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Central American Immigrant Mothers' Mental Health in the Context of Illegality

Structural Stress, Parental Concern, and Trauma

Letiecq, Bethany L. PhD; Mehta, Swati MS; Vesely, Colleen K. PhD; Goodman, Rachael D. PhD; Marquez, Marlene MASW; Moron, Leanna P. BA

doi: 10.1097/FCH.0000000000000233
Original Articles
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Using a community-based participatory research approach, we surveyed 134 undocumented Central American immigrant mothers to examine correlates of maternal mental health. Drawing upon an ecosystemic framework, predictors of depression included structural and familial stressors, parental concerns, and maternal health factors. Mothers' perceptions of child affect, traumatic stress, and general health ratings were among the most salient predictors. However, structural and familial stressors, such as food insecurity and single parenting, also accounted for significant variance in depression scores. Findings informed community actions such as advocating for mental health care and building awareness of families' lived experiences within the local school system.

College of Education and Human Development, George Mason University, Fairfax, Virginia (Drs Letiecq, Vesely, and Goodman and Ms Mehta); Alexandria Department of Community and Human Services, Alexandria, Virginia (Ms Marquez); and Child Trends, Bethesda, Maryland (Ms Moron).

Correspondence: Bethany L. Letiecq, PhD, College of Education and Human Development, George Mason University, 4400 University Dr, MSN 4C2, Fairfax, VA 22030 (bletiecq@gmu.edu).

This study was funded by the Bruhn Morris Family Foundation. The authors thank their funders and community partners for support. Most importantly, the authors acknowledge the participants of this study who gave their time, trusted them, and invited them into their homes so they could learn more about their lived experiences and well-being in the US immigration context.

The authors declare no conflicts of interest.

FROM 1980 to 2015, poor political and economic conditions, high rates of homicide, and widespread gang violence drove Central American (CA) families northward to the United States.1 During that time, the size of the CA immigrant population grew nearly 10-fold to 3.4 million, with the majority coming from El Salvador, Honduras, and Guatemala.1,2 In 2016, an estimated 1.85 million CA immigrants were living in the United States without legal authorization.3 And while the majority of children of immigrants are US citizens, an estimated 40% have at least 1 undocumented parent, suggesting that significant numbers of immigrant families experience “mixed” legal statuses and live in fear of family separation.4 Along with the challenges and vulnerabilities associated with their immigration context, CA immigrants experience lower educational attainment, lower incomes, and higher rates of poverty than their foreign-born counterparts.2

Undocumented CA immigrant parents and their children also are at high risk for trauma exposures pre- to postmigration.4–6 Common forms of premigration trauma include physical/sexual abuse and violence victimization.5 During the migration journey, CA immigrants have to cross dangerous borders, often with coyotes (human smugglers paid to move people across the Mexico-US border) who may extort money and harm them. It is estimated that 60% of girls and women are sexually assaulted during migration.6 Once in the United States, immigrants confront anti-immigrant hostilities and human rights violations, poor living and working conditions, discrimination, and threats of detention, deportation, and family separation.4 Importantly, many CA immigrants state that life is still better in the United States than that in their country of origin (COO), conferring more opportunities, especially for their children.7 Yet, on balance, the immigration experience renders CA immigrant women vulnerable to poor mental health outcomes.4–7

Little is known about the mental health of CA immigrant Latinas, and, in particular, undocumented CA mothers who are rearing their children in the United States. For this study, we draw upon our community-based participatory research (CBPR) in partnership with undocumented CA immigrant mothers to examine maternal mental health and the correlates of depression. Our work is grounded in an ecosystemic framework,7,8 placing CA immigrant mothers in their cultural and legal context, and includes as correlates structural and familial stressors (eg, poor housing conditions, single parenting), parental stressors (eg, isolation, parent concerns, child affect), and maternal health factors (eg, traumatic stress, general health rating). Consonant with a CBPR approach, we conclude our study with a discussion of maternal health and the action steps we have taken with our community partners to advocate for health equity and family well-being.

