Healthcare Needs Assessment of Undocumented Immigrants In the by hmh17149

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									       Healthcare Needs Assessment of Undocumented Immigrants
        In the Farmingville Area for Stony Brook University Hospital
                             Edward Hernandez

Project Overview

      The hamlet of Farmingville, New York has seen an influx of

undocumented immigrants in the last six years. County and Town government,

community groups and others estimate that from 1500 to 3000 new immigrants

reside in and around the Farmingville area. Most are Hispanic and many are non-

citizens. During the warm weather up to 300 men stand on several, highly visible,

street locations seeking work for the day. Many others live 20-30 or more to a

house, in overcrowded conditions, throughout the community. The immigrants,

overwhelmingly men, are a contrast to the largely white, middle class

Farmingville community. The result has been years of tension and sporadic

violence. A small organized group, with about 100 members, in the Farmingville

community has struggled to have these workers removed. The issues around the

presence of the undocumented immigrants and day laborers in the Farmingville

community, and the community‟s response, has received national attention in the

press and has been the subject of an award winning documentary that recently

aired on public television. Community groups working to ease tensions and help

integrate the new immigrants into the community held a number of meetings with

the worker groups and their advocates. One of the efforts to ease tensions and

begin to integrate the workers into the community involved opening a community

center to provide a variety of basic services. Health services were among the

needs identified through the series of meetings. Stony Brook University Hospital

has developed a health initiative through the Community Relations Office for

Underserved Communities with a Community Advisory Board that has been

convened by the Chief Executive Officer. The mission of the health initiative

includes identifying gaps in the delivery of services and ensuring relevant

programming is developed to address those gaps and “to conduct and discuss

research and policy analysis in areas critical for the proper provision of health

care delivery to the underserved populations and communities on Long Island.”

The population of undocumented immigrants in Farmingville fit within the scope

of the health initiative. A local community group, Brookhaven Citizens for

Peaceful Solutions (BCPS) reached out to the Community Relations office to

provide services through this initiative. The Hospital has expressed a willingness

to provide health education, outreach, and screening services to this community,

specifically focused to the undocumented immigrants that comprise the day

laborer population. In order to properly develop and target the services to be

provided, an assessment of need and current health practices of the target group

of undocumented immigrants, mostly day laborers, and their families was

undertaken. One of the Advisory Board members, who was a BCPS member,

and a Ph.D. student worked in conjunction with the Associate Director of

Community Relations to design and conduct an needs assessment.

The Origin of the Need – The Immigrant Experience

       Various attempts have been made to regulate immigration since the

Chinese Exclusion Act of 1882. Laws traditionally dealt with quotas and legal

immigration without addressing the growing numbers of people overstaying their

visas or crossing the borders unchecked or unmonitored. These undocumented

individuals settled in gateway communities and disappeared into the fabric of

American Society. Until the passage of the Immigration Reform and Control Act

of 1986 (IRCA), there have been no attempts to deal with the growing number of

undocumented immigrants (Fix and Passel, 1994). IRCA changed the strategy

from intercepting immigrants at the border or their place of employment to

making the hiring of immigrants who are here illegally a civil and under certain

circumstances a criminal violation. Subsequent legislation continued the attempts

to restrict illegal immigration. The conflict between new laws, history, and

tradition have resulted in limited enforcement, unclear policy directives, and a

governmental “blind eye” to the reality of shifting demographics and their impact

(Hernandez, 2004). Local communities have been forced to find their own

solutions to the influx of new undocumented individuals. The existence of laws

that restrict both the presence and ability of undocumented individuals to become

functional members of the communities, and the lack of enforcement of these

same laws, have led to irreconcilable differences and conflict. Communities are

left to struggle without the benefit of clear guidance or policy from those charged

with making and enforcing the laws.

Immigrant Experience 1990-2000

       Increasingly more restrictive attempts by the government to regulate

immigration have done nothing to reduce the flow of newcomers to the United

States. The decade between 1990 and 2000 is a prime example of recent

immigration trends.

       The best analysis of immigration trends between the 1990 and 2000

according to data collected by the United States Census has been conducted by

the Urban Institute (2002). Passel, Capps & Fix (2004) used the March 2002

Current Population Survey to analyze the population of undocumented

immigrants in the United States. The following statistics are taken from the data

presented in these two studies.

       Between 1990 and 2000, according to the census, 13 million immigrants

entered the United States. Six states accounted for 68% of the foreign-born

population: California (28%), New York (12%) Texas (9%), Florida (9%), New

Jersey (5%), Illinois (5%). This is down from 1990 when 75 percent of the

foreign-born population resided in these six states. Passel et al (2004) showed a

slightly different distribution for the undocumented population, with a total of 65

percent of living in the six states: California (27%), Texas (13%), New York (8%),

Florida (7%), Illinois (6%), New Jersey (4%). The national average growth rate

between 1990 and 2000, according to the census, was 57%. Of the six states

with the highest foreign born populations only Texas (91%) exceeded the

average. These shifting trends point toward the emergence of new destinations

for immigrant populations.

       Census 2000 data has shown that foreign-born populations more than

doubled in 19 states during the 1990's. New growth states saw an average

growth rate of 145 percent, more than double the national average. New growth

states and the corresponding increase for foreign-born population include; North

Carolina (274%), Georgia (233%), Nevada (202%), Arkansas (196%), Utah

(171%), Tennessee (169%), Nebraska (165%), Colorado (160%), Arizona

(136%), and Kentucky (135%). Passel et al (2004) have estimated that

undocumented individuals make up more than 40 percent of the foreign-born

population in 10 states. They also estimate that the rapid growth in Arizona,

Georgia, and North Carolina may have moved these states past New Jersey on

the list of states with the largest percentages of undocumented populations.

