Understanding social, legal, economic and spatial barriers to healthcare access in El Paso County, Texas Colonias

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Understanding social, legal, economic and spatial barriers to healthcare access in El Paso County, Texas Colonias an examination of structural violence using mixed methods
Hutson, Sydney Nicole ( author )
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Denver, Colo.
University of Colorado Denver
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Master's ( Master of arts)
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University of Colorado Denver
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Department of Anthropology, CU Denver
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Subjects / Keywords:
Migrant labor -- Medical care -- Texas -- El Paso County ( lcsh )
Medical anthropology ( lcsh )
Medical anthropology ( fast )
Migrant labor -- Medical care ( fast )
Texas -- El Paso County ( fast )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


Healthcare access is a highly reported problem for immigrant populations in the United States, especially for Hispanic migrants at the US-Mexico border. This statement holds particularly true for populations living in unincorporated communities known as colonias in the borderland region. Residents of a colonia are estimated to suffer from preventable or treatable illnesses including tuberculosis, hepatitis A, cholera, hypertension, type 2 diabetes, depression, substance abuse, among other health problems, at two to four times the national average (Matthiesen 1997; Anders et al. 2010:366; Mier et al. 2013:208; Sharkey et al. 2011; Davidhizar 1999). This apparent disparity is a result of unequal healthcare access due to social, legal, economic, and physical/spatial barriers. Using a structural violence framework as a lens, this study attempted to determine the barriers impeding access to healthcare for colonia residents, as well as analyze the interrelationships between the types of barriers. This study utilized semi-structured interviews to gain an understanding of perceived social, legal, spatial/physical, and other suggested barriers preventing healthcare access in El Paso County, TX colonias. In order to fully demonstrate the role of spatial/physical barriers on access to care, this study utilized Geographic Information Systems (GIS) to map obstacles in the targeted communities.
Includes bibliographical references.
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by Sydney Nicole Hutson.

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University of Colorado Denver
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on10126 ( NOTIS )
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SYDNEY NICOLE HUTSON B.S., University of New Mexico, 2013 B.A., University of New Mexico, 2014
A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Master of Arts Anthropology Program


This thesis for the Master of Arts degree by Sydney Nicole Hutson has been approved for the Anthropology Program
Sarah Horton, Chair
John Brett
Peter Anthamatten
Date: May 13, 2017

Hutson, Sydney (M.A., Anthropology Program)
Understanding Social, Legal, Economic, and Spatial Barriers to Healthcare Access in El Paso County, Texas Colonias: An Examination of Structural Violence Using Mixed Methods
Thesis directed by Associate Professor Sarah Horton
Healthcare access is a highly reported problem for immigrant populations in the United States, especially for Hispanic migrants at the US-Mexico border. This statement holds particularly true for populations living in unincorporated communities known as colonias in the borderland region. Residents of a colonia are estimated to suffer from preventable or treatable illnesses including tuberculosis, hepatitis A, cholera, hypertension, type 2 diabetes, depression, substance abuse, among other health problems, at two to four times the national average (Matthiesen 1997; Anders et al. 2010:366; Mier et al. 2013:208; Sharkey et al. 2011; Davidhizar 1999). This apparent disparity is a result of unequal healthcare access due to social, legal, economic, and physical/spatial barriers. Using a structural violence framework as a lens, this study attempted to determine the barriers impeding access to healthcare for colonia residents, as well as analyze the interrelationships between the types of barriers. This study utilized semi-structured interviews to gain an understanding of perceived social, legal, spatial/physical, and other suggested barriers preventing healthcare access in El Paso County, TX colonias. In order to fully demonstrate the role of spatial/physical barriers on access to care, this study utilized Geographic Information Systems (GIS) to map obstacles in the targeted communities.

The form and content of this abstract are approved. I recommend its publication.
Approved: Sarah Horton

For my loving family.
Thank you for supporting me throughout my life and academic career. I would have never been able to complete journey this without you all.

