI-2), which is a 24-item measure used to assess
perceived sense of community (Chavis, Lee, & Acosta, 2008). The SCI-2 was modeled
after the Sense of Community Index (SCI), a widely used measure of sense of
community, in order to overcome some of its limitation. The SCI-2 has been shown to
have good reliability (α = .94). The SCI-2 includes four subscales related to perceptions
of sense of community: (1) reinforcement of needs (e.g., when I have a problem, I can
talk about it with members of this community); (2) membership (e.g., being a member of
this community is part of my identity); (3) influence (e.g., I have influence over what this
community is like); and (4) shared emotional connection (e.g., I can trust people in this
community). These subscales have also been shown as having good reliability with
coefficient α scores of .79 to .86. Responses to each item are given using a four-point
scale: 0 = not at all, 1 = somewhat, 2 = mostly, and 3 = completely. The SCI-2 renders a
total score by summing up all items in the scale, as well as scores for each subscale. In
this study, a total sense of community score will be used, with higher scores denoting
stronger sense of community.
3. Religiosity, which will be measured using three questions assessing perceptions of
religiosity, influence of religion, and church attendance (Hovey, 2000). The first question
is “how religious are you?” and responses are given in a four-point scale from 1 = not at
all religious to 4 = very religious.” The second question is “how much influence does
religion have upon your life?” and responses are also given in a four-point scale from 1 =
not at all influential to 4 = very influential.” The third question is “how often do you
67
attend church?” and responses are given in six-point scale from 1 = never to 6 = once a
week or more.” These questions have been previously used to assess religiosity with
Mexican immigrants in the US, and have been found to be significantly associated with
anxiety, depression and suicidal ideation in this population (Hovey, 2000; Hovey &
Magana, 2002). For this study, a latent variable with the three aforementioned questions
will be created to assess an overall measure of religiosity.
4. English language proficiency, which will be assessed using three items from the National
Latino and Asian American Study (NLAAS) Questionnaire (Alegría, Vila, Woo, Canino,
Takeuchi, Vera, et al., 2004). The questions assess proficiency in speaking, writing and
reading English using a four-point rating scale from 1 = poor to 4 = excellent. A total
English proficiency score will be calculated by adding up scores to the three questions.
Translation. Measures not available in Spanish for use with Mexican-origin populations will
be translated using established methodology (Beaton, et al., 2002). The steps involved in the
translation process will be the same as those previously described in phase one of this
dissertation. Recommended forms developed by Beaton et al (2002) will also be used for the
written documentation of the translations process (see Appendix E). For this phase of the study,
the following questions/measures will be translated using the aforementioned process:
a. Adapted questions from the DSM-V Cultural Formulation Interview to assess for the
Contextual Concept of Distress associated with Ulysses Syndrome (4 questions).
b. World Health Organization Composite International Diagnostic Interview-Short form of
the Chronic Health Conditions Module.
c. Multidimensional Loss Scale (MLS).
d. Harvard Trauma Questionnaire (HTQ)-Only the experienced events section.
68
e. Family intactness questions (4 questions).
f. Sense of Community Index.
Analyses. Data will be analyzed using SPSS V. 20. Descriptive statistics will be used to
assess prevalence and describe participant characteristics. Multivariate sequential logistic
regression analyses will be used to assess for the association between risk factors and diagnosis
of a mental health disorder after controlling for relevant covariates. Multivariate sequential linear
regression analyses will be used to assess for the association between risk factors and perceived
psychological distress after controlling for relevant covariates. Additionally, various multivariate
regression models will be used to assess for the moderating effect of various protective factors
(i.e., family intactness, social support, sense of community, spirituality/religiosity and English
language proficiency) to the association between migration-related loss/trauma and/or difficulties
and diagnosis of a mental health disorder/perceived psychological distress, after controlling for
relevant covariates. All significance levels will be set at p ≤ .05.
HYPOTHESES
Aim 1. Assess the prevalence of mental health disorders and perceived psychological distress
in this sample of UIs and compare it to rates for other Latino and non-Latino populations in the
US. Given the limited information on the prevalence for mental health disorders among UIs,
prevalence rates for Mexican-origin foreign-born immigrants will be used as reference to
hypothesize prevalence rates for UIs. The decision for using prevalence rates for the Mexicanorigin foreign-born population instead of those for the foreign-born Latino population was based
in that the majority of UIs in San Diego are of Mexican-origin; thus, there rates may be closer to
estimate prevalence in the target population. Table 2 summarizes prevalence rates for the
69
majority of mental health disorders assessed in this study for US-born Non-Latino Whites, USborn Latinos, foreign-born Latinos, and Mexican-origin foreign-born.
Hypothesis 1. The prevalence of overall psychological distress as measured by the BSI18 will be ≥ 14%, which is somewhat similar to that reported in the literature for foreignborn Latino immigrants in the US.
Hypothesis 2. The prevalence for depressive disorders, anxiety disorders, somatic
symptom disorder, stress related disorders (i.e., adjustment disorder and PTSD) and
substance use disorders will be ≥ 14%, which is somewhat similar to that reported in the
literature for foreign-born Latino immigrants in the US.
Hypothesis 3. The prevalence for Cultural Concepts of Distress, specifically Nervios
and Ataque de Nervios, will be ≥ 20% for Nervios and ≥ 6% for Ataque de Nervios,
which is somewhat similar to that reported in the literature for foreign-born Latino
(O’Connor, et al., 2013) and Mexican-origin immigrants in California (Guarnnacia, et al.,
2010).
Hypothesis 4. The prevalence for Contextual Concepts of Distress, specifically Ulysses
syndrome, will be ≥ 20% given it is likely that this estimate may be similar to that
reported for Nervios.
Aim 2. Assess the QOL of this sample population using the WHOQOL-BREF, and identify
its association to prevalent mental health disorders and perceived psychological distress, after
controlling for relevant covariates (i.e., age, gender, and socioeconomic status).
Hypothesis 1. After controlling for age, gender and socioeconomic status, a diagnosis of
a mental health disorder will be associated with decreased QOL.
Hypothesis 2. After controlling for age, gender and socioeconomic status, greater levels
70
of perceived psychological distress will be associated with decreased QOL.
Aim 3. Identify the association between immigration-related risk factors and diagnosis of a
mental health disorder/perceived psychological distress, after controlling for relevant
demographic and socioeconomic factors.
Hypothesis 1. After controlling for age, gender, and socioeconomic status, younger
age upon arrival to the US and longer time of residence in the US will be associated
with increased likelihood of diagnosis with a mental health disorder.
Hypothesis 2. After controlling for age, gender, and socioeconomic status, younger
age upon arrival to the US and longer time of residence in the US will be associated
with greater levels of perceived psychological distress.
Hypothesis 3. After controlling for age, gender, and socioeconomic status, greater
exposure to migration-related loss/trauma and post-migration living difficulties over a
long time, will be associated with increased likelihood of diagnosis with a mental health
disorder.
