Introduction
There is growing acceptance among scientists, practitioners, and policymakers that social and economic contexts are important factors that shape health (Wilensky and Satcher, Reference Wilensky and Satcher2009). With the increased focus on social determinants of health, efforts to address those factors have garnered considerable attention (Butler, Reference Butler2017). Previous efforts have tended to focus on material conditions that might influence health, such as income, education, and employment (Øversveen et al., Reference Øversveen, Rydland, Bambra and Eikemo2017). These efforts, however, are particularly complex for migrants as they face new social and political conditions in their destination countries (Castañeda et al., Reference Castañeda, Holmes, Madrigal, Young, Beyeler and Quesada2015). While social and economic factors may contribute to the impetus for migration, the migration process itself may also constitute a social determinant of health (Castañeda et al., Reference Castañeda, Holmes, Madrigal, Young, Beyeler and Quesada2015). These unique conditions warrant increased attention on the social determinants of health for migrant groups.
Immigrants in the United States confront social inequalities that are shaped by the immigration process and related policies that in turn can drive health disparities (Philbin et al., Reference Philbin, Flake, Hatzenbuehler and Hirsch2018). Notably, anti-immigrant rhetoric and political action gained prominence and seemingly substantial public support in the United States, especially during and after the 2016 presidential election (Morey, Reference Morey2018). Alongside elevated numbers of deportations and publicized debates to reinforce restrictive immigration policies, the public sentiments of anti-immigration and xenophobia have created a precarious sociopolitical climate for immigrant communities, particularly for Latino immigrants (Morey, Reference Morey2018; Massey and Sánchez, Reference Wilensky and Satcher2009). This notable abundance in immigration related policy activity is relevant for understanding health disparities among Latino immigrants.
There is growing interest in understanding how immigration related policies shape health outcomes (Morey, Reference Morey2018; Castañeda et al., Reference Castañeda, Holmes, Madrigal, Young, Beyeler and Quesada2015). A review of studies that examined this relationship for Latino immigrants found that the field of immigration policy and health has tended to engage a “one-policy, one-level, one-outcome” approach (Philbin et al., Reference Philbin, Flake, Hatzenbuehler and Hirsch2018). In other words, evaluation of policies often focuses on a specific policy’s singular impact on an individual health outcome. Policies related to immigration, however, are rarely so self-contained, and consideration of the aggregate impact of the sociopolitical context on Latino immigrant health may be more realistic in understanding how the immigration context functions as a social determinant of health (Philbin et al., Reference Philbin, Flake, Hatzenbuehler and Hirsch2018). A study that examined the state-level policy climate in relation to mental health outcomes among Latinos demonstrated a relationship between individuals residing in states with more exclusionary immigration policies and higher rates of poor mental health (Philbin et al., Reference Philbin, Flake, Hatzenbuehler and Hirsch2018). While this suggests that the policy climate may play an important role in health outcomes, greater understanding of the mechanisms that link these factors is wanting.
One potential mechanism that may link the sociopolitical context and health outcomes among immigrants is the perception of the sociopolitical context. According to the social determinants framework, individual perceptions and experiences of personal status in unequal societies and environments are relevant for understanding health outcomes (Glanz and Bishop, Reference Glanz and Bishop2010; Raphael, Reference Raphael2006). Identifying how Latino immigrants understand and perceive the sociopolitical context may elucidate a possible pathway through which the sociopolitical context impacts health.
Perceptions have been extensively examined in the field of health behavior and identified as a key factor associated with health behaviors and outcomes (McCluney et al., Reference McCluney, Schmitz, Hicken and Sonnega2018; Alcántara et al., Reference Alcántara, Chen and Alegría2014). While there is great diversity in the literature on perceptions and health, there has been particular focus on perceptions of specific health risks and illnesses in relation to related health behaviors and outcomes (Brewer et al., Reference Brewer, Chapman, Gibbons, Gerrard, McCaul and Weinstein2007). There is less understanding about how perceptions of the sociopolitical context are linked to health among Latino immigrants. This potential pathway may facilitate multi-level understanding of factors that influence immigrant health.
The present study explores this potential pathway by integrating the social determinants of health framework and behavioral theories about perceptions. The study’s qualitative approach elicited Latino immigrants’ understanding of the sociopolitical context. Rather than present specific immigration policies to Latino immigrants, we allowed Latino immigrants to characterize how they experienced and perceived the sociopolitical context. We also explored the influence of these perceptions to identify how they might shape health-related behaviors and outcomes among the study population. Health was conceptualized broadly to integrate diverse aspects of health. Notably, health is a complex concept with various conceptualizations. While the definition of health has been frequently debated, there is a general consensus that health encompasses aspects of physical, emotional, mental, and social well-being (Leonardi, Reference Leonardi2018). By engaging a multifaceted perspective of health that encompassed psycho-emotional and physical health, the study acknowledged health’s diverse components as well as the unique ways in which individuals can experience and define health.