       Census 2000 data reports that the United States has 31 million immigrants

or 11% of the total population (Migration Policy Institute, u.d.). This 11% is still

below the record level of 15% at the turn of the last century, in the 1900 Census.

Passel, Capps and Fix (2004) estimate there are 9.3 million undocumented

immigrants in the country representing 26 percent of the foreign born population.

Mexicans make up 57 percent or 5.3 million and 2.2 million or 23 percent are

from other Latin American Countries. Asians comprise about 10 percent.

Europeans and Canadians comprise about 5 percent and 5 percent are from the

rest of the world.

       The Urban Institute (Passel, Capps, & Fix, 2004) cites several policy

implications. The recent immigrants have fewer marketable skills, lower

incomes, and speak less English. They are likely to need benefits and services

such as health insurance, interpretation and English courses. Rapid growth

states will lack the service infrastructure with few organizations, bilingual

teachers and support services available to serve the new immigrants. Welfare

reform has left much of this population ineligible for federally funded programs

while many of the states restrict access to the state-funded safety net programs.

An analysis of undocumented populations by Passel et al (2004) places 6 million

individuals in the workforce or 5 percent of the total workforce. The labor force

participation rate of undocumented men is 96 percent, exceeding both legal

immigrants and US citizens. This is largely due to the younger age of this group

and the lower percentage that are disabled, retired, or in school. By contrast,

undocumented women are less likely to be in the labor force, only 62% which is

lower than women who are US citizens. Passal et al attribute this to a higher

proportion of undocumented women being of childbearing age and more likely to

have children and stay at home. Undocumented workers dominate the low wage

workforce.    About two-thirds of undocumented workers earn less than twice

the minimum wage compared with one-third of all workers. While undocumented

workers are five percent of the total workforce, they comprise 10 percent of the

lower wage workers in the United States.

       The largest of the immigrant groups in the United States are the collection

of nationalities that comprise the Hispanic category. The Hispanic designation

adopted in the 1970s refers to anyone residing in the United States of Spanish-

speaking origin. While there is an extensive debate between the terms Hispanic

and Latino and the differences they may represent, for the purposes of this paper

they may be used interchangeably. Hispanics trace their origins to numerous

countries whose common thread is the Spanish language. The cultures and

traditions are largely heterogeneous although there are some commonalities.

Due to the Census designation, despite the differences, Hispanics are placed in

one large general category.

Farmingville – The Epicenter of the Immigration Debate

       Nowhere has the clash of shifting demographics and inefficient and

broken immigration policies been more evident that in Farmingville, New York. At

one point considered the epicenter of the national immigration debate.

Farmingville has received national attention on numerous occasions. It has also

been the subject of an award winning documentary that has been on the film

festival circuit and aired on national public television.

       Farmingville is a suburban hamlet about 50 miles east of New York City,

on Long Island. According to the 2000 Census Farmingville has about 16,500

residents, over 90 per cent white. With the influx of between 1000 to 2000 new

Hispanic day laborers the demographics noticeably shifted.

       The intense debate began in May, 1998 (Hernandez, 2004). The anti-day

laborer agenda received support from national immigration reform organizations

to develop a model for use across the entire nation. The highly publicized

attempted murder of two day laborers, in September, 2000, by two men with neo-

Nazi tattoos and subsequent battle over the establishment of a publicly funded

hiring hall brought Farmingville to the media forefront. The defeat of the hiring

hall resulted in a national strategy session of immigrant, religious, advocacy, and

funding groups that developed strategies to counter the anti-day laborer agenda.

The session led to the formation of a local alliance of these groups that would be

supportive of immigrants, in general, and to advocate on key issues. The chill of

September 11th and the stalemated agenda of both sides have still not brought

an end to the conflict. In July, 2003 a house with a Mexican family was set on fire

by four local high school students who were convicted of arson and hate crimes.

As 2005 begins, the anti-day laborer forces are attempting to reorganize. In

addition, new County government leadership is taking action against contractors

that are a potential source of employment for the day laborers and a battle is

taking place over the deputization of local law enforcement personnel to identify

criminals in custody without documentation.

      In an effort to move a positive agenda forward and bring the day laborers

and the community at large together, Brookhaven Citizens for Peaceful

Solutions, a community group, and the Workplace Project, an immigration

advocacy group working with the day laborers established a community center in

late 2003. The center was established to provide English as a Second Language,

outreach and advocacy services, access to computers and basic computer

instruction, and health information and screening services. The Associate

Director of Public Relations for Underserved Communities at Stony Brook

University Hospital was contacted to determine the type of health screening and

education services the hospital might be able to provide to this population. The

hospital has expressed an interest in providing the health services that are

needed by this segment of the community. In order to identify needs and targeted

services and the effective use of resources, the hospital requested that a needs

assessment be conducted. One of the Health Initiative‟s Advisory Board

members, who is a BCPS member, and a Ph.D. student, worked in conjunction

with the Associate Director of Community Relations to design and conduct an

needs assessment. The successful development of health services would assist

Stony Brook‟s Health Initiative to Underserved Communities fulfill its mission. At

the same time local community and advocacy groups will have the information

and programs they need to deal with the health needs and issues of the new

immigrant populations.