Hypothesis 4. After controlling for age, gender, and socioeconomic status, greater
exposure to migration-related loss/trauma and post-migration living difficulties over a
long time, will be associated with greater levels of perceived psychological distress.
Aim 4. Identify moderators to the association between immigration-related loss/trauma and
post-migration living difficulties, and diagnosis for a mental health disorder/perceived
psychological distress, after controlling for relevant demographic, socio-economic factors, and
other migration-related factors.
Hypothesis 1. Family intactness will moderate the association between immigrationrelated loss/trauma/difficulties and diagnosis of a mental health disorder/perceived
71
psychological distress, after controlling for age, gender, socio-economic status and length
of time residing in the US. In other words, migration-related trauma and/or difficulties
may be less likely associated to the presence of a mental health disorder/perceived
psychological distress among immigrants with nuclear family living in the US when
compared to those whose families are still left behind in the country of origin.
Hypothesis 2. Sense of community will moderate the association between migrationrelated loss/trauma and/or difficulties and diagnosis of a mental health disorder/perceived
psychological distress, after controlling for age, gender, socio-economic status and length
of residence in the US. In other words, migration-related trauma/loss and/or difficulties
may be less likely associated to the presence of a mental health disorder/perceived
psychological distress among immigrants reported a higher sense of community when
compared to those with limited sense of community.
Hypothesis 3. Religiosity and/or spirituality will moderate the association between
immigration-related loss/trauma and/or difficulties and diagnosis of a mental health
disorder/perceived psychological distress, after controlling for age, gender, socioeconomic status and length of residence in the US. In other words, migration-related
trauma/loss and/or difficulties may be less likely associated to the presence of a mental
health disorder/perceived psychological distress among immigrants reporting higher
religiosity/spirituality when compared to those with lower religiosity/spirituality.
Hypothesis 4. English language proficiency will moderate the association between
immigration-related loss/trauma and/or difficulties and diagnosis of a mental health
disorder/perceived psychological distress, after controlling for age, gender, socioeconomic status and length of time in the US. In other words, migration-related
72
trauma/loss and/or difficulties may be less likely associated to the presence of a mental
health disorder/perceived psychological distress among immigrants reported to be
proficient in the English language when compared to those with less English language
proficiency.
73
TABLE 1
Demographic and socio-economic characteristics by immigration legal status categories*
US-Born
Legal
Residents
Undocumented
Age
% Men ages 20-39
% Population ages ≥ 65
% Children
14.0
12.0
27.0
18.0
16.0
6.0
32.0
1.2
13.0
Household Characteristics
% Couple with family
Mean family size
21.0
35.0
47.0
Education
% < High school (ages 25-64)
8.0
22.0
47.0
Language
% Speaks English proficiently
100
23.0 (1st gen)
88.0 (> 1st gen)
NR
50.000
50,000
70,0
70.0
10.0
18.0
50,000
41,300
54,100
40.0
68.0
NP
NP
NP
35,000
38,000
27.0
45.0
20.0
30.0
36,000
83
73
85
66
94
58
14
25
59
Financial Status
Median household income (< 10 yrs in US)
Median household income (≥ 10 yrs in US)
% Homeownership (< 10 yrs in US)
% Homeownership (≥ 10 yrs in US)
% Adults living in poverty
% Children living in poverty
Employment
% In the labor force (Men)
% In the labor force (Women)
Insurance
% Uninsured
*Information based on 2008 estimates from the Pew Research Center (2008)
NP=Not provided
a
Results based on data from the 2008 ACS (1 year estimate).
b
Results for UIs based on 2007-2008 data provided by the Pew Research Center (2008).
74
TABLE 2
Lifetime prevalence of mental health disorders among Latinos (Alegria, et al., 2008)
a
b
Non-Latino White
Mental Disorder
US-born Non-Latino
White
(N=4,088)
US Latino Population (N=2,554)
US-born Latinos
(n=924)
95% CI
Foreign-born
Latinos
n=(1,630)
%
95% CI
%
%
Any Depressive Disorder
Dysthymia
MDD
27.6
6.2
26.9
25.1 - 30.5
4.7 - 7.8
24.2 - 29.8
19.8
3.4
18.6
17.3 - 22.5
2.2 - 4.5
16.1 - 21.1
14.4
3.1
13.4
Any Anxiety Disorder
Agoraphobia
GAD
Panic Disorder
PTSD
Social Anxiety Disorder
30.8
4.0
10.0
6.0
9.5
16.9
28.0 - 33.7
2.8 - 5.4
8.3 - 11.8
4.7 - 7.4
7.9 - 11.3
14.9 - 19.0
18.9
3.7
4.4
4.5
5.9
8.5
16.2 - 21.5
2.5 - 5.1
3.1 - 5.6
3.1 - 6.0
4.4 - 7.5
6.5 - 10.2
Any Substance Disorder
Alcohol Abuse
Alcohol Dependence
Drug Abuse
Drug Dependence
26.4
12.1
10.1
7.7
6.4
23.6 - 29.0
9.6 - 14.4
8.2 - 12.0
6.0 - 9.5
4.7 - 8.0
20.4
9.3
6.9
6.1
5.1
Any Disorder
52.5
49.5 - 55.3
37.1
95% CI
Mexican-Origin
Foreign-born
(n=498)
%
95% CI
12.6 - 17.0
2.1 - 4.1
11.6 - 15.4
12.9
2.8
11.8
9.9 - 16.0
1.3 - 4.5
9.1 - 14.5
15.2
3.7
4.7
3.4
4.0
6.0
13.2 - 17.3
2.7 - 4.8
3.6 - 5.8
2.2 - 4.6
3.0 - 5.1
4.6 - 7.2
14.2
3.4
4.8
3.4
3.5
4.7
11.3 - 17.1
1.9 - 5.0
3.2 - 6.5
1.6 - 5.1
2.1 - 5.0
2.9 - 6.6
18.0 - 22.9
7.4 -11.2
5.2 - 8.5
4.5 - 7.8
3.6 - 6.8
7.0
3.5
2.8
2.8
1.7
5.4 - 8.5
2.3 - 4.8
1.9 - 3.8
1.4 - 3.1
0.9 - 2.6
7.0
3.5
2.8
2.0
1.7
4.7 - 9.5
1.9 - 5.4
1.4 - 4.2
0.8 - 3.4
0.5 - 3.0
33.9 - 40.0
24.9
22.5 - 27.2
23.9
20.6 - 27.2
MDD=Major Depressive Disorder; GAD=Generalized Anxiety Disorder; PTSD=Post Traumatic Stress Disorder.
a
Data drawn from the 2003 National Comorbidity Survey Replication (NCS-R)
b
Data drawn from the 2003 National Latino and Asian American Study (NLAAS)
75
TABLE 3
Assessment of Cultural and Contextual Concepts of Distress
Cultural
Concept of
Distress
Construct
Criteria
a. Current
acknowledgment
of Nervios
1. Cultural
Syndrome
Measure Used
EMIC:
1. Have you ever suffered
from “Nervios” in your life?