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DEPRESSION AMONG CENTRAL AMERICAN IMMIGRANT LATINAS

Central American immigrants to the United States have typically not been included in large-scale epidemiologic studies of psychiatric disorders, or have been grouped with other Latinos, making it difficult to discern their risk for poor mental health.9 However, evidence suggests that CA immigrants are more likely to experience traumatic events than Mexican immigrants or non-Latino whites, placing them at risk for psychiatric disorders, including posttraumatic stress disorder (PTSD) and depression.10 While little is known specifically about CA immigrant women's mental health, epidemiologic and primary care studies find that Latina immigrants in general experience a greater share of the burden than do Latino immigrants.10,11 Latina immigrants are 2 times more likely than their male counterparts to have a major depressive incident.11 This likelihood increases after childbirth,12 especially for low-income immigrant mothers.13 Depressive symptoms can compromise low-income immigrant mothers' abilities to learn English, work, maintain relational well-being, and promote the healthy, optimal development of their children.14,15 Immigrant Latinos, and especially those lacking legal status, are less likely to have access to and seek mental health services than US-born Latinos,4 and when immigrants do seek help, they turn to the general primary care sector.10 Given that immigrants from El Salvador, Honduras, and Guatemala, including mothers, are among the fastest growing subpopulation of immigrants to the United States,3 it is essential to understand CA maternal mental health and related risk factors for appropriate screening and intervention planning.10

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ECOSYSTEMIC CONCEPTUAL FRAMEWORK

To more accurately capture mental health among diverse Latino communities, recent studies have called for new culturally and contextually specific conceptual models of depression.16–18 These calls are born out of research finding differences within Latino/a immigrant groups, across immigrant generations, and between immigrants and US-born Latinos.9 To account for variance in Latino/a health behaviors and outcomes, researchers have begun to develop distinct cultural models of depression, such as acculturative and somatization models, that entail different pathways of symptom expression and different indigenous psychologies for understanding suffering.19,20 Yet, extant models have been critiqued as individual-centered, failing to capture the cultural and contextual complexities of minority adaptation and mental health outcomes, including social-made “othering processes” such as stigmatization, discrimination, and marginalization.21

Addressing the limitations of individual-centered models, emergent ecosystemic models place (or nest) individuals within their familial, social, cultural, historical, and political contexts and seek to understand the ways in which systems interact with, influence, and are influenced by individuals and families.7,8 Such models of psychological distress among minority populations view depressive symptoms as normal reactions to the severe stress associated with social and personal threats and losses.16 In this study, using an ecosystemic model, we consider macro-level structural stressors as well as familial, parental, and individual-level variables that likely contribute to CA immigrant mental health. But first, we situate undocumented Latinas within their policy context, often referred to as a context of illegality.

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LATINA IMMIGRANT MENTAL HEALTH IN THE CONTEXT OF ILLEGALITY

Immigration scholars studying the influence of immigration policy on family life7,22,23 often view immigrant families with undocumented members through the socially constructed lens of “illegality,” where immigrants' “legal status and deportability place them in a perpetual condition of vulnerability.”24(p3) Undocumented Latinas are often relegated to the social margins, hidden in the shadows while caring for their children and/or working for low wages as informal childcare providers or in restaurants or the cleaning industry. Jobs within the illicit economy often require women work nonstandard hours without job protections or benefits, with little chance of upward mobility.7 Deportation policies that differentially target undocumented men from Mexico and CA for removal can further exacerbate the plight and impoverishment of undocumented Latinas left behind to rear their children as single parents in the United States.25 Shifting rules and “the ambiguities of prosecutorial discretion” in deportation matters before the court also have caused growing uncertainty for undocumented Latina immigrants, increasing fears of family separation.25(p329) These contemporary “deportation regimes” are effective and efficient in producing and maintaining immigrant illegality and marginalization, keeping immigrants in their place within US society, while disrupting the everyday lives of immigrant families.25,26

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Structural and familial stressors

