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Mental Health of Migrant Farmworkers

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					Mental Health of Farmworkers:
The Role of Context and Culture




   Maria de Jesus Diaz-Perez, PhD ( c )
     Salud Family Health Centers
            Fort Lupton, CO
Outline:
• Context of Mexican immigration
  – History, changing demographics
• Why culture?
  – How body works
  – How people get sick: Culture bound
    syndromes
  – How they cope with illness: Therapeutic
    networks
• Implications for services
History of Mexican Immigration
• 1942 – 1964
   – Bracero Program
• 1964 – 1986
   – Start of undocumented
     immigration



• 1986 – Now
   – Era of
     misguided
     legislation
Bracero Program:
1942 - 64
• Federal program to subsidize growers
• Immigrants worked in agriculture and
  farms
• Great number of immigrants were
  documented
• Temporary nature
Era of undocumented immigration:
1964-86
• Characteristics of immigration:
  – Increasingly undocumented
  – Circular movement of male workers
  – Identifiable, predictable patterns
Era of Misguided Legislation:
1986 - Present
• 1986
  – Immigration Reform and Control Act
    (IRCA)
• 1996
  – Illegal Immigration Reform and Immigrant
    Responsibility Act (IIRIRA)
1986: Immigration Reform   1. Employer
     and Control Act          Sanctions
         (IRCA)
                           2. Border control
                              enforcement

                           3. Amnesty
                              Program

  Goal: Reduce
  undocumented
   immigration
1996: Illegal Immigration Reform
                                   • Welfare reform
                                     to exclude
and Immigrant Responsibility Act
                                     immigrants
             (IIRIRA)

                                   • Federal actions
                                     to deny means
                                     tested programs
                                     to immigrants

                                   • State actions to
       Goal: Reduce                  restrict services
       undocumented                  to immigrants

        immigration
                    Increased risks of
                    injury and death
  IRCA and IIRIRA
                    Geographic
                    diversification

                    Shift toward
                    permanency

Ever increasing     Declining wages
  migration,
worsening living
  conditions
How successful has this legislation
  been in stemming the flow of
  undocumented immigrants?
New Arrivals From Mexico Per
Year by Documentation Status
500
450
400
350
300
250                                      Documented
200                                      Undocumented
150
100
 50
  0
      1980   1985   1990   1995   2000
    New destinations


                                                                       2000 – 2007: Main,
                                                                       New Hampshire,
                                                                       Western Virginia had
                                                                       over a 100 times MX
                                                                       population increases


                                                  Mexican population
                                                  increased from 14 to 18
                                                  times in the 90‟s: Alabama,
                                                  Tennessee, Kentucky, North
                                                  and South Carolina
Leite, P., Angoa, M., Rodriguez, M. (2009). La emigración Mexicana a Estados Unidos:
balance de las últimas décadas. Situación demográfica. México: CONAPO.
   Mexican Migration Today
• More permanent
• Feminization and urbanization of
  migrant populations
   Mexican Migration Today
• Will continue growing
• New sending communities
  – More undocumented migration from Southeast
    and Central regions
  – More migration from rural places from
    Southeast region, going to South in the US
New origins
          Factors Against Immigration
600                                       98



500   •   No jobs                         96



400
      •   High anti-immigrant sentiment   94



300
      •   Federal raids                   92
                                               Yearly immigration
                                               US employment rate