2. Do you suffer from
“nervios” now or in the past
12 months?
Response:
Yes/No
b. Somatic
symptoms
(including those
specified in DSMV)
BSI-46
Total score ≥ 14
c. Emotional
distress symptoms
BSI-18
T ≥ 63 in general
distress scale
OR
T ≥ 63 in any of
the individual
subscales
d. Functional
limitation
Adapted from NLLAS:
On a scale from 0-10…How
much your Nervios interfered
with:
1.Household chores
2. Quality of your work
3. Social life/relationships
Frequency per
domain from
0=no
interference to
10= most
interference
a. Life time
Prevalence
EMIC: Have you been
“nervous” since childhood”?
Yes/No
b. Nervios as a
trait
EMIC: Are you a “nervous”
person?
Yes/No
c. Cultural
expression of
distress
EMIC: How do you describe
your experiencing of
“Nervios”?
Qualitative
description
a. Causal
explanation of
perceived distress
EMIC: What is the most
probable cause of your
“Nervios”?
Qualitative
description
Nervios
2. Cultural
Idiom of
Distress
3. Cultural
Explanation
Data/Response
/Cut off
Yes/No
76
a. Current
acknowledgment
of Ataque de
Nervios
1. Cultural
Syndrome
Ataque de
Nervios
2. Cultural
Explanation
EMIC:
1. Have you ever had an
“Ataque de Nervios” where
you felt totally out of
control?
2. Have you had an “Ataque
de Nervios” where you felt
totally out of control within
the past 12 months?
Response:
Yes/No
b. Somatic
symptoms
(including those
specified in DSMV)
NLAAS Ataque de Nervios
Module (Symptoms section)
4 pt Likert Scale:
Scores ≥ 4
suggest
somatization
c. Emotional
distress symptoms
(including those
specified in DSMV)
NLAAS Ataque de Nervios
Module (Symptoms section)
4 pt Likert Scale:
Scores ≥ 4
suggest
emotional
distress
d. Frequency of
Attaques de
Nervios
EMIC: How many Ataque de
Nervios have you had in the
past 12 months?
Frequency
e. Functional
limitation
Adapted from NLAAS:
On a scale from 0-10…How
much the episode or Ataque
de Nervios interfered with:
1.Household chores
2. Quality of your work
3. Social life/relationships
Frequency per
domain from
0=no
interference to
10= most
interference
a. Causal
explanation of
Ataque de Nervios
NLAAS Ataque de Nervios
Module (Causal section)
Responses:
List format
Yes/No
Yes/No
Contextual Concept of Distress: Ulysses Syndrome
Ulysses
Syndrome
a. Emotional
distress symptoms
BSI-18
T ≥ 63 in general
distress scale
OR
T ≥ 63 in any of
the individual
Total score ≥ 14
b. Somatic
symptoms
BSI-46
Total score ≥ 14
1. Contextual
Syndrome
77
c. Functional
limitation due to
distress associated
to loss
MLS
a. Distress associated to
migration-related loss
a. Contextual
expression of
distress
Adapted from DSM-V CFI:
1. How would you describe
your experience as an
undocumented immigrant to
others?
2. What troubles you most
about being an undocumented
immigrant?
2.Contextual
Idiom of
Distress
3. Contextual
Explanation
b. Total score for
losses
experienced as
extremely
distressing
Qualitative
description
Qualitative
description
b. Contextual
effect on identity
Adapted from DSM-V CFI:
1. How do you feel about
being undocumented?
Qualitative
description
a. Causal
explanation of
Ulysses Syndrome
Adapted from DSM-V CFI:
How much distress do you
experience from being
undocumented?
Frequency per
domain from
0=no
interference to
10= most
interference
b. Contextual
effect of
migration-related
loss
MLS
To assess for:
a. Experiencing of migration
related losses
a. Frequency of
losses by
migration-related
domain
EMIC= Explanatory Model Interview Catalogue
BSI-46= Bradford Somatic Inventory
BSI-18= Brief Symptom Inventory (Anxiety, Depression, Somatization)
NLAAS=National Latino and Asian American Study
MLS=Multidimensional Loss Scale
78
Figure 1. Dahlgren & Whitehead (1991) Socio-ecological model of health.
79
APPENDIX A
Screening Questions for Participation in Focus Groups
1. Do you identify yourself as Latino(a)?
___ Yes ___ No
2. Are you over 18 years of age?
___ Yes ___ No
3. Where you born outside the US?
___ Yes ___ No
4. Do you think you have a good understanding of the experiences of undocumented
Latino immigrants living in San Diego and surrounding areas?
___ Yes ___ No
5. In general, do you have weekly interactions with undocumented Latino
immigrants in San Diego or surrounding areas?
___ Yes ___ No
6. Approximately, what percentage of people in your social network of friends and family
in San Diego or surrounding areas are undocumented?
____ (enter %)
80
Appendix B
Mental Health Services Contact List
The service agencies included in this list provide confidential and low cost mental health services
in Spanish that are based on sliding scale fees for patients without insurance and regardless of
immigration legal status.
Linda Vista Health Care CenterSan Diego Family Care
(858) 279-0925
6973 Linda Vista Road
San Diego, CA, 92111
M, W, F 8 am -5 pm
T 8 am - 8:30 pm
S 9 am -1 pm
Logan Heights Family Health
Centers of San Diego
(619) 515-2300
1809 National Ave
San Diego, CA, 92113
M 8 am- 7 pm
T-Th 8 am -6 pm
F 8 am-5:30 pm
S 8 am -5 pm
Logan Heights Family
Counseling Center
(619) 515-2355
2204 National Ave.
San Diego, CA, 92113
M 8 am – 5 pm
T & W 8 am – 8 pm
Th & F 8 am – 5 pm
Nestor Community Health Center
IBCC
(619) 429-3733
1016 Outer Rd.
San Diego, CA, 92154
M, W 8 am – 8 pm
T, Th, F 8 am – 5 pm
Operation Samahan
Mira Mesa Outreach Clinic
(858) 578-4220
10737 Camino Ruiz, S. 235
San Diego, CA, 92126
M-S 8:30 am-5 pm
Operation Samahan
Rancho Penasquitos
(858) 312-6700
9955 Carmel Mountain Rd F2
San Diego, CA, 92129
M-F 9 am – 1 pm
SDSU Psychology Clinic
(619) 594-5134
6363 Alvarado Ct, Suite 103
San Diego, CA, 92120
M & F 9 am -4:30 pm
T & Th 9 am – 7 pm
W 9 am -5 pm
San Ysidro Health Center
Euclid Family Counseling Center
(619) 205-1947
292 Euclid Ave.
San Diego, CA, 92114
M-F 1 pm -5 pm
This list was obtained mostly from the HOPE California Healthcare Resource Guide for
Undocumented Immigrants.