Within this immigration policy context, researchers have begun examining how policies create vulnerabilities within immigrant family systems4 and how undocumented mothers and their children make meaning of and adjust to life in the United States.27–30 From an ecosystemic perspective, it is critical not only to understand individual adaptation but also to consider the ways in which undocumented immigrant women's lives are structured by sociopolitical and economic forces that are beyond their control yet influence their well-being. Understanding these structural stressors may point to intervention and social change agency beyond the individual level to address mental health burden. Structural stressors include the sequelae of illegality and impoverishment, such as a lack of educational opportunities, overcrowded housing, and food insecurity. Research suggests that such structural stressors are related to mental health30; yet, we know of no studies that have delineated these relationships among CA immigrant mothers.

In the United States, undocumented Latina immigrants can encounter a distinctively gendered familial and cultural context characterized by traditional gender roles and a rigid division of household labor, primary care provision of their children, and very limited employment opportunities.5,31 In this study, we examine familial factors including relationship status (single parent vs dual parent) and number of children as they relate to maternal depression. Studies find that being married (and living with one's partner) may serve as a buffer against poor mental health, especially among women in satisfying and supportive unions.10 Research also suggests that, given their situatedness, immigrant mothers are often dependent on their partners financially, resulting in limited access to resources and relational power.7,15 Undocumented status may render some women to feel “trapped” by their familial obligations and maternal burden factors (eg, dependence on others, caregiving demands), increasing their vulnerability to poor mental health.22–24 Single immigrant Latina mothers appear particularly vulnerable to depression and other threats to well-being.10 Yet, some research suggests that immigrant Latinas with access to the labor market can experience a newfound autonomy and economic liberation.3

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Parental stressors

Life in the United States can be harsh for undocumented mothers, who are often separated from their extended families and disconnected from traditional sources of support and kinship networks.4,18 Undocumented immigrants may distrust other community members and service providers, keeping to themselves for fear of deportation and family separation.7 These characteristics can combine to isolate immigrant women and imbue their daily lives with fear.4,5 This context limits immigrant women's access to resources and social networks that they have traditionally relied upon to care for themselves and their families.4 And these experiences can contribute to mental health challenges (ie, stress, trauma, depression, anxiety) that are detrimental to well-being, children's development, and overall family functioning.4,5,32

Research suggests that undocumented women experience pervasive fear and worry, particularly about confrontation in the community, deportation, and the well-being of their children.32 Recent research indicates a salient link—more important than sociodemographic factors—between parents' health and children's health.33 In particular, 1 in 5 children in poor households with parents who have nonoptimal health also have nonoptimal health. Studies also highlight how children's health and well-being contribute to greater parental worry, stress, and poorer health.34 Although less understood, parental stress about how best to provide for and support children in school and community contexts may also relate to maternal mental health. These kinds of “everyday” parental worries and concerns likely interfere with maternal mental health; yet, we know very little about these relationships within CA immigrant families.

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Trauma, physical health, and mental health

Finally, in this study, we examine the relationship between undocumented CA immigrant mothers' experiences of traumatic stress, their general health ratings, and their mental health. As noted, immigrant Latinas from CA are at especially high risk for trauma exposure.4,5 Moreover, research suggests high rates of both trauma exposures and depression among Latina immigrants from CA and that these connected mental health burdens are ecosystemically rooted or social-made.10 Studies also show a clear link between physical health and mental health, with chronic physical health conditions contributing to poor mental health.35 In particular, individuals with depression often experience more physical health challenges.