Methods
This analysis used data from in-depth interviews conducted from November 2015 to April 2017 as part of a larger study focused on HIV testing and health access among Latino immigrants. The larger study employed a mixed methods approach to examine HIV testing behaviors among Latino immigrants in Queens in New York City. The research was approved by the Institutional Review Board at New York University. The target community selected for the study was Corona, which had a greater number of immigrants from Latin America than any other neighborhood in Queens (Lobo and Salvo, Reference Lobo and Salvo2013). The qualitative component of the study included in-depth interviews with community gatekeepers (n=13) and in-depth interviews with Latino immigrants (n=34). This paper presents the analyses of the qualitative data from these in-depth interviews.
Sampling and data collection procedures
Gatekeeper interviews
Purposive samples of gatekeepers and Latino immigrants based on profiles of theoretical interest were defined to include diverse perspectives of the sociopolitical context. Purposive sampling is a form of non-probability sampling, and decisions concerning the participants to be included in the sample were determined by criteria that encompassed participants’ relevance to the research issue.
For interviews with gatekeepers, we sought diversity in gatekeepers’ involvement in key sectors of the community related to health, which included social services, health, policy, and religious sectors. Gatekeepers were identified based on the following criteria: 1) authority figure in Corona, 2) involvement and demonstrated commitment to the health and well-being of residents, and 3) knowledge of need and behaviors of Corona residents.
An extensive search of community organizations was conducted via the City of New York resources site for the Queens Community Board of Corona. Additionally, an independent search of organizations specific to Corona facilitated review of potential gatekeepers.
Gatekeepers were initially contacted via e-mail and asked to participate in an interview for the study. The e-mail letter explained the purpose of the study and described what participation would entail. Gatekeepers who were interested in participating coordinated a date, time, and location for the interview with the interviewer. Gatekeeper interviews took place during November 2015 to March 2016. All participants formally consented to participate.
Interviews lasted approximately one hour and were digitally recorded. Interviews were semi-structured and asked gatekeepers about their experiences and opinions regarding 1) their role in the community, 2) characteristics of the Corona community and residents, 3) migration patterns to Queens, New York; and 4) health access in the community. Sample questions from the interview protocols are included in Supplementary Table 1 (Supplementary Materials).
Latino immigrant interviews
For in-depth interviews with Latino immigrants, we utilized a stratified sampling approach to capture variability in characteristics of theoretical interest that were considered important to participants’ experience of the sociopolitical context. These variables included sex, county of origin, age, length of time in the U.S., and language preference. Eligibility criteria for participation in the Latino immigrant in-depth interviews included: 1) being an adult aged 18 and older, 2) being an immigrant (not born in the continental U.S.), and 3) being of Latino ethnicity.
We used community outreach methods to recruit Latino immigrants for interviews. Project staff explained the study’ purpose to potential participants, and individuals who met inclusion criteria were invited to participate. All participants consented to participation. Interviews lasted about one hour and were conducted in Spanish or English based on the participant’s preference. Interviews were conducted in a private, mutually agreed-upon location between the participant and interviewer. Semi-structured interviews asked about immigrants’ perspectives on their migration experience, the sociopolitical context, and health access. Interviews also explored how immigrants’ experiences shaped their psycho-emotional and physical health. Example questions from the immigrant interview protocol are provided in a supplementary table (Supplementary Table 1). Interviews with Latino immigrants were conducted during March and April 2017, and all interviews were digitally recorded for transcription and analysis.
Data analysis
All interviews were transcribed, and each transcript was analyzed by two researchers. Coding was guided by grounded theory to facilitate theory development from interview indexing (Charmaz and Belgrave, Reference Charmaz and Belgrave2007). Sensitizing concepts that focused on the sociopolitical context guided initial coding of transcripts (Charmaz and Belgrave, Reference Charmaz and Belgrave2007). Two independent coders coded three transcripts with the initial list of codes. After meeting and discussion, coders agreed upon the list of codes and domains (topic areas) and created a codebook.
The two coders co-coded the transcripts, which involved independently coding the transcripts following the codebook. Regular meetings were held to discuss codes and reach consensus. Team discussions emphasized mutual respect and shared power among the coders (Hill et al., Reference Hill, Thompson and Williams1997), which allowed coders to integrate multiple perspectives and engage in a process of consensual validation (Hill et al., Reference Hill, Thompson and Williams1997). Once coders coded and discussed all transcripts, each coder identified core ideas that emerged from each domain. Given the study’s focus on sociopolitical factors, coders examined the overarching context of Latino immigrants to assess identified domains. Then, coders convened to discuss these core ideas and reach subsequent consensus (Hill et al., Reference Hill, Thompson and Williams1997).