81
Appendix C
Demographic Questionnaire: Focus Groups
Participant ID # _____________
Todays date (mm/dd/year): ____ /_____ / ________
Focus Group # _____________
Please read each question and check or circle the answer that corresponds with your answer.
All of the responses are confidential.
1)
2) 1. Please circle your sex
2. Please indicate your age
Men
Woman
______ Years
3)
4) 3. Please circle, what is your marital status?
5)
6)
7) 4. Please circle, what is the highest degree
or level of school you completed?
Single
Married or living as married
Divorced
Widow
Prefer not to answer
No school
Elementary School
Middle School
Some high school (no diploma)
High school with diploma (or GED)
Some college or higher
Prefer not to answer
8)
5. Please circle, are you currently employed?
If Employed , what type of work do you:
6. What country were you born in?
7. How many years have you lived in the U.S.?
Yes
No
Type of work: _______________________
Country: ________________________
______ Years
82
Excellent
Very Good
Good
Fair
Poor
8. Please circle, how would you rate your
overall health?
Excellent
Very Good
Good
Fair
Poor
9. Please circle, how would you rate your
overall mental health?
10. Please circle, have you ever been diagnosed
with a mental health condition?
Yes
No
If YES, what mental health condition(s) have
you been diagnosed with?
_____________________________________
11. Has anyone in your family (including
Yes
No
siblings, parents and grandparents) ever
been diagnosed with a mental heath condition?If YES, what mental health condition(s) have
they been diagnosed with?
______________________________________
12. Approximately, what percentage of people
in your social network of friends and
family in San Diego or surrounding areas
are undocumented?
13) Approximately, how may days a week do
you interact with undocumented Latino
immigrants ?
_____(enter % of people)
_____ (# of days per week)
83
Appendix D
Focus Group Guided Discussion Questions
1. What comes to mind when you hear someone talking about mental health?
2. How relevant do you think is the study of mental health among the undocumented
community in San Diego and surrounding areas?
 Why do you think it is important to study mental health among UIs?
3. What do you think may be some relevant mental health issues for undocumented
immigrants (UIs) in San Diego and surrounding areas?
 What may be some relevant mental health issues for UIs upon their arrival to the
US?
 What may be some relevant mental health issues for UIs later on as they settle in
the US?
 Which of the aforementioned issues may be more relevant to women? Men?
Children? Families?
4. How likely do you think are UIs to participate in health studies?
 Who would be more likely to participate? (e.g., men, women, recent UIs, UIs with
longer time in the US, those working in the field?)
5. How likely do you think are UIs to participate in mental health studies?
 Who would be more likely to participate?
 How is this different from participating in health studies?
6. What do you think may be some concerns, limitation or fears that could make UIs not
want to participate in mental health studies? (e.g., lack of trust, lack of time, family
conflict, fear of deportation, literacy)
7. What would you do to encourage participation in mental health studies among UIs?
 What would you do to increase their motivation to participate? (e.g., use of
incentive, type of incentive)
 What would you do to increase their motivation to refer other UIs in their network
of friends and family to participate in your study?
 What would you do to increase their trust in researchers?
 What would you do to reduce their concerns about disclosing their immigration
legal status to researchers?
8. How would you invite UIs to participate in your study?
 Where would you recruit UIs for your study? (e.g., locations, settings)
 Where would you conduct the study? (e.g. field, university, community center,
church)
 What would be the best way to interview these participants? (e.g., phone, inperson, online)
 How long should the interviews last?
 Who should conduct the interviews?
9. Do you have any other suggestions or recommendations as to how you would
improve studies on the mental health of UIs and their families?
84
Appendix E
Translation forms
Form A: Report on the cross-cultural adaptation of an outcome or covariate measure
Source Questionnaire:
Questionnaire being adapted: _________________________ Version: __________________
Target group information:
Country where it will be used: _________________________
Culture:
_________________________
Language:
_________________________
Resources used and reports included:
Names
Forward translators:
1.
2.
Synthesis of translations:
Expert Committee
Back-translators:
1.
2.
Expert committee:
Methods:
Report
Completed
Clinician:
Language Expert:
All translators:
T1
Pre-testing
Coordinator
T2
BT1
BT2
85
Form B: Forward Translation into Target Language
Translator (Circle one):
T1
T2
Name of Translator: ___________________________
Profile of Translator (Circle one):
Aware of concept
Native to concept
Name of Questionnaire: ________________________________________
Original Version Item:
Instructions:
Items:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Translation of response categories:
Forward Translated Version (T1 or T2)
86
Form C: Form summarizing the synthesis of the two forward translations (Version T-12)
* Submit notes on discrepancies and their resolution on separate form
Name of Questionnaire: ________________________________________
Original Version Item:
Instructions:
Items:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Translation of response categories:
Final Translated Version (T-12)
87
Synthesis process report of discrepancies (dealt with in State II to create T-12)
Issue: (specify item # and describe issue:
Resolution:
88
Form D: Back-Translation into English
*** Back translation is done without looking at this form, or the original questionnaire. Results
are then summarized on this form. It is important that the back translator is blind to the original
instrument.
Back-Translator (Circle one):
BT1
BT2
Name of Back Translator: ___________________________
Country of origin (where was English spoken as first language: _____________________
Name of Questionnaire: _______________________________________________________
Original Version Item:
Instructions:
Items:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Translation of response categories:
Back Translated Version (BT-1 or BT-2)
89
Form E; Expert Committee Report
Membership:
Role:
Name:
Methodologist:
Clinician:
Translator # 1
Translator # 2
Back Translator # 1
Back Translator # 2
Language Specialist
Report of discrepancies and their resoluation:
Issue: (Specify item # and describe the issue) Resolution:
90
Form F; Pilot testing report (Participants in this study will also be used to pilot the
translated measures)
Sample description:
Sample size:
Description:
Age (mean, SD):
Gender:
# males = __________
# females = ____________
Study description
Reliability: (Internal consistency, test-retest reliability)
Please describe the methods used:
Please describe the results:
Validity:
Methods used (list constructs, how they were measured):
Summarize results for each construct:
Responsiveness:
Described methods used:
Describe results:
Other Psychometric testing (e.g., Factor Analysis)
Describe:
Describe results:
91
Appendix F
Screener for Participation Eligibility in Quantitative Study
1) Are you over 18 years of age?
_______________ Yes _____________No
2) Do you self-identify as Latino(a) or Hispanic?
______________ Yes ____________No
3) Where you born outside the U.S.?
______________ Yes ____________No
4) Are you a naturalized citizen of the U.S.?
______________ Yes ____________No
5) Do you have a legal permanent residency (pink, green or brown) card that
permits you to reside in the U.S?
______________ Yes ____________No
6) Do you have a visa that permits you to reside in the U.S. temporarily (e.g., as student,
visitor, business visitor?