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STUDY PURPOSE AND CBPR APPROACH

Drawing upon an ecosystemic framework, we examine the structural, familial, parental, and maternal health correlates of depression among undocumented CA immigrant mothers to determine which factors best predict depression outcomes. To carry out this work, we use a CBPR approach36–38 in partnership with CA immigrant women. A CBPR approach is critical when working with marginalized communities including underserved, minority, and undocumented communities and offers important opportunities for addressing the mental health of minority groups.36–38 A CBPR approach can take many forms, but at the base, CBPR demands that researchers and community partners create mutually beneficial partnerships that are dialogical, egalitarian, and often centered on social justice ends.38 A CBPR approach engenders a trusting, reflexive, collaborative, and iterative process that is community-driven and builds on community strengths, ensures direct benefits to the community, and protects against unintended harms. Such community-based research is needed to inform health interventions and to advance a more just and equitable response to mental health burdens among undocumented Latino mothers.

At the onset of this CBPR project, in 2014, the lead author met with 2 trusted community-based service providers who had long histories of serving the Latino community in a northern Virginia immigrant enclave. The service providers were both bilingual, trained as social workers, one employed by an early childhood program, and the other employed by the local school system. The providers had been jointly hosting a support group with 10 Latina immigrant mothers who were concerned about the well-being of their children and the safety of their community. Facilitated by the service providers, our research team was invited to attend one of the group meetings to discuss the potential for a CBPR project. The group of mothers agreed to form a community-university partnership, called Amigas de la Comunidad or Friends of the Community, and as a collective we began implementing a research and action agenda, which included (a) establishing a community advisory board (CAB; to include the 10 Latina community members, service providers, a bilingual community organizer); (b) establishing strategic partnerships with agencies serving immigrant families; (c) collaborating with the CAB on all phases of research; and (d) implementing community-driven action steps guided by our community partners.38

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METHODS

Procedure

For the current study, the CAB and the research team aimed to better understand maternal mental health and the correlates of maternal depression, with goals of informing the local educational and health care systems about the mental health care needs of CA immigrant mothers. After the research team presented the CAB with various methods we could use for this study, the CAB directed the research team to conduct an interviewer-assisted survey. The research team then worked in concert with the CAB on survey protocol development (ie, CAB members vetted all items on the survey, piloted survey) and recruitment of participants using snowball sampling methods. Each CAB member agreed to invite at least 5 CA immigrant mothers with children (<18 years) to participate in the study. Those recruited mothers were then contacted by our bilingual El Salvadorian CAB member and community organizer (community resident, graduate student; fifth author) and invited to set up an interview either in the mother's home or at a location of her choosing. The lead author (European American, professor, working knowledge of Spanish) and the community organizer coadministered the interviewer-assisted surveys in Spanish, which took approximately 60 to 75 minutes to complete. For child-focused questions, we asked mothers to think about their youngest child 3 years or older. All participants received a $20 gift card for their participation. At the end of the interview, participants were asked to invite other mothers to participate in the study. Between 2014 and 2016, we conducted 134 interviewer-assisted surveys.

Throughout this project, extensive efforts were made to protect the participants' confidentiality. The university institutional review board approved all study protocols and consent forms. We also obtained a Certificate of Confidentiality from the National Institutes of Health. Consent was obtained orally. Signed documentation of consent was waived to further protect participant identity. Given concerns about deportation risk for undocumented participants, no questions soliciting identifying information, such as full names or addresses, were asked during data collection. After explaining the study and establishing consent, the interviewers commenced with the survey by asking participants to describe their immigration journey to the United States. These stories with some additional probing confirmed participant legal status as currently residing in the United States without legal authorization.

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Sample

As shown in Table 1, the sample for this study included 134 undocumented immigrant mothers of children (<18 years) mainly from the CA countries of El Salvador, Honduras, and Guatemala. On average, mothers were 34.6 years old and had resided in the United States for 10.2 years. While the majority of mothers were married or partnered (73.1%), about 1 in 4 mothers was rearing her children as a single mother. Respondents reported on average 7.4 years of formal education, and the majority spoke little to no English (66.4%). The average mother in the study had between 2 and 3 children, with the majority of children (72%) 14 years or younger. The 134 mothers were the parents of a total of 351 children, with 224 (63.8%) born in the United States and the remainder born in the mother's COO. At the time of the study, 299 children (85.2%) were residing in the United States (with 25.1% of those children undocumented). The remainder of children lived with relatives “back home.” Consistent with other studies of CA immigrants,31 our sample represented a complex configuration of mixed statuses and transnational relations. Nearly all mothers described their housing circumstances as overcrowded, with on average 4 persons per bedroom in 1- to 3-bedroom apartments.