Immigrant Healthcare Issues

       According to the Centers for Disease Control's Office of Minority Health‟s

website “Assessing Hispanic Health: Data Activities” (Centers for Disease

Control), it is important to have comprehensive data to make informed

assessments of the extent of health problems facing the Hispanic population. A

2005 Kaiser Commission on Medicaid and the Uninsured Issue Brief (Lillie-

Blanton and Lewis, 2005), reports that there is little data available about patterns

of health care on ethnic/minority groups other than African Americans. Most

research utilizes existing data sources or is a subset of larger investigations.

National data sources rarely have sufficient sample sizes. Lillie-Blanton and

Lewis further state that racial/ethnic minorities make up about one-third of the

United States‟ population, but 52%, roughly 23 million, of the uninsured. The

uninsured are less likely to have a regular doctor or get timely and routine

medical care. In underserved areas 28% of Latinos and 22% of African

Americans report having little or no choice in where to seek health care in

contrast to 15% of whites (Lillie-Blanton and Lewis, 2005). Latinos are twice as

likely to rely on a hospital clinic or outpatient department as opposed to a private

physician or office based provider. Fremstad and Cox (2004), in a review of

Federal and State policies, report that immigrants, both documented and

undocumented, without health insurance have less access to health care and are

less likely to obtain needed health care than immigrants with insurance.

Immigrants, especially those that are undocumented, are less likely than other

individuals to have a regular source of care, visit a doctor, or obtain preventive


        Kaiser (2004) further reports that 26 percent of immigrants are

undocumented and many more are likely to be low income. Their research

indicates that between 43 (more than 6 years in the U.S.) and 51 percent (0-6

years in the U.S.) of non-citizens lack health coverage compared to 15 percent of

native citizens. A disproportionate number of immigrants work in low wage jobs,

in small firms, and in labor, service or trade occupations which are less likely to

offer health benefits. While two-thirds of native citizens get health insurance

through their employer, between 33 and 44 percent of non-citizens have

employer-based coverage. Furthermore, the Kaiser Family Foundation, in

conjunction with the Pew Hispanic Center (Brodie et al, 2002) in The 2002

National Survey of Latinos, report 15 percent of Latinos say they or another

member of their household needed, but did not get medical care in the year prior

to their surveys. The condition in which no medical care was sought was

considered to be very serious (30%) or somewhat serious (38%). Twenty-nine

percent of Latinos said they had problems communicating with health providers.

Similar data, regarding undocumented Latino immigrants, were found in a study

published in Health Affairs by (Berk et al, 2000). Berk et al found that

undocumented immigrants obtained fewer ambulatory physician visits and lower

levels of the intensity of the visits.

Study Objectives

       As cited earlier existing research has indicated that little is known about

the population of undocumented immigrants (Lillie-Blanton & Lewis,2005; Center

for Disease Control, nd). Most research utilizes existing data sources or is a

subset of larger investigations. Many studies target Latinos, in general, or

immigrants without regard for their legal status (Lillie-Blanton & Lewis,2005;

Brodie et al, 2002). However, the studies that have been published (Lillie-Blanton

& Lewis,2005; Fremsted & Cox,2004; Kaiser, 2004; Berk et al, 2000) indicate

undocumented Latino immigrants, lack health insurance, have limited access to

health care, and have a decreased likelihood of receiving needed health care.

Aside from ethnicity, little is known about the new immigrants in the Farmingville

community. The information that has been utilized in the evolving conflicts within

the community has been anecdotal and speculative. Given the lack of existing

research in the literature, the study was designed provide insight in who the new

immigrants are, the level of health insurance, the use of routine and preventive

health care, risky health behaviors, and the amount of information either through

practice (i.e. alcohol consumption) or education (i.e. HIV prevention) they may


   Specifically, the study collected relevant data to:

   -    Gain understanding of the general demographics of the target population

        as well as specific data such as educational level, age and gender in order

        to provide the appropriate level of information and services.

   -    Obtain data on regarding the access to health care to better understand if

        the target population has the means and ability to obtain routine and

        necessary care.

   -    Obtain data to determine the extent that the target population has

        obtained health care information and preventive services in key areas to

        identify needs and gaps that can be addressed.

   -    Obtain data on potentially risky health behavior and risk factors for

        members of this population.


        The study population was undocumented immigrants, who are largely

categorized as day laborers, living in and around the hamlet of Farmingville, New


Quantitative or Qualitative Data Collection

        The purpose of the study was to collect data for Stony Brook University

Hospital Health Initiative for Underserved Communities to identify health needs

and practice among the undocumented immigrants, primarily Hispanic, in and

around the Farmingville area. In order to determine a methodology both a

quantitative and qualitative approach were examined. A quantitative approach

enables the examination of a large number of variables and the ability to engage

a large number of subjects. The instrument could be self-administered and data

could be collected in a variety of settings. Issues of reliability and validity would

be resolved by using an existing instrument. There can be a quick,

comprehensive analysis of the data from a survey. A survey presents several

limitations. The study population cannot be defined, which does not allow for

scientific sampling and the generalization of the results. A self-administered

survey would not provide an opportunity to probe for further information and there

is no flexibility with the survey instrument. In contrast, a qualitative methodology