200
      •   State laws                      90



100
      •   Very dangerous to cross         88



 0                                        86
    91

    92

    93

    94

    95

    96

    97

    98

    99

    00

    01

    02

    03

    04

    05

    06

    07

    08

    09
 19

 19

 19

 19

 19

 19

 19

 19

 19

 20

 20

 20

 20

 20

 20

 20

 20

 20

 20
Relative employment growth




Leite, P., Angoa, M., Rodriguez, M. (2009). La emigración Mexicana a Estados Unidos:
balance de las últimas décadas. Situación demográfica. México: CONAPO.
       Characteristics of Rural
              Mexico
•   High rates of underemployment
•   Mostly Catholic
•   Traditional gender roles
•   Low levels of education
•   Limited availability of basic services
•   Social marker: POVERTY
                         In 2008 Mexico received about 26
                         billion dollar in remittances. Migrant
                         remittances represent the second source
                         of revenue after oil
Community of origin: Families
and Women Left Behind
• Silent actors in the migratory process
• Provide instrumental help
• Hold favorable attitudes toward the United States,
  but value morals and traditions of Mexican culture
• Migration has a similar impact on the mental
  health of those left behind and those who migrate
Migrant‟s families stress inventory
(INEFAM. Inventario de estrés para
familias de migrantes)

• Cultural distance
• Concern about the well-being of the
spouse
• Increasing of responsibilities
• Family disintegration
Source: Salgado de Snyder, V.N. (1993). Family life across the border: Mexican
wives left behind. Hispanic Journal of Behavioral Sciences, 15, 391-401.
      Hispanic Stress Inventory

          • Financial/occupational stress
          • Parental stress
          • Marital stress
          • Migration stress
          • Cultural conflict

Source: Cervantes, R., Padilla, A., Salgado de Snyder, V.N. (1991). The Hispanic Stress
Inventory: A culturally relevant approach to psychosocial assessment. Psychological
Assessment: Journal of Consulting and Clinical Psychology, 3, 438-447.
Risk Factors for Health and Mental
Health Problems in Migrant
Populations
Family Separation
Trauma during crossing
Undocumented residency
Discrimination
Poor labor conditions
Poverty
Isolation
Overcrowded, inadequate housing
Lack of knowledge of English
      The double standard of
        Mexican migrants
• Perceived as someone to be proud of for
  taking the risk of going north and work in a
  hostile environment.

• In the US they are considered “illegal
  aliens”.
       Mexican Immigrants
           in the U.S.
• Come for economic reasons – to work!
• Many of them want to be in the U.S.
  temporarily
• Mexico and their villages remain part of
  the psychic present, not a lost past
                Culture
• Integrated pattern of human behavior of a
  racial, ethnic, religious or social group

• Transmitted to succeeding generations
               Culture

Culturally grounded knowledge… “is often
transparent to those who use it. Once learned,
it becomes what one sees with, but seldom
what one sees”
   Why Does Culture Matter?
• The functioning of the body
• How people get sick
• Whether people seek help and the type of help
  they seek
• How much stigma they attach to different
  illnesses
• Culture also influences the meanings that
  people assign to their illness
The Functioning of the Body

• Balance and imbalance
  – Balance dependent on external
    forces
      How people get sick:
    Culture-Bound Syndromes
• A symptom complex occurring in a specific
  geographic distribution, associated with
  certain unique environmental circumstances
  and cultural beliefs

• Associated with ways in which different
  cultures express, experience, and cope with
  feelings of distress
   Mexican Culture Bound
        Syndromes
• Culturally specific
• More common in rural Mexico
• Contain somatic and psychological
  components
  – Mind-body split does not exist
Mexican Cultural Syndromes
•   Nervios
•   Susto
•   Mal de Ojo
•   Empacho
•   Mollera Caida
•   Aire
  Nervios
   Culturally-specific illness condition that prevails in
   Latin American countries

   More prevalent among women

   Somatic and psychological components manifested
   through a variety of symptoms

   The manifestation of this condition does not
   differentiate the body-mind duality that prevails in
   biomedicine

Salgado de Snyder, V. N., et.al. (2001). The prevalence of nervios and associated symptomatology among
inhabitants of Mexican rural communities. Culture, Medicine and Psychiatry.
                Nervios
• An attempt to re-establish balance under
  excessive demand
• May be a coping strategy: temporarily
  free from demands until balance is
  recovered
• Does not always indicate presence of
  psychopathology
                 Nervios
• Treatment:
  – Many people seek medical treatment
  – Usually resolves with time
  – Patient usually doesn‟t expect meds