TABLE 1

TABLE 1

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Survey measures

Background characteristics

We used a demographic questionnaire to determine mothers' COO, age in years, years living in the United States, English proficiency (1 = can speak English proficiently; 0 = cannot speak English, or only a little), work history, housing characteristics, and child characteristics, among other variables. Guided by our CAB, and because of participants' very low years of formal education, most response options to questions included “Yes (1), No (0).” We avoided Likert-type scales unless noted in the following text.

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Structural and familial stressors

For this study, structural stressors included the number of years of education completed and indicators of poor housing and food insecurity. Housing problems were measured using the following 4-part question: “In the last 12 months, have you experienced any of these problems inside your apartment: (a) bed bugs, (b) mice or rats, (c) cockroaches, or (d) paint or maintenance problems?” The items were summed to yield a total score ranging from 0 to 4. Food insecurity was assessed by asking, “In the last 12 months, did you have to reduce food portions or not eat because you did not have enough food?” We also asked participants whether they “worried about not having enough food for you and your family.”

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Parental stressors

Perceptions of feeling isolated, deportation worry, parental worries, and child affect were considered as parental stressors. To assess isolation, participants were asked to rate on a scale from 0 to 10 (0 = not isolated; 10 = very isolated) how isolated they feel in their community. Parental worry included the sum of 3 items (score range, 0-3) measuring concerns about (1) not understanding the school system, (2) not being able to provide for children, and (3) not being able to maintain one's own health and wellness. Finally, to measure child affect, we summed 2 items assessing maternal perceptions of child well-being using a 3-point scale (0 = never; 1 = sometimes; 2 = most times) including “My child has sudden mood swings/feelings” and “My child is unhappy, sad, or depressed.”

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Maternal health: Traumatic stress and general health rating

To assess whether participants had been exposed to traumatic stress, we adapted the Primary Care PTSD Screen (PC-PTSD).39 We first asked participants to briefly describe a difficult immigration-related experience and then, thinking about the traumatic experience, respond (Yes/No) to the following: (1) Have you had nightmares or thought about that experience without wanting to? (2) Did you try not to think about it or avoid situations that reminded you of that situation? (3) Were you constantly on guard, watchful, or easily startled? (4) Did you feel immobilized or disconnected from others, from activities, or your surroundings? Responses were summed to form a total scale score for traumatic stress (α = .82). Scores of 3 or higher are indicative of PTSD.39 To measure general health perceptions, participants were asked to rate their health on a scale from “poor” (0) to “excellent” (3).

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Mental health

To measure depressive symptoms, we used an abbreviated 10-item version of the Center for Epidemiologic Studies-Depression (CES-D).40,41 This measure rates symptoms of depression (eg, “Me sentí solo/a” or “I felt lonely”) during the past 7 days using a scale ranging from “rarely or none of the time” (0) to “most or all of the time” (3). Two items (happy, enjoyed life) were inversely recoded and then responses on all 10 items were summed. Higher scores indicate greater depression symptoms, with a cut score of 10 indicating clinical concern or caseness for depression.41 The scale internal consistency was α = .83, which was acceptable and consistent with prior studies conducted with Mexican immigrants.41

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Data analysis

We ran descriptive statistics to check for assumptions of normality, linearity, and independence on all study variables. Next, χ2 tests and multivariate analyses of variance were conducted to examine whether there were any statistically significant differences in the means of the study variables as a function of participants' COO. We then examined bivariate correlations between study variables of interest and depression scores. Significant correlations between study variables and depression scores aided in determining which variables to enter into or omit from our regression model. Finally, in an effort to operationalize our ecosystemic framework within the limits of our sample size, we ran a hierarchical regression analysis. This analysis allowed us to identify the most salient predictors of depression among structural and familial stressors (education, poor housing, food insecurity, relationship status, number of children), parental stressors (feeling isolated, parental concerns, child affect), and health factors (traumatic stress, health rating).