Findings from gatekeepers were triangulated with that from Latino immigrants to verify data validity. After coders identified the core domains from the original transcripts, main themes and specific examples from gatekeepers and Latino immigrants were compared to identify overlapping themes (Farmer et al., Reference Farmer, Robinson, Elliott and Eyles2006). Coders integrated examples from gatekeepers and immigrants into shared themes. Similar examples with different themes were discussed between the coders to determine the final set of themes. Coders carefully examined themes and examples without overlap between gatekeepers and immigrants and reviewed original transcripts to determine whether any examples were overlooked. When coders concluded that there was no overlap of a particular theme, findings were marked as specific to either gatekeepers or immigrants. Given our study’s focus on the perspectives of Latino immigrants, themes identified only among gatekeepers were not reported (Farmer et al., Reference Farmer, Robinson, Elliott and Eyles2006).
Results
We conducted interviews with 13 gatekeepers and 34 Latino immigrants. Immigrant participants were diverse across variables of theoretical interest. Gatekeepers included leaders across diverse sectors: policy sector (n=2), health sector (n=5), religious sector (n=5), and social service sector (n=4). Notably, gatekeepers may have also self-identified as Latino and/or immigrants and have resided in the Corona neighborhood.
Among Latino immigrants, 35.3% were male and 64.7% were female. Participants ranged in ages from 18 years to 84 years (Mean: 39.2 years). The average length of time residing in the United States ranged between 7 months to 33 years (Mean: 15.8 years). Half of participants were from Mexico, 14.7% from the Dominican Republic, 23.5% from Ecuador, and 11.8% from other countries (Colombia, Peru, Venezuela, and El Salvador). Approximately half of participants spoke only Spanish, about a third (35%) spoke more Spanish than English, and 15.1% spoke either both Spanish and English equally or more English than Spanish.
Perceptions of the sociopolitical context
Latino immigrants and gatekeepers described how they perceived the current sociopolitical context, providing insight into their understanding and assessment of policies, political events, and the political discourse. Three major themes emerged from participants’ perceptions: 1) discrimination towards immigrants, 2) unpredictable and mercurial circumstances, and 3) confusion and lack of information.
Discrimination towards immigrants
Gatekeepers highlighted the lack of attention on communities with large immigrant populations such as Corona, Queens. Specifically, gatekeepers explained that “Corona, for a long time, has been neglected,” (policy sector) and that “Queens kind of remains in the back where nobody can see it…” (religious sector). Sentiments of being ignored were largely attributed to the growth of the immigrant population:
“[There is] a lack of services, lack of funding, poverty… This is my perception, okay – nothing scientific about it, but I’m really convinced that it is because Queens is heavily immigrant” (religious sector).
These experiences compounded perceptions that as immigrants, “we’re not entitled to anything” (health sector). The inequitable treatment towards immigrants reflected in gatekeepers’ assessments of Corona demonstrated that discrimination was a key component of the sociopolitical context.
Latino immigrants echoed gatekeepers’ perspectives that discriminatory attitudes towards immigrants prevailed above all others: “the majority of people come to think that they [immigrants] are delinquents, they’re criminals, drunkards, lazy, unkempt… everything bad” (female, Mexico, age 32).Footnote 1 The tendency to group Latino immigrants into a singular, homogenous category in the political discourse contributed to immigrants’ perceptions of discrimination towards their community:
“They say that Mexico, there are a lot of, what do you call them, drug dealers. And then, when they say Mexico, they’re generalizing the entire country. But in reality, it’s not the entire country, in reality there are zones – states…They don’t distinguish. For example, on TV, is there is a murder, and it’s a Latino… well then, all Latinos are bad… They generalize everyone” (female, Mexico, age 32).
This negative perception was common among participants as they explained experiencing and viewing “violence towards immigrants” (female, Mexico, age 36). These sentiments were particularly heightened as Latino immigrants reflected upon the 2016 presidential election. Participants’ understanding of the political debates were centered upon how policies were exclusionary towards immigrants:
“The president is going to come, I’ve heard… and he’s going to kick us out of the country because we are immigrants” (female, Mexico, age 35).Footnote 1
“Here, they don’t want us. But we are the ones who are working the most, more than the citizens… but they don’t like immigrants,” (male, Mexico, age 36).Footnote 1
Several Latino immigrant participants perceived the 2016 presidential election as unfairly anti-immigrant and emphasized that Donald Trump was hostile towards the immigrant community. Many described Trump’s attitudes and policies to be “racist.” One participant made a direct comparison between Trump and Hitler:
“I feel like Donald Trump is like Hitler. And I feel like Hispanics are like… I feel like we just have this big star here… so your immigration status is your everyday life” (female, El Salvador, age 20).
In lieu of naming specific policies or events, participants described an overarching anti-immigrant sentiment that characterized the sociopolitical climate. Regardless of specific country of origin or one’s specific character or behavior, Latino immigrants explained that being an immigrant was impetus for discrimination.