would provide more depth and richness of data with the flexibility to probe,

understand meanings, concepts and definitions. In both methodologies there will

not be a clearly defined study population, using a qualitative methodology, a

researcher could target subjects that meet pre-defined characteristics. On the

negative side, categorizing data, defining concepts, and analyzing data is labor

intensive. A trained researcher and assistants are needed to collect and analyze

the data and the number of subjects is limited. While a qualitative methodology

utilizing interviews and focus groups would yield rich, in depth data, the utilization

of this methodology would not meet reasonable time constraints to allow the

hospital to develop services. To develop a research plan and get institutional

approval then to collect hours worth of semi-structured or unstructured data,

transcribe, categorize, code, triangulate, and analyze would take an extensive

period of time, well beyond the two semester timeframe available to the

researcher, who was a Ph.D. student. In addition, a data collection instrument

would need to be translated into Spanish, tested, and analyzed without the

primary investigator being fluent in Spanish. Translating interviews would present

the added challenge of agreeing upon a translation of idiomatic phrases and the

understanding of regional variations of Spanish.

       As a result of assessing the pros and cons of each approach and the time

frame provided, the researcher made a decision to use a quantitative

methodology for the study. Given the circumstances, the quickest and most

efficient way to maximize the amount of data that could be collected and

analyzed to assess needs was to use a survey. Other factors that weighed in on

the decision included the fact that a large proportion of the target population is in

this country illegally and could be subject to detainment and deportation at any

time. Subjects may be reluctant to come forward and interact with a stranger,

making access to this group challenging. Given the potential risk to this

population in the collection of data, it was more likely that participants would

spend a few minutes to anonymously complete a survey than spend 1 to 2 hours

in an interview or focus group. The initial target number of completed surveys

was 200. The two hundred would represent between 5 to 10 percent of the

estimated 1500 to 3000 undocumented immigrants in the Farmingville area.

The Survey Instrument

       A search was conducted to find a survey instrument that has been tested

and used with a similar population. An established instrument would have been

field tested for reliability and validity, translated into Spanish, and a basis for

comparison. Given the time frames of the need to complete the study and the

length of the school year, the University review process, and the absence of

financial resources available, there was no opportunity to develop an instrument

to capture the information that would be necessary to collect the appropriate

data. Even with the noble intent of finding an existing instrument, it became

evident that there is a dearth of research that has been conducted nationally on

this subject. Most of the research that has been published regarding the target

population has been taken from existing data sources or are pieces of larger

investigations (Lillie-Blanton & Lewis,2005).

       After an extensive literature review and search, an appropriate instrument

was identified. The Tulane Hispanic Health Initiative (Tulane University Health

Sciences Center) developed a survey instrument that used a series of questions

from the National Health Interview Survey (NHIS) and the Behavioral Risk

Factors Surveillance Survey (BRFSS). The National Health Interview Survey is

the principle source of information on the health of the civilian non-

institutionalized population in the United States (NHIS, nd). It is a cross-sectional

household survey administered by the National Center for Health Statistics. The

NHIS consists of two parts: a basic set of health and demographic items and one

or more sets of questions on current health topic. The Behavioral Risk Factors

Surveillance Survey was established by the Centers for Disease Control and

Prevention to collect statewide data to monitor the prevalence of major

behavioral risks among adults associated with premature morbidity and mortality

(BRFSS,nd) . The Tulane Hispanic Health Initiative selected 47 questions from

the NHIS and BRFSS to gain specific insights into the Hispanic population in the

New Orleans, Louisiana area. Tulane conducted six Latino health fairs and

collected 505 surveys using trained bilingual public health and medical students.

Permission was received from Tulane to use the English and Spanish versions of

the survey. The instruments were reviewed by the University Hospital Community

Relations Department‟s Associate Director for Underserved Communities and

School of Social Welfare faculty. The wording of the responses of several

questions had to be modified to ensure that the choices matched the question

prior to submission for CORHIS approval. The wording of the questions were not

changed. CORHIS granted final approval to proceed in January, 2005. The final

survey forms used in the study are in Appendix A.

While the questionnaire was adopted for use in the study, the results of Tulane's

survey were never posted or published and have not been made available. The

questionnaire was administered to the general community at health fairs

targeting Latinos in the New Orleans area. Tulane did not specifically target or

provide a means to identify the undocumented population. Analysis of the Tulane

results may provide additional background data, however, the relevance of the

data as background for this study is limited.

Data Collection Strategy

       A large part of the study population is undocumented and in the United

States illegally. Due to the risk of detainment and deportation, the target group

has a strong desire to remain unknown. As a result, it would be extremely difficult

to adequately define a study population that can be scientifically sampled.

Without knowing the true size and location of the population a decision was

made to collect data either by identifying as many potential subjects as possible

by accessing them in locations that they frequent or in a snowball sample by

using survey subjects or key informants to identify further subjects to administer

the survey.

       The original data collection plan was to be conducted in two ways. The

first access method was to have questionnaires completed by potential subjects

at the various street gathering locations in the Farmingville community. This

would involve engaging the desired target group directly. However, the street

data collection could not be used due to a number of factors including a lack of

Spanish-speaking volunteers or funds to hire and train people to distribute and

collect the questionnaires or verbally administer the survey. The second access

method was to seek subjects at other key gathering places in the community,

such as the local church, and also their residences. A number of locations were

identified by advocates and community groups. This turned out to be the primary

data collection method.