• Note:
  – Similar to anxiety or mood disorders
  – The word “Nervios” has two meanings
Comorbidity of “Nervios” with Mood and
Anxiety Disorders among Mexican Rural
Population
             35               32.7
             30        27.9
             25
             20                                                      Any mood
                                                                     disorder
             15                                                      Any anxiety
             10                                     9.5              disorder
                                              7.1
              5
              0
                       Women                   Men

Salgado de Snyder, V. N., et.al. (2000). The prevalence of nervios and associated symptomatology
among inhabitants of Mexican rural communities. Culture, Medicine and Psychiatry, .
Prevalence of Somatic Symptoms among Rural
Women who Declared Having “Nervios”
        Vomiting throughout the entire pregnancy              14.4
        Gastrointestinal problems                             19.2
        Headaches                                             11.5
        Backaches                                              4.8
        Lump in the throat                                    10.6
        Chest pains                                            3.8
        Difficulty breathing                                   3.8
        All other symptoms*                                   29.8




* This category was comprised of 30 somatic symptoms other than those listed

Salgado de Snyder, V. N., et.al. (2000). The prevalence of nervios and associated symptomatology
among inhabitants of Mexican rural communities. Culture, Medicine and Psychiatry,
                 Susto
• Sudden fright
• Soul is dislodged from the body and can
  be lost
• Crosses all age, sex, and socioeconomic
  groups
                     Susto
• Symptoms:
  –   Multiple somatic complaints,
  –   Appetite disturbances,
  –   Sleep disturbances,
  –   Feelings of low self worth, sadness
  –   Weight loss
  –   Can cause diabetes
                    Susto
• Treatment:
  – Determined by severity of illness
  – Herbal teas for mild cases
  – Ritual „sweeping‟ in more severe cases
    (limpia, barrida)
     • Best performed by a curandero but can be
       performed by family member or other
       traditional healer
     • focused on cleansing the body so the soul can
       return
             Coping Styles
• Culture relates to how people cope with
  everyday problems and more extreme types
  of adversity

• Spirituality and Religion
  – Religiosity, positive reframing, denial
         Influence of Culture
• Familismo
  – Importance of family over individual
  – Respect for elders
  – Family needs to be included in treatment decisions
• Fatalismo
  – Our fate is out of our control
  – Coping mechanism
  – Can lead to non-compliance if not addressed
       Therapeutic Networks
• Simultaneous use of multiple forms of therapy
   – Popular sector
   – Folk sector
   – Professional sector
• Based on availability, payment, and on how
  the sick person explains the origin of ill health
   – What makes sense
• Use different sources of care at the same time
  or in sequence
Pathways to Mental Health Services
                             1.
                          Selfcare                2. Social
                                                  Network
                                                                            3. Informal
                                                       R                      Services
           Cognitive                                   E
           Evaluation                                  S
             of the                                    O                                4. General
           Symptom                                     U                                Physician
                                                       R
                                                       C
                                                       E
                                                       S                                     5. Specialist
         Symptom
             is
         Alleviated

Source: Salgado de Snyder, V. N., y cols. (1998). Pathways to mental health services among inhabitants of a Mexican
village with high migratory tradition to the U.S. Health and Social Work, 23(4), 249-261.
Services Utilization for Mental Health
Problems
                                                                   24.3
          Physician                                14
                                      6.5
        Homeopath             1.4
                                     5.4
                          0
                                             10                                Any Mood disorder
      MH specialist                        8.6                                 Any anxiety disorder
                                    4.8
                                                                21.4           Any substance abuse
             Priest                                      17.2
                                                  12.9                         disorder
        Folk healer                       7.1
                                    4.3
                          0
                                    4.3
     Hospitalization                      8.6
                                       6.5
                                                                   24.3
    Remedies, prays                                                              34.4
                                           8.1
                      0         5          10     15      20      25      30   35       40
Why this matters to you…here?
• Continue to hold the same beliefs and repeat the same
  behavioral patterns learned and internalized while growing
  up in their communities of origin.

• Beliefs and behaviors remain unchanged until the
  immigrants get familiar with the new culture and feel
  comfortable dealing with the new health system.