______________ Yes ____________No
92
Appendix G
Questionnaires for Quantitative Study
Participant Voucher # (RDS Serial Number) ______________________
Date of Interview (mm/dd/year): ____ /_____ / ________
Interviewer’s initials: ___________________________
Interview location: _______________________________
INSTRUCTION TO INTERVIEWER: (Follow IRB procedures to explain this study and confidentiality
protection procedures. Obtain definitive verbal consent prior to interview).
READ: I will ask you many questions that are sensitive and private. I want to remind you that the interview is
completely anonymous and that any information you share with me cannot be tracked back to you. You can
refuse to answer any question that you do not want to answer. If you do not want to answer a question, just
tell me and we will move to the next question.
I. Demographics
I.1. Gender. Please circle participants’ gender
I.2. How old are you?
REF
Men
Woman
_______________ years
(777) DK
(999)
I.3. What is the highest level of school you completed?
(1) No school
(2) Elementary school (6th grade)
(3) Middle School (9th grade)
(4) Some high school (no diploma)
(5) High school with diploma (or GED) (12th grade)
(6) Technical education
(7) Some college (no degree). Ask:
(8) College degree or higher
(777) DK
(999) REF
I.4 Are you currently employed?
(1) Yes. Ask Type of work: __________________________
(2) No
(777) DK
(999) REF
I.5 Would you mind if I ask which one of the following ranges was your total gross household income for last
year?
(1) Less than $ 5, 000
(6)
$ 40, 000 to $ 49,000
93
(2) $ 5,000 to $ 9,999
(3) $ 10,000 to $ 19,999
(4) $ 20,000 to $ 29,999
(7)
$ 50,000 or more
(777) DK
(999) REF
II. Immigration history
II.1. Where were you born?
Country: ________________________ State: ____________________
REF
(777) DK
(999)
(777) DK
(999)
II.2. Where did you spend most of your life?
Country: ________________________ State: _____________________
REF
II.3. At what age did you first come to the U.S. to live?
___________ Age first came to U.S. (in years)
(777) DK
(999) REF
II.4. From the time you first moved to U.S. until today, how many years have you lived in the U.S.?
_____________ years
(777) DK
999. REF
III. Respondent Driven Sampling Questions
III.1 What is the name of the area you live (e.g., town name) (for mapping recruitment location purposes
only)? ________________________________________________________________________
III.2 How many friends, relatives or anyone you know by name do you have in or near San Diego who are
undocumented? ________________________________(enter # of people)
III.3 What is your relationship with the person that gave you the coupon?
(1) Relative
(2) Friend
(3) Acquaintance
(4) Stranger
(5) Other. Specify: _________________
III.4 How long have you known this person?
____________months
OR
______________years
94
IV. Quality of Life
IV.1 CITI Chronic Conditions
What chronic health conditions, if any, did you have prior to immigrating to the US?
Yes
No
(777) DK
(999) REF
No
(777) DK
(999) REF
(1) Arthritis or Rheumatism
(2) Chronic pain. Specify:
(3) Heart disease
(4) High blood pressure
(5) Asthma or respiratory disease
(6) Diabetes or high blood sugar
(7) Stomach problems
(8) Cancer. Specify:
(9) Mental disorder. Specify:
(9) Other. Specify:
(10)
What chronic health conditions do you currently have?
Yes
(1) Arthritis or Rheumatism
(2) Chronic pain. Specify:
(3) Heart disease
(4) High blood pressure
(5) Asthma or respiratory disease
(6) Diabetes or high blood sugar
(7) Stomach problems
(8) Cancer
(1) Other. Specify:
(2)
95
IV.2 World Health Organization Quality of Life –BREF (WHOQOL-BREF)
Are you currently ill?
Yes
No
(777) DK
If something is wrong with your health, what do you think it is?
(999) REF
______________________________________________________________________________
This assessment asks how you feel about your quality of life, health and other areas of your life.
Please answer all the questions if you can. If you are unsure about which response to give to a
question, please choose the one that appears most appropriate. This can often be your first
response. Please keep in mind your standards, hopes, pleasures and concerns. We ask that you
think about your life in the LAST TWO WEEKS.
1.
2.
How would you rate your quality of
life?
How satisfied are you with your
health?
Very poor
Poor
1
2
Very
dissatisfied
Dissatisfied
1
2
Neither
poor, nor
good
3
Neither
satisfied,
nor
dissatisfied
3
Very good
Good
4
5
Satisfied
Very
Satisfied
4
5
The following questions ask how much you have experienced certain things in the last two weeks.
A little
A moderate
amount
Very
much
An extreme
amount
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
A little
2
2
A moderate
amount
3
3
Very
much
4
4
Extremely
Not at all
1
1
1
2
3
4
5
Not at all
3.
4.
5.
6.
7.
8.
9.
To what extent do you feel that
(physical) pain prevents you from
doing what you need to do?
How much do you need any medical
treatment to function in your daily
life?
How much do you enjoy life?
To what extent do you feel your life to
be meaningful?
How well are you able to concentrate?
How safe do you feel in your daily
life?
How healthy is your physical
environment?
5
5
The following questions ask about how completely you experience or were able to do certain things in the last two
weeks.
96
10.
11.
12.
13.
14.
15.
Do you have enough energy for
everyday life?
Are you able to accept your bodily
appearance?
Have you enough money to meet your
needs?
How available to you is the
information that you need in your dayto-day life?
To what extent do you have the
opportunity for leisure activities?
Not at all
1
A little
2
Moderately
3
Mostly
4
Completely
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Very poor
Poor
Neither
poor, nor
good
Good
Very good
1
2
3
4
5
How well are you able to get around?
The following questions ask you to say how good or satisfied you have felt about various aspects of your life over
the last two weeks.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Very
dissatisfied
Dissatisfied
1
2
How satisfied are you with your ability
to perform your daily living activities?
1
How satisfied are you with your
capacity for work?
Neither
satisfied,
nor
dissatisfied
Satisfied
Very
Satisfied
3
4
5
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
How satisfied are you with the support
you get form your friends?
1
2
3
4
5
How satisfied are you with the
conditions of your living place?
1
2
3
4
5
How satisfied are you with your access
to health services?
1
2
3
4
5
How satisfied are you with your
transport?
1
2
3
4
5
How satisfied are you with your sleep?
How satisfied are you with yourself?
How satisfied are you with your
personal relationships?
How satisfied are you with your sex
life?
97
The following question refers to how often you have felt or experienced certain things in the last two weeks.
26.
How often do you have negative
feelings such as blue mood, despair,
anxiety, depression?
Never
Seldom
Quite often
Very
often
Always
1
2
3
4
5
V. Mental Health
V.1 Brief Symptom Inventory-18 (BSI-18)
Below is a list of problems that people sometimes have. Please indicate how each problem has
distressed or bothered you during the past 7 days including today.