       Questionnaires were designed to be self-administered by the subject in

writing or the survey could be read to the subjects by volunteers from the various

groups involved in the process. The instrument did not include personal

identifying information which could result in having an effect on the rights and

welfare of the subjects or means of tracing the answers to any particular

individual. Since many of the subjects are in this country illegally, to obtain a

written consent could possibly put them at risk with government authorities or

lead to a refusal to participate in the study. Thus, the subjects were not required

to sign a written consent. The instructions at the beginning of the survey

instrument detailed the purpose of the study, provided contact information, and

advised the subjects that they did not have to respond to any question they did

not feel comfortable answering. If the questionnaire was admininstered verbally,

or if the subject could not read, the instructions were read to the subject, by a

volunteer, prior to their participation. Subjects had the option not to participate.

       The methodology employed in identifying subjects did not allow for a

probability sample, since the study was descriptive in nature. Therefore, data

analysis is limited to frequencies and cross-tabulations. Data will be reported in

aggregate form. The number of subjects that were sought was designed to be

sufficient to provide data that adequately represents the target population. The

aggregated data will by used by the hospital to plan and develop health

education, outreach, and screening services to the day laborers that will be

provided in the Farmingville community.

       A number of venues were identified to administer the survey that would

have a high likelihood of reaching the target group. The largest number of

surveys were collected at the community center where the University Hospital is

expected to provide services. There were approximately 15 collected in one of

the English as a Second Language classes at the center and 70 collected during

the process of obtaining a Matricular Consular identification card from the

Mexican government. The Mexican Consulate used the center to collect

application, take photographs, and distribute the cards. Over 200 people

received the Matricular cards. This is a form of identification that is accepted by

banks and other institutions when there is no legal form of identification, such as

an Alien Identification or “green” card. Therefore there is a high probability that

the surveys completed in that setting were from undocumented individuals. The

local Catholic Church participated, as well. The Parish Outreach Coordinator

asked people that she, based on her ongoing work with the target group,

believed were undocumented to complete the survey while they were waiting for

assistance. An opportunity was provided after one of the Spanish masses that

collected 12 surveys. One of the day laborer organizations, Human Solidarity,

was enlisted to help with the survey. They identified subjects, coordinated the

data collection after the Spanish mass, had its members complete surveys at one

of their meetings and had others take surveys back to their residences for

completion. The goal of the survey and the rights of the respondent not to answer

any question that they were not comfortable with was discussed with the

organization‟s leadership by the researcher. There were 12 surveys completed at

one of there meetings and several workers took surveys to their housemates for


       A question on the legal status of the respondent was never included. This

was consistent with the University research guidelines outlined for use with an at

risk population not to collect information that could possibly put the subjects at

risk if they were identified. In addition, those enlisted in assisting with data

collection were told that there would be no identifying data. The usefulness of the

data from that type of question, due to the sensitive nature of the information,

would be called into question given the political climate in the geographic area of

data collection. While this is an item of interest, it was not relative to the nature of

the survey or included in the original survey instrument. It was felt that the

inclusion of this type of question would have a negative impact on the trust that

was required to enlist the cooperation of the individuals completing the surveys

and the groups that assisted in the data collection process.

Plan of Analysis

       The purpose of the study was exploratory. With a non-probability sample

the plan of analysis is to obtain frequencies and cross-tabulations. Data would be

reported in an aggregate form. The responses to the questions would be

sufficient to establish a level of baseline data that could be used by University

Hospital to identify needs and develop services.

       The data collected was entered into an SPSS data file. Each survey was

given a number, based on the order that it was entered along with the date of

entry. A basic frequency count was run utilizing SPSS on the original 52

variables. The data was reviewed for anomalies and cleaned by going back to

the original survey forms and correcting erroneous entries. Once corrected a

frequency count was done in SPSS on every variable. Thirty of the original

variables were selected for the analysis. This was based on factors such as the

number responding, variation within the responses, and the relevance of the

data. Ratio level variables such as age, questions dealing with the number of day

(i.e. days depressed, days drank per week) or counts (i.e. number of children in

the house) were recoded into ranges. An analysis was done on the frequencies

and is summarized in the Data Analysis section. Further analysis beyond this

report would involve the cross tabulation of selected variables.


       One hundred and twenty-nine surveys were collected from the study

population representing between four and nine percent of the estimated

population of undocumented immigrants in the Farmingville area. Data from 30 of

the variables in the survey instrument yielded key demographic and health

related information that provided insights into the study population. The findings

reported in the preliminary analysis of the data consist of an analysis of

frequency counts. The non-scientific methodology used in obtaining subjects,

due to the nature of the population, does not allow for the use of more

sophisticated statistical techniques to analyze the data. Each of the study goals

can be associated with specific sections of the analysis:

Goal - Gain understanding of the general demographics of the target

population as well as specific data such as educational level, age and

gender in order to provide the appropriate level of information and


           The majority of the respondents were male (n=103, 84%) and in their

twenties in age (n=51, 40%). The mean age was 31 (median=29, standard

deviation=9.771). The ages ranged from 18 to 62. Table 1 shows the distribution

of responses to the gender question.

           Table 1





          Table 2 shows the distribution of the recoding of the responses to the question

          “What is your age at your last birthday?”.

                     Table 2

                     Age Range





                         under 20   20-29   30-39   40-49   over 50

                     Age Range

                 The overwhelming number of respondents were from Mexico (n=106,

          88%) with no more than 3 from any other country.

                 Regarding marital status, most of the respondents were single (n=51,

          43%), half reported being married (n=42, 35%) or living together (n=18, 15%).