I would first like to thank my thesis advisor Dr. Horton of the Department of Anthropology at the University of Colorado Denver. Due to her diligence and guidance, I was able to conduct my research and complete this thesis.
I would also like to thank Dr. Shirley Heying at the University of New Mexico Gallup for starting me on the path leading to this project. With her friendship, expertise, and advice, I was able to get through this process.
Lastly, I would like to acknowledge all of the assistance provided by the Teaching Sisters of Saint Francis and the Sisters of Saint Joseph in El Paso, Texas. Without your support, I would have never been able to complete my research.

I. INTRODUCTION....................................................1
II. LITERATURE REVIEW...............................................3
The Role of Structural Violence in the Bracero Program and its Aftermath ... 3 Medicare, Medicaid, and The Affordable Care Act...............6
Medicare and Medicaid......................................7
Private Insurance Through the Affordable Care Act.........11
Legal Barriers to Healthcare Access............................13
Physical Barriers to Healthcare Access.........................17
Review of Health Problems in the Colonias......................21
III. MATERIALS AND METHODS..........................................24
IV. RESULTS........................................................28
V. DISCUSSION.....................................................40
Locations and Distance to Healthcare Facilities................41
Law Enforcement................................................42
Insurance Status...............................................43
VI. CONCLUSION.....................................................45
VII. LIMITATIONS....................................................51

FIGURE 1: Process for generating a new network dataset using ArcCatalog..........60
FIGURE 2: Survey questions for medical professionals in El Paso County, TX.....61
FIGURE 3: Survey questions for other expert members of the community...........62
FIGURE 4: Survey questions for residents of El Paso County, TX colonias........63
FIGURE 5: Medical facilities utilized by colonia residents in the larger El Paso, TX area
FIGURE 6: Closest Facility analysis locating the nearest medical facilities to Agua Dulce,
Dairyland, College Park Addition, and San Elizario..........................................65
FIGURE 7: Service Area analysis of select El Paso, TX medical facilities in relation to distance (miles) to Agua Dulce, Dairyland, College Park Addition, and San Elizario..........66
FIGURE 8: El Paso County Rural Transit #30 Horizon route to and from El Paso colonias ......................................................................................67

Since the 1950s and 1960s, the US has witnessed a massive movement of migrant workers from Mexico into the borderland region in Texas (Matthiesen 1997). Due to the lack of housing available for migrant workers throughout and immediately following the Bracero Program, a number of developers purchased large tracts of land at the US-Mexico border, subdividing them into empty and inexpensive lots (Matthiesen 1997). These unincorporated communities, commonly known as colonias, provided housing to immigrants and their families. Colonias are often impoverished communities characterized by a lack of adequate sewage systems, safe and sanitary housing, potable water, electricity, paved roads, public transportation, security, healthcare facilities, and so on (Anders et al. 2010; Davidhizar 1999; Meyer et al. 2013; Mier et al. 2008; Mier et al. 2013; Ortiz etal. 2004).
Due to inadequate infrastructure and lack of necessary resources, residents in colonias often are reported to suffer from two to four times the national average of treatable and/or preventable illnesses including: tuberculosis, typhoid, hepatitis A, mumps, measles, depression, hypertension, heart disease, and substance abuse (Meyer et al. 2013; Anders et al. 2010; Davidhizar 1999; Matthiesen 1997; Mier et al. 2008;
Mier et al. 2013; Ortiz et al. 2004). Recently, researchers have attempted to examine the health disparities in US colonias, particularly in Texas. A common factor influencing the general health of a population, specifically migrant populations, is access. Current migrant health research places an emphasis on the impact of documentation status and immigration enforcement compared to the interrelationships between multiple barriers,

including infrastructural and spatial/physical obstacles in colonias. In this project, I answer the following questions: What are the social, legal, economic, and physical/spatial barriers to healthcare access in colonias in the El Paso County, TX and how are these barriers interrelated? I will examine these barriers and their sources using a structural violence framework. This popular theoretical approach has been used by critical anthropologists to analyze the political, economic, cultural, and social factors impeding health care access for vulnerable populations (Farmer et al. 2006; Flynn et al. 2015; Konczal and Varga 2012).