Unpredictable and mercurial circumstances
In addition to unfair treatment towards immigrants, participants explained that the sociopolitical context was in a period of major shifts and changes. Participants perceived the political climate as unpredictable, in large part, due to the presidential election and proposed policy changes publicized in the media. A gatekeeper noted, however, that the proposed policies that deal with immigration rarely come to fruition to have tangible impacts:
“Immigration reform has been – something that has been promised for years, you know. Every year it seems to be a dead end, right? Every president for the last few decades that has talked about immigration reform has kind of hit that dead end road. I’m hoping that whoever becomes the next president this year can actually make it a reality. But again, whoever that person is needs to deal with congress, right?… So, it’s difficult. So, it doesn’t trickle down to the folks here” (policy sector).
Latino immigrants also explained the disconnect between what is publicized to the larger immigrant community and actions taken in reality:
“They promised a lot of stuff like giving green cards for people that don’t have it; not deporting… but they don’t do what they promised in the beginning. I think it’s going to continue the same because if the president wants to do something, but then the congress is holding… “ (female, Dominican Republic, age 52).
This discrepancy demonstrates the perceived unpredictability of the sociopolitical environment, where the messages and information received do not translate to aligned activities.
Confusion and lack of information
Related to perceptions of unpredictability regarding the sociopolitical environment was confusion about the impacts and ramifications of shifting social and political factors. Both gatekeepers and immigrants described a profound lack of information within the immigrant community. One gatekeeper repeatedly mentioned confusion as an important barrier to social and political progress: “I think there’s a lot to be done still. I think there’s a lot of confusion” (health sector). Another gatekeeper added to this sentiment and pointed to misinformation as a culprit of confusion among Latino immigrants:
“I think that the information people are receiving is incomplete, and in many cases, wrong. So, I’ll be worried about what people are really learning from the news, you know… And the fact that in New York City, people now have paid sick leave, you know, regardless of your cognition, people don’t know it. People just don’t know it. People don’t know what the law allows them” (religious sector).
As this gatekeeper explains, the skew in the media can lead immigrants to believe information that is untrue and can prevent awareness of the resources or services available. The confusion experienced by Latino immigrants demonstrates the disparity between the actual manifestation of proposed policies and their presentation in the news or media.
Another gatekeeper pointed to immigrants’ unique situation as foreign-born residents, explaining the challenges to engaging with and understanding their sociopolitical context in the United States.
“Many of the immigrants are so heavily involved in their home countries… the politics of their home countries, that they’re really not paying attention here. If I had a dollar for everyone who tells me I’m only staying here for a few years, then I’m going back home – I’m going back home to my home country… that usually isn’t going to happen… so all that time instead of getting involved, they didn’t because they had this illusion that they were going to go back home… Their whole thing is that politics – that’s something outside of my purview.” (policy sector).
This gatekeeper explains how the perceived sociopolitical context of Latino immigrants in the United States is often linked to the policies and events in their countries of origin. As a result, Latino immigrants’ knowledge and information about policies and actions in the United States is limited. Moreover, this gatekeeper illustrates how proposed policies and social shifts that are directly related to the lives of immigrants in the United States can sharply differ from the actual priorities and needs of Latino immigrants. This disconnect may add to confusion regarding the sociopolitical context.
Latino immigrants reiterated being confused or lacking information regarding the sociopolitical context. Some participants attributed this to language barriers, while others had questions about the feasibility of proposed policy changes, pointing to inadequate information: “…because about the whole… um, what’s Trump… like what he wants to do… I don’t know how, like how that’s gonna work” (female, Peru, age 25).
While adequate and accurate information factors into comprehending one’s sociopolitical context, both gatekeepers and immigrants explained the array of challenges to fully knowing the true impact of proposed social and political changes.
Psycho-emotional health impacts
As gatekeepers and Latino immigrants described their perceptions of the sociopolitical context, they expressed how these perceptions affected their psychological and emotional health. Given participants’ perceptions of the sociopolitical context, it is unsurprising that their psychological and emotional reactions were adverse and undesirable. Specifically, feelings and thoughts of fear, sadness, helplessness, and hopelessness negatively shaped their psycho-emotional health.
Fear
Fear was a common emotion expressed by participants regarding the perceived effects of proposed policies and social shifts. A gatekeeper noted that the way information is relayed to the public inevitably imposes this emotion:
“So, you probably pick up the newspaper once in a while… My impression is that these kind of publications are very alarmist and leave people in a place where they are more afraid” (religious sector).
As this gatekeeper suggests, media outlets embed fear into the news consumed by Latino immigrants, and immigrants consequently experience this fear. Additionally, gatekeepers made direct linkages between the lack of accurate information and the fear that permeates the Latino community:
“…they fear immigration. They fear getting deported, and this is why I say we need more education in terms of teaching and educating our community around the laws that there are to protect them” (social service sector).
Without the knowledge of resources or efforts that can quell concerns about immigration policies, gatekeepers explain that Latino immigrants remain fearful of potential consequences. Moreover, this fear affects all aspects of life, including engagement with health and social systems. Latino immigrants confirmed these feelings and explained how fear invades their individual, family, and community life:
“Do you hear what Donald trump is saying? But when you’re in my place, money and immigration is where I am. I’ll actually sit there and watch what he says… unlike others. When it comes up in conversation, they’re like oh, I don’t know. Well they were born here so you’re lucky… so sometimes it does put a fear. It puts a fear in my parents too” (female, El Salvador, age 20).