          While 6 (5%) considered themselves to be separated, it was unclear if this was a

          legal designation or that there family remained in their native country. Forty-

          seven (43%) reported having children in the house. Sixteen (34%) did not report

          the number of children in the house, of those that reported a number, 9 (19%)

          had one child, 13 (28%) had two children, and 6 (13%) had 3 children. Table 3

          shows the distribution of responses to the question “What is your current marital


                     Table 3

                     Marital Status

   Living Together
   Widow ed
   1.6%                                           Single
   Divorced                                       39.5%


Most of the respondents (n=87, 72%) had less than a high school education.

When high school or vocational/trade school were included it accounted for 93%

(n=103) of the respondents. Only six (5%) said they attended college and two

(2%) stated that they did not attend school. Table 4 shows the distribution of

responses to the question “What was the highest grade of school you


          Table 4 Highest Grade of School Completed

                     Highest school






                      Elementary             High School          College    No school can't read
                                   Jr High            Voc/Trade      No School Can Read

                     Highest school

          Over two-thirds (68%, n=83) of the respondents considered themselves

          employed, while 34 (28%) considered themselves to be unemployed.

          Goal - Obtain data regarding the access to health care to better understand

          if the target population has the means and ability to obtain routine and

          necessary care.

                 The overwhelming majority of the respondents (n=105, 86%) indicated

          that they have no health insurance. Despite the large percentage without health

          insurance, only 13% (n=15) indicated that they never had a routine check up.

          Most respondents, 73% (n=82) reported having a routine check up in the last two

          years. The majority (45%, n=51) reported having a routine check up within the

          last year. Sixteen (14%) reported not having their last routine check up within the

          last two years. Table 5 shows the distribution of responses to the question „About

          how long has it been since you last visited a doctor for a routine check up?”

                     Table 5

                     Last check-up





                             Never   Past year   Past 2 yrs   Past 5 yrs

                     Last check-up

                 Despite the large number of respondents having contact with a health care

          provider in the last two years, 53% (n=63) reported that there was a time in the

          last twelve months when they needed to use a doctor, they could not because of

          the cost. Forty-two percent (n=50) responded that this was not the case.

                 The responses to the question “How long has it been since you last visited

          a dentist or a dental clinic?” yielded similar results to the question regarding

          routine check ups. Only 16% (n=18) reported that they never had visited a dentist

          or dental clinic, while 61% (n=70) reported having been to a dentist or dental

          clinic within the last two years, with 21% (n=24) reporting that it was over two

          years. Table 6 shows the distribution of responses to the question.

          Table 6

                     Last Dentist visit





                          Never                 Within 2 yrs           More than 5 yrs ago
                                  Within year                  Within 5 yrs              DK/NS

                     Last Dentist visit

          Goal - Obtain data to determine the extent that the target population has

          obtained health care information and preventive services in key areas to

          identify needs and gaps that can be addressed.

                 Questions were asked regarding if the person was “talked to” by a doctor

          or other health professional regarding drug use and sexual practices. In

          response, 66% (n=70) reported that they were talked to about drug use.

          Additionally, 79% (n=91) indicated they were talked to about sexual practices,

          including family planning, sexually transmitted diseases, AIDS, or the use of

          condoms. Thirty-four percent (n=39) responded that they received this

          information within the last 12 months and an additional 21% (n=24) within the last

          three years and 25% (n=28) more that three years ago. Table 7 shows the

          distribution of responses to the sexual practices question.

          Table 7

                     Talked about sex-std




                            No                  Within 3 years                   DK/NS
                                  Within 12 months         More than 3 yrs ago

                     Talked about sex-std

                 Twenty-eight percent (n=33, out of 116 respondents) responded that they

          have been tested for HIV. Only 5 percent (n=7, out of 119 respondents) reported

          being treated for a sexually transmitted or venereal disease in the last five years.

                 Due the small number of women that completed the survey, there were

          only 19, the number of responses to the women‟s health questions were small.

          All 19 of the women responded to the questions whether they ever had a

          mammogram, 58% (n=11) answered no, and whether or not they ever had a pap

          smear, 89% (n=17) answered yes. Seventeen of the nineteen women responded

          to the question if they ever had a breast exam, 65% (n=11) answered yes.

                Other preventive questions included “How long has it been since you last

          had your blood pressure taken by a doctor, nurse, or other health professional?”

          Twenty-one percent (n=24) responded never and 66% (n=77) report having it

          checked within the last two years. The largest group 31 (27%) report having it

          checked within the last 6 months with another 21 (18%) have it taken within the

          last year. Another 12 (10%) reported having it checked more that 2 years ago.

          Table 8 shows the distribution of responses to the blood pressure question.

                     Table 8

                     Last blood pressure



                         Never           Within past year    Within past 5 yrs        DK/NS
                                 6 months ago      Within past 2 yrs   5 or more yrs ago

                     Last blood pressure

                When asked if they ever had their blood cholesterol checked, 77% (n=92)

          responded that they did not. Regarding children, only 57 (44%) responded to the

          question “Have all your kids taken their shots?”, of that group 79% (n=45)

          responded yes.

Goal - Obtain data on potentially risky health behavior and risk factors for

members of this population.