The Role of Structural Violence in the Bracero Program and its Aftermath
Farmer defines structural violence as, "exerted systematically-that is, indirectly-by everyone who belongs to a certain social order (2004:307). Structural violence often unintentionally impacts individuals or populations as and serves as a social machinery of oppression (Farmer 2004:307, 315). Despite the lack of intention, this violence typically impacts vulnerable populations both actively and passively (Konczal and Varga 2012:92). In the active sense, structural violence occurs when social institutions prevent specific groups from, "...realizing their full potential through, for example, impeding access to resources or opportunities (Konczal and Varga 2012:92). Active structural violence often results in discriminatory social norms or policies (Konczal and Varga 2012:92). For example, Konczal and Varga found immigrants often refrain from utilizing healthcare out of fear of discovery and a lack of education regarding eligibility requirements (2012:100-101). Passive structural violence is the perpetuation and acceptance of social norms or policies that are normalized within society (Konczal and Varga 2012:92).
The concept of structural violence is not solely limited to legislation, social ideas and norms, and behaviors. Recent literature suggests structural violence is present in the physical world, beyond the social setting. According to Rodgers and ONeill, infrastructure can be considered a form of structural violence, a concept they refer to as "infrastructural violence(2012). Infrastructure, though seemingly independent of the social world, " also completely caught up within the workings of social, cultural,

economic and political arrangements, structures, and technologies (Rodgers and ONeill 2012:403). The physical world, similar to structural violence, can prevent a group from, "...realizing their full potential (Konczal and Varga 2012:92). For example, systematic class or racial discrimination is often apparent in urban planning, specifically with respect to the organization of communities or the construction of walls or fences (Rodgers and ONeill 2012:405). Ross and Leigh provide the example of the inner city in Chicago (2000). According to current urban planning theory, the level of poverty and organization found in the inner city of Chicago is directly attributed to what is described as structural racism (2000:371). Ross and Leigh also describe how the amount of affordable housing within reasonable distances from employers is decreasing, placing an undue burden on minority and low-income populations (2000:372).
Within US society, we can see obvious examples of structural violence and oppressive attitudes in regards to migrant populations. While the list of examples is long, I will primarily focus on more recent events, which targeted Hispanic immigrants during the mid-1900s to present day. One such example of structural violence is that of the Bracero Program.
The US entered into a bilateral agreement with the Mexican government to import Mexican laborers on temporary labor contracts to stimulate economic growth for the US agricultural and railroad industries between 1942 and 1964 (Heisler 2008:65). Initially, the agreement, described as, "...a temporary emergency labor recruitment program...during the Second World War, intended to address a labor shortage resulting from the massive enlistment of working males (Heisler 2008:65;

Congressional Record 2002). This attempt at temporary labor employment perpetuated racial discrimination towards Mexican immigrants. Heisler observes that the US government and employers viewed Mexican immigrants as nothing more than inexpensive and deportable workers, "...making them desirable as laborers, but not as citizens (2008:66).
According to Heisler, the US agreed upon a number of requirements and benefits
entitled to migrant workers selected for the 6-month labor contracts including:
...adequate housing, and living expenses, equal to that of domestic farmworkers in the area; pay prevailing area wages, not less than 30 cents per hour; guarantee a minimum number of working days; pay transportation from recruitment centers in Mexico to places of employment in the United States and return to recruitment centers after the contract was fulfilled. Workers were to be protected against discrimination... (2008:68)
However, these promises fell short and workers reported violations regarding pay,
housing, healthcare, food quality, and a lack of social support from camp managers
(2008:68). In addition, workers reported racial discrimination. Heisler writes, "When
braceros ventured into nearby towns they encountered signs that they were not
welcome (Heisler 2008:68). Though workers were to be treated fairly and with respect,
the government, as well as local managers, utilized institutions and structures as a
means of oppression and discrimination. Workers often did not receive the minimum
pay of 30 cents, had little to no access to healthcare, adequate food supplies, or proper
protection from the elements due to substandard housing, and had little access to the
outside world or adequate social interaction (Heisler 2008:68). Managers in the camps
could not speak Spanish, preventing proper communication between workers and the
managers, which was said to have alienated residents. Workers reported facing
discrimination not only within the camps, but also in surrounding communities.