Latino immigrants described how individuals who are born in the United States are fortunate to be able to disregard the political rhetoric surrounding immigration while the foreign born must deal with fears related to their sociopolitical context. Another participant explained that fear is constant among immigrant communities and noted always feeling scared because “you never know when they might take you” (female, Mexico, age 35). Similarly, another participant explained that discussion of deportation in the news was the primary source of fear in her life:
“…they’re gonna send all the immigrants back to their country…I mean, I have like my sister, and she’s only 14… and then my brother, like he’s 17…like what they gonna do without my mom and my dad… and I’m not gonna be here either…” (female, Peru, age 25).
Separation from family was a common concern among Latino immigrants as they worried about what would happen if family members were deported back to their countries of origin. As these quotes illustrate, participants’ understanding of the current sociopolitical context led to intense psychological and emotional reactions of fear.
Sadness
In addition to feeling scared about the implications of the social and political context, Latino immigrants expressed feeling sad about the current state of politics. Emotions of despondency naturally followed participants’ description of unfair treatment towards Latino immigrants and the discriminatory language used in the media. One participant explained that the characterization of Latino immigrants in the media and other contexts elicited dejected emotions:
“Honestly, it’s sad when I think that we are human beings, and it’s sad that they divide us into categories – You are this or you are that…” (male, Peru, age 35).Footnote 1
As this participant explains, the categorization of individuals within the Latino immigrant community based on particular characteristics was particularly dehumanizing. Another participant expounded upon this sentiment and noted that the division was particularly based on documentation status:
“I feel sad or angry. Because I’m a U.S. citizen, I know I can go anywhere I go. But I see most people, around me, that they don’t have status here… And I remember when I was like that when I came to this country. I feel sad” (female, Mexico, age 24).
This participant expresses disappointment regarding the perceived restrictions placed upon undocumented individuals in the United States. She also sympathizes with them because she, too, had to endure similar challenges.
“Well, there is a lot of pain and sadness because there are lots of dads and moms that are separated from their families… Yes, it hurts a little. I don’t want to think about it, right, because it could happen to me…” (female, Mexico, age 36).Footnote 1
As participants explained the impact of legal actions against Latino immigrants in the United States, they demonstrated how their feelings of sadness were associated with the potential that these events could also occur in their own lives.
Helplessness and hopelessness
A sense of helplessness and hopelessness were also common reactions among participants as they explained the current sociopolitical context. Specifically, participants felt unable to defend against legal or political forces and lacked hope in the possibility that conditions would change. One participant explained that, “because we don’t have a say, we can’t do much,” (female, El Salvador, age 20), which elucidates the psychological and emotional reactions to Latino immigrants’ perceived sociopolitical environment.
The social and economic barriers to community involvement or participation are often insurmountable for this population. When asked about accessing resources or obtaining greater information about how to navigate the current sociopolitical context, many participants indicated that the lack of money or the lack of documentation status prevented them from doing so:
“People who don’t have it [papers] have their defenses. I have family members who don’t have papers and they also suffer because they don’t have a doctor and they can’t work” (female, Ecuador, age 26).Footnote 1
It’s hard to get it [services] because… at least you have to get education to get something from the government. Same thing, you have to pay to get those things. And sometimes people don’t have enough money to get it” (female, Mexico, age 30).
Latino immigrants describe the debilitating circumstances associated with being an undocumented immigrant or an immigrant without economic resources. There was a common assumption that people lacked agency without money or legal status in the United States. Eventually, this experience contributed to a hopeless outlook for the future:
“I think everybody comes here with a purpose. But being here they lose it… And once they’re here, that’s their last thought… I know I’ve heard a lot that they want to leave. Because oh, I came here I work so much, and I don’t see the money. And like, for example, even my dad will say it sometimes, maybe playing around or whatever. Like I came here, I’m working my ass, I’m working my butt out just so that I’m helping others get up there when I’m down here. So, I think it gets to people after a couple of years” (female, Ecuador, age 29).
The perceived lack of change or improvement in Latino immigrants’ sociopolitical context was increasingly difficult to manage with the passage of time. Consequently, the need to “leave” or “get out” of the United States demonstrates Latino immigrants’ feelings of hopelessness.
Gatekeepers concurred with these sentiments and explained that these feelings were reflected in the lack of political involvement among the Latino immigrant community:
“As far as political power, it’s not there. Why? When you look at the numbers of people that can vote, the majority of the Hispanic population are legal residents… I mean legal within the country… But no American citizen votes… so when it comes to the power, we don’t have it because we don’t have the money power… we only have the purchasing power and as far as the political power, it’s only at 40%. So therefore, we’re always put behind” (social service sector).