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RESULTS

On average, undocumented CA immigrant mothers in this study scored 9.43 on the depression measure, with 50.0% of the sample scoring a score of 10 or higher, indicating “caseness” or cause for clinical concern.41 As can be seen in Table 2, comparisons as a function of COO revealed that Honduran mothers expressed the greatest number of depressive symptoms (M = 10.93, SD = 5.86) whereas Guatemalan mothers reported the least amount of symptoms (M = 7.58, SD = 5.82); however, these differences revealed a trend only in the data (P < .10).

TABLE 2

TABLE 2

Other COO comparisons revealed statistically significant differences in mothers' education, relationship status, deportation worry, parental concerns, and traumatic stress scores (see Table 2). Mothers reported low levels of educational attainment, with nearly 50% of the sample reporting less than 6 years of education completed. Guatemalan women averaged the fewest years of education (M = 4.92, SD = 4.29), revealing significant differences between them and their CA counterparts, who completed about 8 years of education on average (F2,121 = 5.04, P < .01). Regarding relational status, most women (73.1%) were married or partnered (and most [94.9%] were living with their mate). Guatemalan mothers were more likely to be partnered than immigrant mothers from El Salvador and Honduras (χ22,131 = 7.32, P < .05). On average, immigrant mothers from Guatemala and Honduras reported greater concerns related to parental concerns (eg, not understanding the school system in the United States) than mothers from El Salvador (F2,121 = 3.22, P < .05). Immigrant mothers from Guatemala were also more likely to express deportation worry than their CA counterparts (χ22,131 = 6.76, P < .05); however, more than 80% of the overall sample expressed deportation worry, suggesting it was on the minds of many. The majority of mothers (74.6%) experienced a traumatic life event, with 43.3% experiencing trauma symptoms indicative of PTSD. Traumatic stress scores were significantly different by COO, with Guatemalan mothers reporting significantly fewer trauma symptoms than their CA counterparts (F2,121 = 5.36, P < .01).

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Bivariate analyses

The results of bivariate correlation analyses (Table 3) indicated that no independent variables were highly intercorrelated. The absolute value of correlation coefficients ranged from 0.18 to 0.60. We also ran linear regression models with independent variables iteratively to check variance inflation factors (VIFs). The VIFs were less than 10, which suggested no evidence of multicollinearity.42 Depression scores were related to key study variables. For example, depression was significantly negatively correlated with educational attainment and relational status (single = 0) and positively correlated with housing problems, food insecurity, and number of children. Significant positive correlations between depression scores and parental stressors suggested that as mothers felt more isolated, more concerned about their ability to meet their children's needs, and worried about their child's affect, they experienced more depression symptoms. Of course, these relationships are bidirectional and could also reflect the deleterious effects of depression symptoms on parental functioning. Depression scores were also significantly positively related to mothers' traumatic stress scores and negatively related to their general health rating. As traumatic stress symptoms increased, so too did depression symptoms. Conversely, as health ratings improved, depression scores decreased.

TABLE 3

TABLE 3

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Hierarchical regression

As presented in Table 4, we ran hierarchical regression analyses to examine the contribution of key structural and familial stressors, followed by parental-level variables, and then maternal health variables in accounting for the variance in depression scores. In model 1, the structural and familial stressors accounted for 27% of the variance in depression scores, with food insecurity and relationship status as the only significant predictors of depression. Housing problems suggested a trend in the model (P < .10). The best predictor, in the order of beta weights, was food insecurity. Overall, model 1 significantly contributed to depression scores (F5,121 = 8.76, P < .05). Introducing parental stressors in model 2 increased the explanatory power of the model to 47%, and this change in R2 was significant (F8,118 = 13.17, P < .05). The best predictors at model 2, in the order of beta weights, were perceptions of child affect, parental concerns, and feeling isolated. Finally, introducing maternal health stressors in model 3 accounted for a total of 52% of the variation in depression scores, and this change in R2 was also significant (F10,116 = 12.68, P < .05). In model 3, both traumatic stress and health rating were significant predictors. In terms of beta weights, the best predictors of depression scores in the final model included child affect, traumatic stress, health rating, food insecurity, and relationship status. Findings point to the need for complex and layered ecosystemic health intervention.