      A number of questions focused on certain behaviors that may have health

consequences or implication in developing services. Three questions were

related to cigarette smoking. The question “Have you ever smoked 100

cigarettes in your life?” had 62 (52%) responding no, 52 (43%) responding yes,

and 6 (5%) did not know or were unsure. The question “Do you now smoke

cigarettes everyday, some days, or not at all?” had 49% (n=60) responding not at

all, 37% (n=45) responding some days, and 15% (n=18) reporting that they

smoked every day. The answers to the question “On the average, about how

many cigarettes a day do you now smoke?” were not included in the analysis due

to the fact that 78 (61%) of the surveys had missing data and an additional 19

(15%) did not know or were not sure.

      Three questions were included on alcohol and drug usage. The two

alcohol questions “During the past month, how many days per week or per month

did you drink any alcohol beverages, on the average?” and “Considering all types

of alcoholic beverages, how many times during the past month did you have 5 or

more drinks on occasion?” had a large number of missing responses 25% (n=32)

and 61% (n=78) respectively. Of those that responded, 62% (n=60) did not drink

alcoholic beverages in the last month, 18% (n=17) drank once, and 7% (n=7)

drank alcoholic beverages twice in the last month. Of the respondents the five or

more drinks on occasion during the last month question, 28% (n=14) said that

they did not drink 5 or more drinks at all, 29% (n=15) responded they did once in

the last month, and 12% (n=8) responded they drank 5 drinks on occasion twice.

A question was included “Have you ever used drugs for non-medical purposes?”,

88% (n=102) responded no.

       The question “How many times in the past week did you eat fried foods?”

had 56% (n=64) respond once or twice per week, only 8.4% (n=12) ate fried

foods 5 or more times and 3% (n=3) reported that they didn‟t eat fried foods in

the past week.


       The respondents clearly indicated that they realized the importance of

health care and health prevention information. Seventy-three percent visited a

doctor and sixty-one percent visited a dentist for routine care in the last two

years. A mechanism should be put in place by Stony Brook University Hospital to

ensure that access to routine health care is maintained to minimize the length of

time between routine check-ups. Despite the fact that most of the respondents

received recent routine care, over half (53%) reported that there was a time in

the last twelve months that they needed to use a doctor, but could not, due to the

cost. The hospital should provide resources to the community to assist the

undocumented workers in accessing needed care at little or no cost to the


       In the prevention and screening question responses, 66% reported that

they were talked to about drug use and 79% about sexual practices. Additionally,

66% reported having their blood pressure checked in the last two years. While

these numbers are impressive, it is important that these preventive and

screening services remain available and accessible to this population. It is

equally important that efforts are made to reach those that have not accessed

these services yet. The hospital has the ability to coordinate the provision of

these services. The number of female respondents was small (n=19, 15%),

however, most had breast exams and pap smears, but most never had a

mammogram. It is important that access to women‟s service be made available

when planning for this population.

       Services need to be designed to address certain risk factors such as

tobacco prevention (43% indicated that they smoked). Additionally, with 12% of

the respondents indicating that they drank 5 or more drinks twice in the last

month and 11% using drugs for non-medical purposes, services should be

identified to provide linguistically and culturally appropriate mental health and

substance abuse treatment to those that may need it. In general, information on

mental health resources should be made available in Spanish.

       The study was an exploratory study whose purpose was to collect and

analyze data through a survey and identify the areas where the University

Hospital services could be developed to meet the needs of undocumented

immigrants in the Farmingville area. The goals of the study were to:

   -   Gain understanding of the general demographics of the target population

       as well as specific data such as educational level, age and gender in order

       to provide the appropriate level of information and services.

   -   Obtain data on regarding the access to health care to better understand if

       the target population has the means and ability to obtain routine and

       necessary care.

   -   Obtain data to determine the extent that the target population has

       obtained health care information and preventive services in key areas to

       identify needs and gaps that can be addressed.

   -   Obtain data on potentially risky health behavior and risk factors for

       members of this population.

Strengths of the Study

       To the extent of achieving the goals set forth, the survey was successful in

providing data to meet each goal. The data will be presented to Stony Brook

University Hospital to better target and develop screening and preventive

services. One measure of success was that 129 surveys were completed within

the tight six week time constraints of the data collection phase of the project.

The cooperation of the various groups involved in the survey process allowed

access to a difficult to reach population and made the data collection possible. As

a result of these efforts, the study provided critical insights into a little studied

population, undocumented immigrants. Access to this population is difficult due

to possible detainment and deportation of individuals who participate as subjects

if they are identified. The data collected varied from the expectations based on a

review of the literature. As a result of the study, the services to be developed in

the Farmingville area will be based on data rather than theory.

Limitations of the Study

       The study targeted a challenging population, undocumented immigrants,

who face possible detainment and deportation if they are identified. In order to

gain access to the group, an emphasis had to be placed on assuring that the

participation of the subject guaranteed anonymity. This limited the amount of

personal data that could be asked. Even with these constraints, access to the

target population was difficult. The advocacy and community groups that

participated used various gatherings as venues to collect data. These groups

were heavily relied upon to collect data due to a lack of a Spanish-speaking

researcher and volunteers. This lack of Spanish-speaking volunteers did not

allow the opportunity to gather more data at other venues that have a high

likelihood of having subjects from the target population, such as the various

street hiring locations or the homes of the undocumented immigrants. The time

limits of the researcher‟s schedule within the scope of the school year limited the

development of options to gather more data. Ideally, services developed by the

hospital will have the most impact during the warmer seasons when the

concentration of undocumented immigrants in the Farmingville area is the

highest. The data is now available as the summer begins, given the time

necessary to analyze the data and develop programs and services, the

immediate opportunity to have the maximum impact may have been missed for

this year.