“Throughout their entire amount of years they’ve been living here, they’ve never gotten involved, they’ve never said the word, they’ve never gone to a town hall – so it’s hard to break that cycle… because their whole thing is politics – that’s something outside of my purview, I’m just worrying about my job and my life” (political sector).
As gatekeepers describe the lack of involvement among Latino immigrants in political activities, they explained why there was a lack of hope and agency within the community.
Physical health impacts
As psycho-emotional health can shape individual behaviors, participants demonstrated a clear linkage between the emotional impact of their perceived sociopolitical context and health-related behaviors. Figure 1 illustrates the linkages between Latino immigrants’ perceptions of the sociopolitical context, psycho-emotional health, and individual behaviors. Specifically, participants described how the psycho-emotional effects of the perceived sociopolitical context shaped engagement in risk behaviors and avoidance of protective or preventive behaviors.
Figure 1 Integrated framework of the relationship between sociopolitical context and immigrant health and well-being
Health risk behaviors
Gatekeepers described how Latino immigrants engaged in risky health behaviors such as alcohol or drug use and sex work as a means for survival:
“If you’re going to have a sports bar where there are going to be girls in skimpy clothing, serving drinks because they don’t have any other source of income… you need to go there because there is the potential of survival sex, sex for money, and if you mix it with drinks, well that’s a pretty bad mix. So, many people drink in the streets, drink in cars, drink in bodegas… You go on Sunday afternoon to any bodega, Mexican bodega, and there’s a lot of drinking in the back. You know, and there’s a lot of sex also” (religious sector).
Another gatekeeper explained that these risk behaviors could be connected back to Latino immigrants’ perceptions of the current sociopolitical context:
“…if it wasn’t for immigration policies, I feel we wouldn’t have such high risk work, or high risk situations or circumstances because if you look at the people that are working in the bars as the waitresses or at the dancers… okay… and then you look at the patrons and then you look at the managers – we’re all immigrant Latinos… And it’s to survive… because most of them – not all – but most of them don’t have documentation status or don’t speak the language and they’re trying to survive. What other kinds of jobs? And most of them have children at home. So I think immigration policies are really having a lot to do with what’s happening” (social service sector).
Gatekeepers described how the emotional reactions to the sociopolitical context are attributable to the risk behaviors occurring among the Latino immigrant community. These risk behaviors can be linked to negative health outcomes such as substance abuse, HIV/STI infections, or sexual violence.
Avoidance of protective health behaviors
Latino immigrants also explained that the poor psycho-emotional health resulting from their perceptions of the sociopolitical context prevented individuals from engaging in protective or preventive health behaviors. For example, a participant explained that due to fear, Latino immigrants were “scared to see a doctor or go to a hospital because of their immigration status” (male, Colombia, age 70). Another participant reiterated this point:
“There are a lot of people who are scared just because they are illegal and they are scared to go to a hospital or to a doctor, and that’s why they don’t take care of their health early. When there is an opportunity, it’s very late” (female, Ecuador, age 26).
Another gatekeeper explained that preventive health behaviors or health issues are “not the first thing on their mind when they’re a new immigrant” (health sector), and that the demands of surviving in the current sociopolitical context often precludes immigrants from attending to their health. The overwhelming prioritization of finding employment and earning money allowed Latino immigrants to ignore important health issues. One Latino immigrant explained that her friend avoided treatment for cancer because she “was thinking about money and not about her health” (male, Mexico, age 25). This preoccupation with money and employment is linked to the seemingly precarious social and economic conditions for immigrants in the United States. As previously noted, fear and helplessness associated with the precarious sociopolitical context may facilitate neglect of preventive health behaviors among immigrants and result in poor physical health.
Discussion
This study demonstrates a potential pathway between the sociopolitical context and health among Latino immigrants. By examining factors beyond material conditions, we elucidated how Latino immigrants’ perceptions of the sociopolitical context – discrimination towards immigrants, unpredictable and mercurial circumstances, confusion and lack of information – shaped their psycho-emotional health, health-related behaviors, and physical health (Figure 1). Perceptions among Latino immigrants not only generate feelings of fear, sadness, helplessness and hopelessness, which affect their psycho-emotional health, but may also contribute to risky health behaviors, such as alcohol or drug use, risky sex, and neglect of protective health behaviors.
A growing body of research, practice, and advocacy efforts aims to change specific legislative, policy, and service provisions to promote the health of Latino immigrants (Philbin et al., Reference Philbin, Flake, Hatzenbuehler and Hirsch2018). Notwithstanding the potential benefits of such initiatives, our study suggests that immigrants’ perceptions and experience of the sociopolitical context can manifest in summative form, which may be beyond specific and individual legislatures, policy documents, or institutional arrangements. Study participants did not mention a specific document or policy when asked about the current sociopolitical context; rather, they highlighted their perceptions of the overall context and how these experiences impacted their health. Our study aligns with extant research that acknowledges the potential influence of Latino immigrants’ perceptions of social and political factors on health outcomes (Philbin et al., Reference Philbin, Flake, Hatzenbuehler and Hirsch2018).