According to Heisler, workers often told they were not welcome in the community or specific establishments (2008:68).
The injustices the U.S. allowed during the Bracero Program are a blatant example of structural violence. However, the violence towards Hispanic migrants did not end with the termination of the Bracero Program, but instead continued across the US, especially in the US-Mexico borderlands, in both a legal and physical capacity. Some forms of structural violence present in unincorporated communities in the US-Mexico borderlands include, poverty, anti-immigration legislation and enforcement, infrastructural violence, and healthcare access. In the following sections, I will attempt to illustrate the different forms of structural violence impacting migrant populations and residents of unincorporated communities.
Medicare, Medicaid, and The Affordable Care Act
The lack of health insurance is frequently cited as a principal factor behind poor migrant health, specifically within US colonias. Primary types of coverage among migrant communities in the colonias include Medicare, Medicaid, and the Childrens Health Insurance Program. In recent years, Medicaid coverage has expanded due to the Affordable Care Act (ACA), increasing the number of eligible candidates in US colonias. In addition to the Medicaid expansion, the ACA has enabled eligible residents with legal status to purchase affordable, subsidized insurance plans through marketplaces or exchanges. Though some immigrant populations and colonia residents currently are covered by private insurance plans, the majority utilizes Medicare Medicaid, CHIP, or does without insurance, due to low income or eligibility. The influence of each policy will be covered individually in the following sections.

Medicare and Medicaid
In 1965, President Lyndon B. Johnson enacted Social Security Act Title XVIII and Title XIX sections establishing the Medicare and Medicaid healthcare programs (CMS Program History 2017). According to the federal Medicare webpage, "Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease...(Whats Medicare n.d.). For Hoffman et al., the purpose of Medicare was to address a lack of comprehensive coverage for the elderly, disabled, and those with ESRD (2000:175). In contrast, Medicaid assists those with low incomes, pregnant women, children, and people with disabilities access quality medical treatment and coverage (Medicaid Overview n.d.).
Title XIX, commonly referred to as Medicaid, attempted to address a coverage gap for low-income people across the nation (Medicaid Program History n.d.). However, Medicaid is a state-federal partnership, and therefore individual state control over the program has resulted in inconsistent implementation of Medicaid throughout the country (Medicaid Program History n.d.). In 1997, the Childrens Health Insurance Program (CHIP) expanded Medicaid to ensure that children in families with an income higher than the Medicaid threshold but who still could not afford private insurance coverage could receive medical coverage through state and federal funding (Medicaid Program History n.d.). According to the Kaiser Family Foundation, the maximum income limit for those applying for CHIP in Texas is reported at 206% of the FPL (Medicaid and CHIP 2017). In 2010, the Affordable Care Act extended eligibility for

Medicaid to single childless adults for the first time in U.S. history and attempted to expand universal eligibility for Medicaid up to 133% of the Federal Poverty Level 2015).
However, despite the general promise of Medicaid and subsequent expansions, not all who are designated as low-income are eligible for Medicaid coverage (Hoffman et al. 2000:185). Applicants must satisfy certain requirements in order to receive benefits, outside of income eligibility requirements, which are known to change frequently (Hoffman et al. 2000). Moreover, the eligibility status of applicants may also be subject to change. Stuber and Bradley state, "A low-income child who is not eligible at one moment is likely to be eligible at some point in the near future because of common fluctuations in income and frequent changes in eligibility rules (2005:292). Such variability can work in reverse, with some individuals or families losing coverage due to factors such as a temporary rise in earned income or relocations to another state (Hetrick 2015). As has been discussed, states do not all follow identical eligibility criteria, aside from federally determined criteria (Hoffman et al. 2000:185-186). For example, while the majority of states have elected to expand Medicaid under the Affordable Care Act, nineteen statesincluding Texas-have refrained from participating (Garfield and Damico 2016). This has placed an undue burden on those above the federal poverty level (FPL) but who lack enough income to purchase coverage through the marketplace (Garfield and Damico 2016).
Coverage gaps in Medicaid are well documented, especially in south Texas colonias. It is estimated that more than 2.5 million adults fall under the coverage gap nation-wide (Garfield and Damico 2016). Over a quarter of those in the coverage gap are found in Texas alone (Garfield and Damico 2016). The coverage gap