       The use of an established survey instrument eliminated the translation

issues and expedited approvals. However, the survey instrument was designed

in another venue. As a result, a number of questions did not get full responses

and the nine page length of the survey instrument may have been intimidating to

potential respondents. This could be due to the fact that the majority of

respondents had less than a high school education or possibly due to the

questionable legal status of the respondents and the amount of data being

requested by an unfamiliar entity. The following section highlights specific issues

with the questions and responses.

Survey Issues and Proposed Modifications for Future Use

Format - The length of the survey, nine pages, made the questionnaire

somewhat intimidating to complete. The questions were spread out and easy to

read, however, a shorter survey both in the number of questions and the number

of pages would increase the likelihood of a subject voluntarily completing the

survey. Over 84 per cent of the respondents were male, however, there were 8

questions over a page and half in the middle of the survey related to women‟s

health. Even though the instructions said to skip over the questions, these

questions, specific to women‟s health, added to the overall size of the

questionnaire and their location in the middle of the questionnaire resulted in

between five and six percent of the respondents to stop answering the questions

at that point. Their decision to stop at that point may have resulted in the loss of

relevant data. These questions in this section should be condensed in size and

number and/or moved to improve the overall flow of the survey for the majority of

those completing it.

Reliability/Validity– Several questions would require clarification in future

surveys to assist in the collection of data. The use of pounds in the weight

question and feet and inches in the height question created some problems. The

countries of origin of most of the respondents use the metric system. Although

some respondents put kilos and meters in the answers to those questions, the

option for the U.S. and metric standards should be part of the question. Metric

responses were converted to U.S. measurements. Under “Marital Status”, the

choice of “Separated” could possibly be interpreted to mean that the person

answering the question is in the United States and their spouse is in another

country and not the valid marital status category. This should be clarified in future

versions of the survey. The variable “Children in the House” may appear clear,

however, it was felt given certain assumptions about the population being

surveyed that there was an unusually high number with children in the house,

forty-three percent. This seems unusual in light of the high percentage of married

or living together males (47%) and low overall number of females (16%)

completing the survey. While this may be a valid number, future surveys should

ask for clarification if the children are in the United States or their native country.

A statistic of particular interest was 46% of the respondents responded that they

felt “sad, blue, or depressed” once a week or more in the month prior to

completing the questionnaire. However, the survey instrument did not allow for

clarification to determine if there were clinical implications or if it was merely a

reaction to being far away from home and family.

       The “Number of Cigarettes Per Day” had seventy-five percent of

responses as missing or unknown. In the interest of reducing the size of the

survey, this question should be eliminated. The variable “Annual Household

Income” had 57 percent missing values and the amounts that were entered were

all over place. Some had annual incomes, some had weekly incomes that were

converted and some entered in numbers that made no sense at all. While this

information would be useful, the quality of the responses would require either

further clarification of the question to attempt to capture better data or the

elimination of the question. “Hormone Replacement” had eleven percent

answering “no”, and eighty-nine percent missing. This question should be

eliminated as well. The variables “Heart Attack”, “Stroke”, “Cancer”, and

“Diabetes” had no positive responses. The series of questions in this section

should be revisited in the process of reducing the size of a future survey. Since

there were so few women completing the survey the questions “Months since last

mammogram”, “Months since last breast exam”, and “Months since last PAP” the

results obtained yielded only a few widely scattered responses. The questions

could be collapsed and combined with the yes or no questions on the same

subject preceding them or eliminated. The same issue arose with the variable

“Last Cholesterol Check.”

Implications for Practice and Future Research

       The study provided insights into a population that has little available

research. The Farmingville findings vary from the expectations set forth in the

literature. The literature realizes the limitations of the data available and the

studies that have been conducted. It is also clear that the undocumented

immigrants have been around for years and, despite efforts to change the

situation, will be here for the foreseeable future. In order to address this

population more information is necessary to better understand the geographical

and demographic characteristics of the group defined as undocumented

immigrants and identify service needs. Clearly, more research needs to be done.

Not only will more data be beneficial for the Farmingville area, a similar study

should be conducted in other locations. This research will paint a broader picture

of undocumented immigrants, in general, and provide data to make comparisons

by geographic area and key characteristics to better understand the similarities

and differences. Data is needed to understand if the differences in the literature

that indicate limited access to health care and a decreased likelihood of receiving

needed health care and the findings from the data collected on the

undocumented population in the Farmingville area. Are these differences due to

sampling, the lack of adequate prior research, or something that is unique to the

study area. Data is also needed to understand if undocumented immigrants living

in the Farmingville area are similar or different from other concentrations of

undocumented immigrants regarding key demographics, health needs, and risks.

       While the study provides useful data to a specific population, the non-

probability sample does not allow the generalization of the findings to other

concentrations of undocumented immigrants. Practitioners need to be aware that

each group and geographic area may be unique. It is important to gather data

prior to attempting to address similar populations. It is equally important to

develop linkages to advocacy and community groups working with this population

to gain access and establish trust with those here without documentation.

       In conclusion, this was an exploratory study. While a number of insights

were gained into the undocumented immigrant population in the Farmingville

area, many questions were raised for future study. Two things must be

considered in developing and conducting further research. Better instrumentation

needs to be developed to target specific areas of interest and to improve

reliability and validity of the questions. In addition to improving the survey

process, further more qualitative research is needed to better understand how

health care services are accessed.


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