In addition to current discussions about social policy and immigrant health, study findings demonstrate the specific challenges that Latino immigrants face in the United States. These challenges illustrate the barriers to successful integration among immigrant communities (Harder et al., Reference Harder, Figueroa, Gillum, Hangartner, Laitin and Hainmueller2018). Immigrant integration refers to immigrants’ participation in social, cultural, and economic activities facilitated by equal access to resources (Greenspan et al., Reference Greenspan, Walk and Handy2018). Notably, psycho-emotional health and mental health have been commonly identified as important indicators of immigrants’ integration (National Academies of Sciences, Reference Waters and Pineau2015; Vega and Rumbaut, Reference Vega and Rumbaut1991). When immigrants are integrated in their host society, they are less likely to experience the feelings of isolation and loneliness that can lead to poor mental health outcomes (National Academies of Sciences, Reference Waters and Pineau2015). Hence, study findings call for improved health service provisions for immigrants as well as improved services and policies that can enhance the integration of immigrants across diverse arenas (Greenspan et al., Reference Greenspan, Walk and Handy2018).
As migration between countries, including the United States, continues to increase, reducing discrimination against and exclusion of migrants will be critical to supporting positive health outcomes (Acevedo-Garcia et al., Reference Acevedo-Garcia, Sanchez-Vaznaugh, Viruell-Fuentes and Almeida2012). Conditionality in immigration and social welfare policies that restrict access to rights and benefits for particular migrant groups can create arbitrary divisions and influence perceptions that shape health (Shutes, Reference Shutes2016). Immigrant integration and policies that support this process can result in greater social cohesion and less societal fragmentation as demonstrated by case examples of other immigrant-receiving countries (Borowski, Reference Borowski2000; Cheung and Phillimore, Reference Cheung and Phillimore2017; Mulvey, Reference Mulvey2018). As such, integration can have positive effects not only for immigrants but also for members of the host society.
An integral characteristic of Latino immigrants in the United States is their physical detachment from their home countries resulting from the migration process. At the same time, immigrants are still connected to their countries of origin. The complex interaction of perceptions and experiences that stem from the sending and the receiving context is worth noting. Our study highlights how the unfamiliarity and new challenges presented by the U.S. context can exacerbate the negative psycho-emotional and physical health outcomes of immigrants. Hence, integration of immigrants in their host society warrants attention to receiving-country factors as well as sending-country factors (Acevedo-Garcia et al., Reference Acevedo-Garcia, Sanchez-Vaznaugh, Viruell-Fuentes and Almeida2012). A transnational perspective that integrates the critical roles of both contexts can further our understanding of immigrants’ perceptions of the sociopolitical context and health outcomes (Acevedo-Garcia et al., Reference Acevedo-Garcia, Sanchez-Vaznaugh, Viruell-Fuentes and Almeida2012).
Aligned with the theory of transnationalism, our research findings illustrate that immigrants may experience living “between worlds,” and that these experiences shape their perceptions of the sociopolitical context (Acevedo-Garcia et al., Reference Acevedo-Garcia, Sanchez-Vaznaugh, Viruell-Fuentes and Almeida2012). Notably, the value of transnational approaches for addressing the health and needs of migrant populations around the world has been well-established (Calzada, Reference Calzada2018). To better support immigrants’ understanding of the sociopolitical context, future studies and interventions should take the transnational experience of immigrants into consideration, and further explore how immigrants’ experience before and after immigration shapes their current life experiences.
Taken together, study findings illustrate an alternative conceptualization of the sociopolitical context from the perspectives of Latino immigrants. Findings suggest the need for services that can facilitate immigrants’ understanding and navigation of the current sociopolitical context. Considering the specific challenges that Latino immigrants face in the current sociopolitical climate, increased education and tailored information for Latino immigrant groups are warranted. For example, efforts to support immigrants, both documented and undocumented, adequately receive news sources and access relevant information may facilitate positive health-related behaviors. Based on study findings, such initiatives may have positive impacts on Latino immigrants’ psycho-emotional well-being and lead to positive health-related behaviors. Specifically, researchers and practitioners should pursue multi-sectoral and multi-outcome approaches in shaping Latino immigrant health (Philbin et al., Reference Philbin, Flake, Hatzenbuehler and Hirsch2018). Among the multi-level factors that shape health outcomes, perceptions of the sociopolitical context and their associated emotions and behaviors may be relevant targets for interventions and policy development.