(0) = Not at all
(1) = A little bit (2) = Moderately
Not at
all
(0)
A little
bit
(1)
(3) = Quite a bit
Moderately
(2)
Quite a
bit
(3)
(4) = Extremely
Extremely
DK
REF
(4)
777
999
1. Faintness or dizziness
2. Feeling no interest in things
3. Nervousness or shakiness
inside
4. Pains in your chest
5. Feeling lonely
6. Feeling tense or keyed up
7. Nausea or upset stomach
8. Feeling blue
9. Suddenly scared for no reason
10. Trouble getting your breath
11. Feeling of worthlessness
12. Spells of terror or panic
13. Numbness or tingling in
parts of your body
14. Feeling hopeless about the
future
15. Feeling so restless you
couldn’t sit still
16. Feeling Weak in parts of
your body
17. Thoughts of ending your life
18. Feeling fearful
V.2 M.I.N.I. Neuropsychological Clinical Interview.
The following disorders will be assessed using specific modules of the MINI based on DSM-V
and/or ICD-10 diagnosis, as well as risk of suicidality:
98
Category
DSM-V /ICD-10
Specifiers
DSM-V Code
ICD-10 Code
Depressive
Disorders
Major Depressive
Disorder (MDD)
Current (2 weeks)
Past
Recurrent
296.2x
296.2x
296.3x
F32.x
F32.x
F32.x
Agoraphobia
Current
300.22
F40.00
Generalized Anxiety
Disorder (GAD)
Current (Past 6
months)
300.02
F41.1
Panic Disorder
Current (Past month)
Lifetime
300.0
300.0
F41.0
F41.0
Social Phobia (Social
Anxiety Disorder)
Current (Past month)
Generalized
Non-generalized
300.23
300.23
300.23
F40.10
F40.10
F40.10
Post-traumatic Stress
Disorder (PTSD)
Current (Past month)
309.81
F43.10
Alcohol Dependence
Past 12 months
30x.xx
F10.x
Alcohol Abuse
Past 12 months
30x.xx
F10.x
Substance Dependence
(Non-Alcohol)
Past 12 months
Varies by drug
F1x.x
Substance Abuse (NonAlcohol)
Past 12 months
Varies by drug
F1x.x
Suicidality
Current (Past month)
Low, Moderate, High
Not applicable
Not applicable
Anxiety
Disorders
Trauma & Stressrelated Disorders
Substance-related
& Addictive
Disorders
Suicidality
V.3 SCID-RV DSM-V
The following disorders will be assessed using specific modules of the SCID-RV for DSM-V
diagnosis:
Category
DSM-V /ICD-10
Specifiers
Depressive
Disorders
Persistent
Depressive Disorder
(Dysthymia)
Current (Only)
Early/Late Onset
Persistent
Intermittent
DSM-V Code
ICD-10
Code
Duration of
Administration
300.4
F34.1
Approx 3 min
99
Somatic
Symptom &
Related
Disorders
Somatic Symptom
Disorder
Trauma &
Stress-related
disorders
*Adjustment
Disorder
Current (only)
With/Without Pain
Persistent/Not
persistent
Mild/Moderate/Severe
Current (Only)
With Depression
With Anxiety
Mixed
(Depression/Anxiety)
Disturbance of conduct
Disturbance of
emotion
300.82
F45.1
Approx 5 min
309.0
F43.2x
Approx. 3 min.
*Adjustment disorder must be evaluated as the last mental health disorder in this clinical
assessment, and should ONLY be assessed if individual reports symptoms of psychological
distress at a clinical level based on BSI-18 scores and if he/she does not meet criteria for any
other DSM-V diagnosis.
V.3 Cultural Concepts of Distress
V.3.1 EMIC Nervios and Ataque de Nervios assessment (Section B)
1.Have you been “nervous” since childhood”?
2.Are you a “nervous” person?
Yes
No
Yes
No
(777) DK
(777) DK
(999) REF
(999) REF
3.Have you ever suffered from “nervios” in your life?
Yes
No
(777) DK
(999) REF
If Yes, ask  Do you still suffer from “nervios” now or in the past 12 months?
Yes
No
(777) DK
(999) REF
If Yes, ask  How do you describe your experiencing of “nervios”? What do you feel?
___________________________________________________________________________
___________________________________________________________________________
What do you think is the most probable cause of your “nervios”?
___________________________________________________________________________
___________________________________________________________________________
V.3.2. Bradford Somatic Invetory (BSI)
100
Please tell us if you have had any of the following symptoms during the past month . . .
0
No
1,Have you had severe headaches?
2. Have you had fluttering or a feeling of
something moving in your stomach?
3. Have you had pain or tension in your
neck or shoulders?
4. Has your skin been during or itching all
over?
5. Have you had a feeling of constriction of
your head, as if it wwas being gripped
tightly from outside?
6. Have you felt pain the chest or heart?
7. Has your mouth or throath felt dry?
8. Has there been darkness or mist in front
of your eyes?
9. Have you felt burning sensation in your
stomach?
10. Have you felt a lack of energy
(weakness) much of the time?
11. Has your head felt hot or burning?
12. Have you been sweating a lot?
13. Have you felt as if there was pressure
or tightness on your chest or heart?
14. Have you been suffering ache or
discomfort in the abdomen?
15. Has there been a choking sensation in
your throat?
16. Have your hands or feet have pins and
needles or gone numb?
17. Have you felt aches or pains all over
the body?
18. Have you had a feeling of heat inside
your body?
19. Have you been aware of palpitantions
(heart pounding)?
20. Have you felt pain or burning in your
eyes?
21. Have you suffered from indigestion?
1
YES
< than 15
days in the
past month
2
YES
> than 15
days in the
past month
777. REF
999. DK
101
22. Have you been trembling or shaking?
23. Have you been passing urine more
frequently?
24. Have you been having low back
trouble?
25. Has your stomach felt swollen or
bloated?
26. Has your head felt heavy?
27. Have you been feeling tired, even when
you are not working?
28. Have you been getting pain in your
legs?
29. Have you been feeling sick in the
stomach (nausea)?
30. Have you had a feeling of pressure
inside your head as if your head was going
to burst?
31. Have you had difficulty in breathing,
even when resting?
32. Have you felt tingling?
33. Have you been troubled by
constipation?
34. Have you wanted to open your bowels
(go to the toilet) more often than usual?
35. Have your palms been sweating a lot?
36. Have you had difficulty in swallowing
as if there was a lump in your throat?
37. Have you been feeling gitty or dizzy?
38. Have you had a bitter taste in your
mouth?
39. Has your whole body felt heavy?
40. Have you had a burning sensation when
passing urine?
41. Have you been hearing a buzzing noise
in your ears or head?
42. Has your heart felt weak or sinking?
43. Have you suffered from excessive wind
(gas) or belching?
44. Have your hands or feet felt cold?
FOR MEN ONLY
102
45. Have you had difficulty getting full
erection?