TABLE 4

TABLE 4

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DISCUSSION

Immigrant mothers from CA are among the fastest growing subpopulation of immigrants to the United States1; yet, we know little about their mental health burdens or how best to intervene.10 Extant research suggests that Latina immigrant mothers who lack legal authorization to be in the country can experience significant mental health challenges as they rear their children and attempt to build a better life for their families.4 In this study, we found 50% of participants to be experiencing depression symptoms in the range for clinical concern. Given the salience of parental health for child and family health,15,32–34 it is imperative that we document health outcomes among CA immigrant mothers and work to understand the relevant individual, familial, and structural risk factors that may hinder immigrant family functioning more broadly.

Undocumented CA immigrant mothers are also vulnerable to traumatic exposures premigration, along their migration journey, and while establishing their new lives in the United States. Consistent with findings from one other study of trauma among Latina immigrants from CA,10 in this study, we found that a majority of participants had experienced at least 1 traumatic event, with more than 40% of mothers expressing traumatic symptoms indicative of PTSD. Such findings related to both depression and PTSD, while not generalizable, suggest the need for epidemiologic and primary care studies to explicate rates of psychiatric disorders and associated risk factors among immigrant Latinas from El Salvador, Honduras, and Guatemala. Given that we found differences by COO (eg, traumatic stress, education), future research should disaggregate data by COO, if feasible, and consider culture- and COO-specific immigrant interventions as well.

It is imperative that we approach this work ecosystemically,6–8 placing CA immigrant mothers in their contextual milieu. This is important for at least 2 reasons. First, researchers, practitioners, and policy makers must understand the immigration policy context—in this case, a context of illegality—that is systematically creating mental (and physical) health burdens that are unduly experienced by CA immigrant women and particularly undocumented Latina immigrant mothers. Second, an ecosystemic framework is important because it redresses individual-centered models of depression that place the onus of good health on individuals rather than on a complex combination of factors to include structural forces that influence maternal health yet reside outside of immigrant mothers' control. Ecosystemic models of psychological well-being and resilience view depression symptoms as normal reactions to the severe stress associated with social-made inequalities and personal threats and losses.16

Social-structural factors included in this study were low levels of educational attainment and the sequelae of illegality and impoverishment (poor employment opportunities, poor housing conditions, food insecurity). Importantly, CAs do not have access to free public education in their COOs through high school as we do in the United States. Low levels of education (often just to grade 6) relate to low maternal literacy levels in both Spanish and English, mothers' capacity to navigate systems, and mothers' abilities to support their families both economically and via systems navigation (eg, schools, health care).7 As we found in this study, lower educational attainment is significantly related to higher depression scores among CA immigrant women in the United States. And while housing problems and educational levels were not the best predictors of depression in our final analysis, food insecurity was, suggesting that this context of illegality and impoverishment connects to poor mental health outcomes.

In this study, we also examined familial factors that likely relate to CA immigrant mothers' mental health and, consistent with extant research,10 found that relationship status matters. Being married or partnered may serve as a protective factor, particularly given the primacy of family or familismo in many Latino cultures. In the context of deportation regimes that target Latino men for detainment and deportation, women are at risk of losing their partners and the primary breadwinners of their families.25,26 Undocumented mothers left to rear their children as single parents and provide economically can experience significant hardships, particularly as their illegality precludes opportunities to work in “good jobs” with living wages, job protections, and benefits. Taken together, as demonstrated in this study, the structural and familial challenges can erode maternal mental health among undocumented immigrant mothers. It is important to note that some research has found that single mothers and those working for pay can experience a newfound independence and autonomy that can buffer poor mental health outcomes.3 For women who value traditional gendered roles and relations, loss of a partner can be devastating. In this study, single status was a significant predictor of higher depression scores.