disproportionately affects Hispanic populations, as approximately 27% of all Hispanics in the US are uninsured and Hispanics constitute approximately 18% of the Medicaid coverage gap (Garfield and Damico 2016). Although it is estimated that approximately two-thirds of colonia residents were US citizens in 2015, and therefore are technically eligible to obtain health insurance plans through the Exchange, many residents currently fall under the coverage gap of the ACA (Holeywell). According to Ura, colonia residents are a large majority of those in Texas who fall under the coverage gap (2014).
Lack of legal status bars many migrants in the colonias from insurance through Medicaid and from purchasing subsidized health insurance on the federal exchange (Eligibility for Non-Citizens 2014). Migrant populations in the US are eligible to apply for Medicaid benefits if they are legally considered either citizens or "qualified noncitizens (Eligibility for Non-Citizens 2014). In the colonias, eligible residents include; lawful permanent residents (LPRs/Green Card Holders), asylees, refugees, or those granted a stay of deportation (Eligibility for Non-Citizens 2014). While only these groups of qualified non-citizens are eligible to apply for Medicaid coverage, there are certain restrictions in place limiting access. In order to prevent immediate access for groups such as LPRs, the federal government has imposed a restriction on Medicaid eligibility for their first five years (Hetrick 2015:448). Also, despite common misconceptions about immigration and healthcare, there are a number of immigrant populations who are not eligible for Medicaid services. According to Wiley, those under the Deferred Action for Childhood Arrivals (DACA) program are also excluded from accessing Medicaid, as they are not considered qualified non-citizens (2014). Restrictions of select migrant populations, the 5-year ban, the fluctuating eligibility

requirements and variable individual legal status impact immigrants living in the US, potentially including many residents of unincorporated colonias. Meanwhile, in order for immigrant populations to qualify for Medicare, they must be lawfully present (LPRs, asyles, and refugees) and live in the US for 5-years before gaining access to federally funded programs such as Medicare (Who is Eligible for Medicare 2015). This impacts migrant populations and colonia residents, preventing access to federally funded and affordable healthcare.
While accessing Medicare/Medicaid services requires legal residency status, it should be noted that emergency services function independently of status. Emergency room services can be provided to undocumented migrants and/or those who do not fulfill indicated requirements. However, recent research indicates that many immigrants will abstain from utilizing emergency services due to fear and a lack of trust (Maldonado et al. 2013).
Documented migrant populations at the US-Mexico border frequently cite Medicare and Medicaid as their primary forms of healthcare coverage. Underutilization of Medicare and/or Medicaid is often attributed to increased levels of poverty, limited knowledge of health care systems, language barriers, among other factors (Leclere et al. 1994). According to Leclere et al., "In the United States, income and health insurance are critical to entry into the formal medical care system...the economics of the American health care system prevents much of the needed utilization, since immigrants are much less likely to be employed in jobs that provide health insurance benefits... (1994:372). Publicly funded assistance programs, such as Medicare and Medicaid are vital to immigrant populations in the US. In conjunction with the 5-year ban, variability in the

Medicaid expansion, frequent changes in federal and state eligibility requirements, and fear of utilization jeopardizing their immigration benefits, these additional factors place a greater burden on immigrants, increasing the coverage gap for the population.
Private Insurance Under the Affordable Care Act
The Affordable Care Act, better known as the ACA or Obamacare (referred to as ACA for the remainder of this paper), was the largest reform of health care in the US since the enactment of Medicare and Medicaid. Proposed by the Obama administration, the ACA was signed into law in 2010 in order to address the shortcomings of both private and public health care policies for Americans, he ACA intended to decrease the number of uninsured Americans by expanding public programs including Medicaid and including an "individual mandate. Those covered under the expansion provision included children, pregnant women, and adults with incomes up to 133% of the FPL (Summary of the Affordable Care Act 2017). Meanwhile, US citizens and legal residents whose incomes exceed that amount are required to purchase subsidized insurance plans on the American Health Benefit Exchange, where, "...individuals can purchase coverage, with premium and cost-sharing credits available to individuals/families with income between 133-400% of the federal poverty level... (Summary of the Affordable Care Act 2017). Premium tax credits, which are based on household income, are refundable credits used to cover the premiums of heath plans purchased through the Exchange (Premium Tax Credit n.d.). Cost-sharing credits and subsidies are discounts, lowering out-of-pocket costs for deductibles, coinsurance, and copayments (Cost Sharing Reduction n.d.). Such benefits were designed to help low- and middle-income households obtain affordable healthcare. Though undocumented migrants are excluded