46. Have you felt that you have been
passing semen in your urine?
Using a 0 to 10 scale, where 0 means no interference and 10 means very severe interference,
think about the month or longer in the past 12 months when your “Nervios” was most severe.
What number describes how much your Nervios interfered with:
1. Household chores (e.g., cleaning, shopping, taking care family)
_____(Number 0-10)
2. Quality of your work
_____(Number 0-10)
3. Social life and relationship with others
_____(Number 0-10)
V.4 Cultural Concept of Distress: Ataque de Nervios
1. Have you ever had an “Ataque de Nervios” where you felt totally out of control?
Yes
No
(777) DK
(999) REF
If Yes, ask  Have you had an “Ataque de Nervios” where you felt totally out of control within
the past 12 months?
Yes
No
(777) DK (999) REF
If Yes, ask How many “Ataque de Nervios” where you felt totally out of control have you had
during the past 12 months?
______________ (number of “Ataques de Nervios”)
Earlier you mentioned having an episode or
nervous attack when you felt totally out of control.
During that episode did you:
1. Shout a lot?
2. Have crying attacks?
3. Break things or become aggressive?
4. Get very angry or in rage?
5. Feel very scared or frightened?
6. Become hysterical?
7. Tremble a lot?
8. Fell strange like it was not you who was doing this?
9. Have a period of amnesia?
10. Get dizzy?
11. Fall to the floor with a “seizure”?
12. Have heart palpitations (your heart beats hard)?
13. Have chest tightness or heat in your chest?
14. Faint or feel on the verge of fainting?
14. Try to hurt yourself or attempt suicide?
Yes
(1)
No
(2)
DK
777
REF
999
103
Using a 0 to 10 scale, where 0 means no interference and 10 means very severe interference,
think about the month or longer in the past 12 months when your episode of losing control or
nervous attack was most severe. What number describes how much the episode or nervous attack
interfered with:
4. Household chores (e.g., cleaning, shopping, taking care family)
_____(Number 0-10)
5. Quality of your work
_____(Number 0-10)
6. Social life and relationship with others
_____(Number 0-10)
Did this episode of losing control or Ataque de Nervios
occur as the result of any of the following situations?
1. Receiving bad news. Specify:
2. Death of a family member.
3. Family problem or conflict. Specify:
4. Marital problem
5. Natural disaster or accident. Specify:
6. Frightening, disturbing or irritating event. Specify:
7. Strong emotion such as sadness or ange.
8. Worries
9. Assault or physical or sexual abuse
10. Economic problem
11. Illness or physical condition. Specify:
12. Use of alcohol or drugs
13. Another situation. Specify:
Yes
(1)
No
(2)
DK
777
REF
999
V.5 Contextual Concept of Distress: Ulysses Syndrome
(Adapted from DSM-V cultural formulation interview (CFI)
Contextual definition of the problem:
1. In a few words, how would you describe your experience as an undocumented immigrant to
others?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. What troubles you most about being an undocumented immigrant?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. On a scale from 0 = no stress to 10=most distress, how much distress do you experience from
being undocumented? Please describe.
______________________________________________________________________________
______________________________________________________________________________
Contextual effect on identity:
4. How do you feel about being undocumented?
______________________________________________________________________________
104
______________________________________________________________________________
VI. Risk Factors
VI.1 Pre-migration Loss/trauma Questionnaire
I would like to ask you some questions about matters that you may have experience prior to
immigrating to the United States or as a result of coming to live in the United. Please tell me
YES, if this is something you have experienced. For statements indicated as YES, please tell me
how much these experiences are upsetting you or causing you difficulties in any way.
Have you experienced:
1. Leaving your house/home
2. Leaving your land
3. Leaving your country
4. Leaving your possession or animals behind
5. Change in your role/position in your family
or community
6. Change in who you can call on for support
and assistance
7. Change to the type of work you do
8. Change in how you are treated by other
people
9. Long separation from a family member
10. Death of a family member
11. Long separation from friends or community
members
12. Death of a friend or community member
13. Been cut off from Familiar food
14. Been cut off from hearing, speaking or
seeing your language
15. Been cut off from traditional or religious
ceremonies important to you
16. Been cut off from familiar music or song
17. Been cut off from important family values
or traditional values
18. Been cut off from your dreams for the future
or plans for your life
19. Been cut off form your hopes for your
family
20. Been cut off from your beliefs about how
life should be
Have you lost…
YES
Not at
all
A little
Quite a
bit
Extremely
105
21. Some freedom, choice or autonomy in your
life
22. Some of your health or sense of wellbeing
23. Some of your wealth or inheritance
24. Some opportunities you previously looked
forward to
In addition to the aforementioned losses, are there any other looses that you experienced prior to
immigrating to the U.S. and that are extremely upsetting to you?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
VI.2 Migration trauma
Harvard Trauma Questionnaire: Trauma experienced only scale
We will now ask you some questions about traumatic experiences that you or your family
experienced prior to, during your migration to the U.S. or while living in the U.S. Please tell me
if you or your family has experience any of these events. Family refers to nuclear, as well as
extended family. If these memories are too disturbing, please stop at any time.
Have you experienced or witnessed:
Trauma you or a family member
experienced
Experienced
1. Lack of food or water
2. Ill health without access to medical care
3. Lack of shelter
4. Imprisonment/detention/deportation (Circle the
ones that apply)
5. Serious injury. Specify:
6. Combat situation. Specify:
7. Brain washing. Specify:
8. Rape or sexual abuse (e.g., by smugglers,
authorities). Specify:
9. Forced isolation from others
10. Being close to death. Specify:
Witnessed
106
11. Forced separation form family members
12. Murder of family or friend
13. Unnatural death of family or friend
14. Murder of stranger or strangers
15. Lost or kidnapped
16. Torture (e.g., physical abuse). Specify:
17. Threatened by dangerous animals
Total
In addition to the aforementioned hurtful or traumatic events, are there any other hurtful or traumatic
events that you or your family experienced prior to, while crossing the border to come to the US or
while living in the U.S.? Specified if experienced or witnessed.
VI.3 Post-migration living difficulties
Problems of living Questionnaire
Below is a list of living difficulties that immigrants who have arrived in the U.S. sometimes
experience. Have you experience any of these difficulties in the last 12 months (a year)?
Have you experienced:
1. Unable to return home in an
emergency
2. Fear/threat of [deportation]. Specify:
3. Concern for family in country of
origin
4. Unemployment (Difficulty finding
jobs)
Was not a
problem/
Did not
happen
A small
problem
Moderately
serious
problem
A serious
problem
Still a
problem
today
107
5. Insufficient money to buy food,
necessary clothes, pay rent.