In addition to structural and familial stressors, we also examined parental concerns as they relate to CA immigrant maternal mental health. The strongest predictor in our regression analysis was mothers' perception of their child's affect. Feeling isolated from networks of support and worrying about one's ability to provide and meet the needs of one's children were also significant predictors, but child affect accounted for the most variance in the overall model. This finding is consistent with extant research linking maternal health to child health.32,33 It is not possible to determine the directionality of this relationship in this study, but it is reasonable to consider that mothers' perceptions of their children as unhappy, depressed, or moody could call into question all the sacrifices that mothers are making to forge a better life for their children in the United States. Conversely, maternal depression could be hampering mothers' functionality and ability to meet the socioemotional needs of their children. Recent study on the linkages between maternal and child health33 suggests more research is needed.

The final 2 predictors of depression scores that emerged as significant in this study were mothers' ratings of their general health and their traumatic stress scores. Also consistent with extant research linking health and trauma to depressive symptoms,10 these findings call for the rethinking of policies that limit undocumented CA immigrant mothers' access to health care. The trauma exposures that undocumented immigrant women and their families experience largely go unacknowledged and untreated, yet traumatic stress coupled with depressive symptoms can impede maternal functioning and the ability to not only take care of oneself but also meet the needs of children and family members.7,10 As we document elsewhere,7 trauma exposures and resultant stress and maternal mental health burden can also impede resilience building or the ability to overcome life's adversities. Findings from this study support extant calls for trauma-informed care and health care access for immigrant families to promote family and community health.4,5,10 But comprehensive immigration reform should be at the forefront of any efforts to intervene in the lives of undocumented immigrant mothers as we work to ameliorate suffering and advance health equity and immigrant justice.

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Study limitations and future research

This study is not without limitations. The data are cross-sectional, and the directionality of the findings cannot be determined. Our small sample size and snowball sampling strategy limit the generalizability of findings. Despite our extensive work in partnership with our CAB to ensure our measures were culturally appropriate and valid (eg, item vetting, cognitive interviewing, pilot testing), our field experiences, particularly with women with very little formal education (eg, 0-2 years) and low literacy, left us questioning whether we generated mutual understanding of survey items and actually measured what we set out to measure. Our use of Yes/No options rather than Likert scales may have also limited variability in participant responses. Future research is needed to consider other relevant ecosystemic predictors of depression (eg, discrimination)21 and determine the best ways to screen for mental health and intervene (including community-based intervention) with diverse immigrant Latina mothers.

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Conclusions and steps for action

Our commitment to CBPR requires that our research matters for people's lives and that we take seriously community-based change agency. From project inception, we have engaged in equal parts research and action, including holding clothing drives, Know Your Rights trainings, and advocating for systems change to support, for example, immigrant mothers' capital to navigate schools and health care systems on behalf of themselves and their children.7 Recently, our CAB has begun to disseminate study findings, targeting decision makers within city government and in the local school/health systems. The CAB has also begun to educate practitioners about the lived experiences (eg, trauma exposures, overcrowded housing, food insecurity) and mental health needs of undocumented CA immigrant mothers rearing children in a high-cost-of-living urban enclave. This work is especially important as anti-immigrant hostilities continue to escalate. We find that our action steps strengthen partnerships, trust, and community ties and promote resilience, resistance, and resolve to overcome the severe stressors that challenge immigrant family and community health, particularly in the context of illegality.

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REFERENCES

1. Lesser G, Batalova J. Central American Immigrants in the United States. Washington, DC: Migration Policy Institute; 2017. http://www.migrationpolicy.org/article/central-american-immigrants-united-states. Accessed January 10, 2019.
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Keywords:

CBPR; depression; family health; immigrant mothers

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