from such programs, citizens or qualified non-citizens theoretically should benefit from the ACA. However, there are restrictions on who may obtain subsidized insurance policies. Similar to Medicaid, qualified non-citizens, such as lawful permanent residents, are eligible to purchase insurance through the marketplace (Coverage for Lawfully Present Immigrants n.d.). LPRs are only eligible following the five-year waiting period (Coverage for Lawfully Present Immigrants n.d.). DACA recipients, unlike LPRs, are ineligible to purchase subsidized health insurance plans through the marketplace (Wiley 2004). Such eligibility requirements and bans place additional burdens on some migrants in the US.
According to Davidhizar, approximately two-thirds of colonia residents were US citizens in the late 1990s, with similar rates reported in 2015 (Holeywell). Based on this statistic, the majority of residents in living in colonias are technically eligible to purchase subsidized health insurance plans through the Exchange. However, residents are often unable to qualify for tax credits, which offsets high healthcare costs, due to low income (Ura 2014). Residents face difficulties in obtaining insurance under the ACA, though its original purpose was to help those living in such situations, perpetuating decreased insurance rates.
In 2014, the rate of uninsured in the US dropped from 20% to 16% (Alcala et al. 2017). In addition, reports indicate increased access and utilization of health services (Alcala et al. 2017). However, this is not reflected equally across the US population. According to Alcala et al., Latinos reportedly displayed lower rates of utilization as well as access compared to non-Latinos (2017). Researchers not only cite citizenship status, but also language, socioeconomic status, and knowledge about the ACA to be driving

factors in the observed disparity (Alcala et al. 2017). Recent studies indicate that while there has been a slight increase in healthcare utilization and access amongst the Latino population in the US, it still trails behind non-Latino population (Alcala et al. 2017). Some groups report that while overall insurance rates have increased in the US, certain Latino populations have not experienced an increase in insurance rates (Alcala etal. 2017). This indicates that while the ACA has been beneficial for some groups in certain circumstances, Latino, including migrant populations and colonia residents have not shared equally in its benefits. Ura states, Colonia residents, who are predominantly Hispanic migrants, are among the minorities who make up three-quarters of uninsured adults in the states coverage gap (2014).
Legal Barriers to Healthcare Access
Although the legacy of the Bracero Program lingers in south Texas, recent antiimmigrant legislation acts as a highly influential force in limiting healthcare access for migrant populations, especially those from colonias. Anti-immigrant policies, such as the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), the Illegal Immigration and Immigrant Responsibility Act, the 287(g) program, the Secure Communities program (later to become the Priority Enforcement Program, or PEP) both directly and indirectly prevent immigrant populations from accessing healthcare, receiving affordable treatment, and/or receiving quality treatment (Park et al. 2000; Akins 2013; Alexander and Fernandez 2014; Castaneda 2015; Horton 2014; Maldonado et al. 2013). These programs and bills have resulted in increased border militarization, increased detention and deportation, decreased mobility, and limited access to health insurance and care (Park et al. 2000; Akins 2013; Alexander and