• Not familiar with obtaining formal health services even as
  adults in their own country.
Services Utilization for Mental Health
Problems among Mexican Origin
Population
 • Seventy-three percent of the respondents who
   had one or more mental disorders didn‟t
   receive services for their condition

 • Only 15.4% of immigrants received care
   compared to 37.5% of US born Mexicans


Source: Sergio A. Aguilar-Gaxiola. Linking Research to Practice: Implications for Cultural Competence and Mental
Health Services. Conference presented at Beyond Sensitivity & Awareness: Serving the Mental Health Needs of a Diverse
Community. Oregon Department of Human Services. Portland, OR., October 31, 2001
Barriers to Health Care Utilization
• Economic barriers
      – Poverty
      – Lack of medical insurance
• Language
• Low literacy
• Cultural Background
• Immigration Status
      – fear, lack of knowledge of programs available,
        and concern over repercussions to their
        immigration status
• Discrimination
           Health Care Quality Survey,
              Commonwealth Fund
• Minorities more likely to report being treated
  with disrespect or being looked down upon in
  the patient-provider relationship
       •   Asians: 20.2%
       •   Latinos: 19.4%
       •   African Americans: 14.1%
       •   Whites: 9.4%



Blanchard & Lurie (2004)
 Survey of Latinos in Colorado
• My doctor
  discriminates against   50
  me                      45
                          40
                          35
• My doctor doesn‟t       30
                          25
  always respect me
                          20
                          15
                          10
• My doctor can‟t         5
  speak my language       0
Prevalence of Psychiatric Disorders
among Mexican Origin Population

• Mexican immigrants: 24.9%
• US born Mexicans: 48.7%
• US general population: 48.6%

• The risk of having a mental disorder increased
  significantly among MX immigrants with more than
  13 years living in the US



Source: Vega, W.A., Kolody, B., Aguilar-Gaxiola, S. et al. (1998). Lifetime prevalence of DSM-III-R psychiatric
disorders among urban and rural Mexican Americans in California. Archives of General Psychiatry, 55, 771-778.
Prevalence of Psychiatric Disorders
among Mexican Migrant Farmworkers




Source: Alderete, E. et al (2000). Lifetime prevalence and risk factors for psychiatric disorders among Mexican migrant
farmworkers in California. American Journal of Public Health, 90(4), 610-614.
Integration of Mental Health Care and
Primary Care
• Minorities are more likely to seek help in primary
  care as opposed to specialty care.

• Minority patients are among those at greatest risk
  of non detection of mental disorders in primary
  care.
Services Utilization for Mental
Health Problems
  • The general medical sector was the preferred
    source of help among those who suffered at least
    of one mental disorder (18.4%)

  • Only 8.8% received care in the mental health
    sector



Source: Sergio A. Aguilar-Gaxiola. Linking Research to Practice: Implications for Cultural Competence and Mental
Health Services. Conference presented at Beyond Sensitivity & Awareness: Serving the Mental Health Needs of a Diverse
Community. Oregon Department of Human Services. Portland, OR., October 31, 2001
    Salud Family Health Centers
•   Migrant/community health center
•   60% Latino
•   Fully integrated behavioral health care
•   Universal screening for behavioral/mental
    health problems
            Screening Results
•   PTSD             13%
•   Anxiety          35%
•   Depression       38%
•   Total positive   50%
      Culture Counts


• Patient‟s culture
• Clinician‟s culture
       – Western medicine
       – Emphasizes body/mind separation
       – Evidence-based
 Recommendations to Service Providers
• Maximize already existing personal and social
  resources:
   – Religion
   – Culture
   – Family
   – Social networks
   – Personal
Source: Salgado de Snyder, V. N., y cols. (1998). Pathways to mental health services among
inhabitants of a Mexican village with high migratory tradition to the U.S. Health and Social Work,
23(4), 249-261.
Final comments
Don’t forget context
• Come for economic reasons – to work!
• Increased violence and trauma
• Increased anti immigrant sentiment:
  discrimination
Don’t forget culture: Culture goes both ways
Build partnerships and bridges

				
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