6. Loneliness and boredom
7. Communication difficulties (e.g.,
limited English language)
8. Separation from family
9. Feeling isolated from others
10. Poor access to treatment for health
problems
11. Poor access to emergency medical
care
12. Poor access to long-term healthcare
13. Poor access to dental care
14. Poor access to counseling/mental
healthcare
15. Bad work conditions. Specify:
16. Discrimination
17. Difficulties obtaining help from
charities
18. Difficulty getting help from social
services
19. Conflict with immigration officials
20. Interviews by immigration officials
21. Limited access to traditional foods
from your country
22. Delay in the immigration legal
process
23. Difficulties adjusting to cultural life
in the US. Specify:
108
EXTRA
24. Difficulties with transportation
25. Inability to have frequent
communication with family/friends
back home
26. Conflict with other ethnic groups in
the US. Specify:
27. Overall, how do you feel about your
life in the United States ?
Very
satisfied
Satisfie
d
Unsatisfie
d
Very
unsatisfi
ed
None
In addition to the aforementioned living difficulties, are there any other difficulties that you have
experienced during the past 12 months?
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
VII. Protective Factors
VII.1 Family Intactness
1. What is your marital status?
(1) Married or living as married
 Ask: Did your spouse immigrate with you to the U.S.?
 If YES, ask: Do you live with or near you spouse?
REF
 If NO, ask: Is you spouse left behind in your country of origin?
(2) Divorced
(3) Widowed
(4) Separated
(5) Single, never been married
(777) DK
(999) REF
2. Do you have children?
(1) Yes
 Ask: How many? ________ Sons _________ Daughters
 Ask: Did your children immigrate with you to the U.S.?
 If YES, ask: Do your children live with or near you?
 If NO, ask:
Do you have any children left behind in your country of origin?
(2) No
(777) DK
(999) REF
Yes
No REF
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
REF
REF
REF
REF
109
3. Do you have parents or siblings left behind in your country of origin?
(1) Yes
(2) No
(777) DK
(999) REF
4. Do you live in a mixed-immigration status family? A mixed-immigration status family is a family
in which members vary in their immigration legal status. For example, a child may be a U.S. citizen,
but the parent may be undocumented.
(1) Yes
(2) No
(777) DK
(999) REF
VII.2 Sense of Community
Sense of Community Index II
The following questions about community refer to: the community that you live in, as well as the
group of people with whom you interact and engage in your regular activities (e.g., work,
church, children’s school).
How important is it to you to feel a sense of community with other community members?
1
Prefer not to be
part of this
community
2
Not important at
all
3
Not very
important
4
Somewhat
important
5
Important
6
Very important
How well do each of the following statements represent how you feel about your community?
Not at
all
1. I get important needs of mine met because I am
part of this community.
2. Community members and I value the same
things.
3. This community has been successful in getting
the needs of its members met.
4. Being a member of this community makes me
feel good.
5. When I have a problem, I can talk about it with
members of this community.
6. People in this community have similar needs,
Somewhat
Mostly
Completely
110
priorities, and goals.
7. I can trust people in this community
8. I can recognize most of the members in this
community.
9. Most community members know me.
10. This community has symbols and expressions
of memberships such as clothes, signs, art,
architecture, logos, landmarks and flags that
people can recognize.
11. I put a lot of time and effort into being part of
this community.
12. Being a member of this community is a part of
my identity.
13. Fitting into this community is important to me.
14. This community can influence other
communities.
15. I care about what other community members
think of me
16. I have influence over what this community is
like.
17. If there is a problem in this community,
members can get it solved.
18. This community has good leaders.
19. It is very important to me to be a part of this
community.
20. I am with other community members a lot and
enjoy being with them.
21. I expect to be part of this community for a long
time.
22. Members of this community have shared
important events together, such as holidays,
celebrations or disasters.
23. I feel hopeful about the future of this
community.
24. Member of this community care about each
111
other.
How many years and months, have you lived in your community?
___________years
_____________ months
VII.3 Religiosity
Hovey (1999)
1. How religious are you?
1. Not at all religious
2. Slightly religious
3. Somewhat religious
4. Very religious
777. DK
999. REF
2. How much influence does religion have upon your life?
1. Not at all influential
2. Slightly influential
3. Somewhat influential
4. Very influential
777. DK
999. REF
3. How often do you attend church?
1. Never
2. Once or twice a year
3. Once every two or three months
4. Once a month
5. Two or three times a month
6. Once a week or more
777. DK
999. REF
VII.4 English Language Proficiency (Items from the NLLAS)
Refused
4
Don’t
know
777
3
4
777
999
3
4
777
999
Poor
Fair
Good
Excellent
1. How well do you speak
English?
2. How well do you read English?
1
2
3
1
2
3. How well do you write English?
1
2
999
That’s my last question. Thank you very much for taking the time to participate! Before we finish
let me emphasize again that your answers cannot be identified with any of your personal
112
information. Everyone’s answers will be combined to give us information about the quality of life
and mental health of undocumented Latino immigrants in San Diego and nearby areas. We
appreciate your time and effort. Here are 3 coupons. Here is how it works (Interviewer explains
the referral process).
Referral coupon numbers given to subject:
____________________________
Envelope #:
Coupon # 1: __________________________________
Coupon # 2: __________________________________
Coupon # 3: __________________________________
VIII. Interviewer’s observations
Adapted from CITI Interviewer Observation form (IO)
1. Overall, in your opinion how honest was the respondent to the questions?
(1) Very honest
(2) Honest
(3) Somewhat honest
(4) Not very honest
(5) Not honest at all
(6) Not sure
2 How well did the respondent understand the questions?
(1) Excellent
(2) Good
(3) Fair
(4) Poor
3 How was the respondent’s cooperation during the interview?
(1) Excellent
(2) Good
(3) Fair
(4) Poor
4 How much effort did the respondent put into answering the questions?
(1) A lot
(2) Some
(3) Very little
(4) None
5 Did the respondent behave as if he/she was hallucinating (e.g., hearing voices, seeing visions,
giggles to self)
113
(1) Yes
(2) No
6 Did respondent have any other type of behavioral or emotional responses that struck you as
very inappropriate or very unusual? (e.g., laughed at odd times, became angry or fearful at times,
talk to him/herself, acted overly familiar, acted hostile)?
(1) Yes. If yes, describe:
_____________________________________________________________________
_
(2) No
7 Were there any interruptions during the interview?
(1) Yes. If yes, describe:
_____________________________________________________________________
_
(2) No
8 Did the participant expressed any concern about sensitive/personal information?
(1) Yes. If yes, describe:
_____________________________________________________________________
_
(2) No
9 Did the participant expressed any other concern about his/her participation in this study?
(1) Yes. If yes, describe:
_____________________________________________________________________
_
(2) No
10 Describe setting where the interview took place (i.e., public restaurant, library, medical office,
SDSU)
______________________________________________________________________________
___________________________
11 What time was the interview completed?
Time ________________ AM _______________PM
12 Duration of the interview?
_______________hours _________________ minutes
13 Please describe any other feedback/comments made by the participant during or after the
interview:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
114
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