Fernandez 2014; Castaneda 2015; Horton 2014; Maldonado et al. 2013). The resulting factors are all examples of how legal structures and institutions, or in this case, legislation, can both intentionally and unintentionally prevent populations from gaining access to necessary resources.
Three primary policies influencing health in US colonias are Secure Communities (which later changed to PEP) and the 287(g) program. In 1996, the Illegal Immigration Reform and Immigrant Responsibility Act amended the 1965 Immigration and Nationality Act to create the 287(g) program. According to Akins, "...287(g) authorizes federal authorities to enter into formal agreements...with state and local law enforcement agencies regarding their participation in illegal immigration enforcement (2013:228). Under this bill, local law enforcement agents may be "deputized to detain unauthorized immigrants after investigating minor or major offenses (e.g. traffic stops) (Akins 2013:228). This bill has resulted in a fear that being pulled over by law enforcement will result in being detained on immigration charges (Maldonado et al. 2013). This has discouraged many immigrants from driving and therefore prevented many immigrants and their family members from accessing healthcare (Alexander and Fernandez 2014; Maldonado et al. 2013).
The Secure Communities Actlater replaced by the Priority Enforcement Program-- has had a similar effect on healthcare access among migrant populations. Under this Act, the fingerprints of all those who are arrested are sent to the Department of Homeland Security (DHS) to determine whether they are unauthorized immigrants (Miles and Cox 2014). Secure Communities requires law enforcement officials to hold unauthorized immigrants until Immigration and Customs Enforcement (ICE) agents can

arrive to detain those who are identified as putatively deportable noncitizens (Miles and Cox 2014:939). According to ICE, "With Secure Communities, only federal officers make immigration enforcement decisions, and they do so only after a completely independent decision by state and local law enforcement to arrest an individual for a criminal violation of state law separate and apart from any violations of immigration law. Although Secure Communities program was intended to address flaws in previous immigration legislation, critics charge that it encourages racial profiling and discourages immigrant families from reporting crime to local law enforcement (NILC 2015).
However, in 2014 the Secure Communities program was replaced with the Priority Enforcement Program (PEP). The US Immigration and Customs Enforcement department describes the PEP as:
PEP begins at the state and local level when an individual is arrested and booked by a law enforcement officer for a criminal violation and his or her fingerprints are submitted to the FBI for criminal history and warrant checks. This same biometric data is also sent to the US Immigration and Customs Enforcement (ICE) so that ICE can determine whether the individual is a priority for removal, consistent with the DHS enforcement priorities...ICE will seek the transfer of a removable individual when that individual has been convicted of an offense listed under the DHS civil immigration enforcement priorities, has intentionally participated in an organized criminal gang to further the illegal activity of the gang, or poses a danger to national security (US Immigration and Customs Enforcement n.d.)
This policy is different than that of Secure Communities as not all individuals with civil immigration offenses alone would be transferred to DHS from local law enforcement, but the program instead only requires the transfer of those who have been convicted of serious crimes (US Immigration and Customs Enforcement n.d.). This program was intended to be more selective in prioritizing the deportation of those with a history of gang activity or more serious criminal offenses (US Immigration and Customs

Enforcement n.d.). In addition, PEP does not generally require that law enforcement hold unauthorized immigrants until ICE can detain them but rather requests notification of such immigrants release (NILC 2015). Little research has been conducted to determine the impact of PEP on health-influencing factors, such as mobility, or on the migrant community in the US. However, research into the effects of the 287(g) program and the Secure Communities Act indicates a negative impact on non-emergency healthcare access for migrant populations (Maldonado 2013).
Policies like Secure Communities and the 287(g) program have been described as root causes of constraints on migrants mobility, an essential part of everyday life. Though the bills do not actively prevent immigrants from traveling, they do influence many to refrain from leaving their homes or communities. As many feel that they will be pulled over or potentially detained due to documentation status (of themselves or family members), many will not seek medical care (Alexander and Fernandez 2014). Alexander and Fernandez quote clinicians who state, "People are afraid to be traveling, so they prefer not to visit centers if they dont need it...They are more reluctant to drive to medical appointments out of fear of being stopped for license checks... (2014:14). Currently, only twelve states including California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maryland, New Mexico, Nevada, Utah, Vermont, and Washington as well as the District of Columbia allow unauthorized immigrants to obtain a drivers license (NCSL 2015). In states without such legislation, the fear of discovery by law enforcement can severely curtail mobility, which is supported by the 287(g) Program and the Secure Communities Act. Mobility is crucial for access to medical treatment,