Our results are consistent with previous studies that identified the psycho-emotional mechanisms through which social policies that signal social exclusion may impact the health of stigmatized populations such as Latino immigrants. At the individual level, stigmatized persons living in a context with discriminatory policies may be more likely to have negative perceptions about their marginalized personal status (Santos et al., Reference Santos, Menjívar, Godfrey, Magaña and Lee2013). Stigmatized individuals are also more likely to withdraw from interactions and feel as though they do not “belong” (Baumeister and Leary, Reference Baumeister and Leary1995). These feelings and behaviors may lead to psychological distress and depressive symptoms (Hatzenbuehler et al., Reference Hatzenbuehler, Phelan and Link2013). Relatedly, our study identified the importance of individuals’ perceptions; however, these perceptions centered on that of the sociopolitical context. These findings may be relevant for other marginalized groups. As such, our conceptual framework (Figure 1) is transferable to other stigmatized groups beyond Latino immigrants.
Furthermore, our study aligns with the call for greater understanding of how policy processes should address social determinants of health (Carey et al., Reference Carey, Crammond and Keast2014; Fisher et al., Reference Fisher, Baum, Macdougall, Newman and McDermott2016). In a previous study, policy practitioners indicated that policymaking based on linear conceptualizations of the policy process are often “out of touch” with its complex reality (Carey and Crammond, Reference Carey and Crammond2015). In the case of immigration policies that may shape health, we found that the policy process assessed by prior researchers (Philbin et al., Reference Philbin, Flake, Hatzenbuehler and Hirsch2018; Hatzenbuehler et al., Reference Hatzenbuehler, Prins, Flake, Philbin, Frazer, Hagen and Hirsch2017) may differ from that perceived by Latino immigrants. This demonstrates the importance of including the perspectives of immigrants in policy related research and program development. A top-down and linear approach of understanding policy processes can overlook relevant factors that shape individuals’ behavior and health outcomes. Integration of bottom-up and dialogic approaches to guide development of strategies to influence target behaviors and health outcomes is important, especially for Latino immigrants who are experiencing a flux of sociopolitical changes.
Our findings move beyond a narrow focus on political, economic, or social rights and highlight the overall impact of immigrants’ sociopolitical context on their mental and physical health. Further, our study points to potential ways to buffer against the cumulatively deleterious effects of the sociopolitical context on immigrants’ health through interventions or policies that enhance integration of immigrants and improve their sociopolitical context. As findings highlight the exclusionary sociopolitical context experienced by Latino immigrants, future research may further examine strategies for developing a more inclusive and participatory sociopolitical context for immigrants.
Limitations
Findings should be considered in light of the study’s limitations. First, the study focused on a purposive sample of gatekeepers and Latino immigrants in Corona, and findings are not necessarily generalizable to all Latino immigrants in the United States.
Second, participants’ reports of the sociopolitical context and related health outcomes may be associated with particular sociodemographic characteristics. For example, age, sex, country of origin, and income, are all factors that can shape perceptions, psycho-emotional health, and physical health. While we assessed these characteristics, our study sought to assess common themes among immigrants’ experiences. Hence, results are not stratified by specific background characteristics. Future studies may be able to explore the sociodemographic mechanisms that shape immigrants’ perceptions of the sociopolitical context.
Third, the study presumed that perceptions of the sociopolitical context would be a mediating factor between the sociopolitical context and health among Latino immigrants. Given the study’s cross-sectional design, we are unable to determine the causal mechanisms between perceptions and health outcomes. However, the conceptualization of this pathway may provide a useful framework for future studies.
Lastly, findings should be considered within the scope of the larger study. The interviews were conducted as part of a mixed-methods study focused on HIV testing and health access among Latino immigrants. Hence, participants’ responses may have been influenced by other research questions not reported in this study.
Despite these limitations, the study has several methodological strengths. We utilized a stratified sampling strategy to include diverse groups of gatekeepers and immigrants based on variables of theoretical interest. Additionally, we obtained data from community gatekeepers to triangulate and increase validity of study findings.
Conclusion
As the current sociopolitical context for immigrant populations in the United States is in a period of major shifts, research on how sociopolitical factors shape health outcomes is of growing importance. This study provides an important contribution to the multi-level understanding of social determinants of health for Latino immigrants facing a challenging sociopolitical environment.
Future research may operationalize key concepts identified in this study to quantitatively and longitudinally measure the effects of the pathways between perceptions of the sociopolitical context and specific health outcomes. Additionally, interventions that target perceptions of the sociopolitical context among Latino immigrants and other marginalized populations may be a potential strategy in shaping psycho-emotional factors and health-related behaviors. Findings suggest the need to integrate perceptions in strategies to improve health among marginalized groups such as Latino immigrants. Findings also suggest the need for paradigm shifts in the policy process from top-down and linear approaches to more bottom-up and dialogic methodologies.
Supplementary material
To view supplementary material for this article, please visit http://doi.org/10.1017/S0047279419000163
Acknowledgements
The study was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number R36MH108395. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Additional support was provided by the Center for Latino Adolescent and Family Health at New York University Silver School of Social Work.
Conflict of interest
Author JL declares that she has no conflicts of interest. Author YZ declares that she has no conflicts of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Review Board at New York University and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent
Informed consent was obtained from all individual participants included in the study.