meaning that anti-immigrant policies, which impact migrant mobility, codify a form discrimination against migrant communities.
Physical Barriers to Healthcare Access
In comparison to immigration enforcement, physical barriers to healthcare access are not widely studied among migrant populations in US colonias. The literature primarily emphasizes the influence of social and legal factors when examining health disparities and inequalities. However, not only are there physical barriers to accessing medical facilities, but they in themselves can be considered to comprise a form of structural violence, specifically infrastructural violence (Rodgers and ONeill 2012).
During an unaffiliated research project associated with the University of New Mexico, researchers spoke with adolescents within colonias within El Paso County,
Texas in 2013. The adolescents revealed that not only were legal factors responsible for influencing family healthcare decisions, but also factors within the environment. According to Allen, physical barriers are documented to influence healthcare access in colonias (2004:5). Previous work in El Paso County has revealed that there are no formal healthcare facilities in the Dairyland, Agua Dulce, and College Park Addition colonias, aside from a recently reopened clinic, which requires residents to travel lengthy distances to reach medical facilities. Oftentimes, according to youth within the El Paso County colonias, this is unlikely to occur due to the limited number of vehicles within households available for transportation (Personal Communication, August 2013). Public transportation is typically unavailable within US colonias. For Agua Dulce, Dairyland, and College Park Addition, a single bus stop is present in Agua Dulce, forcing residents to rely on private transportation. As a result, there are some who forgo

treatment or instead turn to alternative forms of self-medication (Personal Communication, August 2013). This lack of public transportation or any type of transportation assistance by local governments prevents individuals from not only accessing healthcare, but from accessing any resources necessary for survival that exist outside of colonias boundaries.
In addition to the lack of nearby healthcare facilities, colonia residents and other immigrant populations have indicated that a key physical barrier to healthcare access is related to immigration enforcement agents. According to Nunez and Heyman, the presence of immigration checkpoints along high traffic roads along the border act as deterrents for residents seeking medical treatment (2007). While this has been described as a legal barrier, this factor can double as a physical barrier because of preexisting obstacles to mobility. Based on previous mapping projects of colonias, it is apparent that there are few road networks leading into unincorporated communities. With physical, long-term checkpoints placed along those roads, travel for residents, particularly those with undocumented family members, becomes more difficult, potentially impacting the health of residents. Local, state, and federal governments utilize law enforcement agents in order to monitor the mobility of migrant populations, limiting their access to necessary resources, such as healthcare.
There has also been a great amount of media attention and documentation of major flooding events in Texas, particularly in rural communities (Collins 2010). According to Castaneda, the presence of flooded regions can impact the health of colonia residents (Personal Communication, Castaneda, November 18, 2015). Flooding causes damage to both the unpaved and paved roads in colonias, preventing residents

from commuting to urban centers and medical facilities (Collins 2010). In addition, flooding events are linked to sewage system ruptures and outbreaks of water- and mosquito-borne diseases (Collins 2010). According to Collins, flooding commonly occurs in colonias (2010). However, due to poor access to emergency and maintenance resources, recovering from floods is an extended process in colonias, thereby impacting access to road networks (Collins 2010). Little aid is provided to repair the damage from major flooding events, even in cases of sewage system ruptures. Very little action is taken by local governments to repair the damage, aside from providing water pumps to remove stagnant pools of water days after large storms (Tyx 2016). For example, following Hurricane Dolly in 2008, Governor Rick Perry attempted to reallocate funds used to assist colonias to other incorporated communities, until various NGOs and other organizations/institutions protested the act (Tyx 2016). Though these communities were ranked the most likely to suffer damage from flooding events, the local government attempted to use funding to minimize structural support in colonias. Governmental neglect of the infrastructure of colonias, which exacerbates the impact of flooding, is a further example of how the structural violence of poverty and discrimination that adversely affects residents health.
Structural violence relating to infrastructure and the built environment has recently been coined infrastructural violence, a subset of the original theory. Infrastructural violence focuses on infrastructure and physical resources and how they are managed and allocated across the population and landscape (Rodgers and ONeill 2012:403-404). Infrastructure, a crucial aspect of everyday life, has been documented to impact the general population. Often times, however, infrastructure

disproportionally affects vulnerable populations (Rodgers and ONeill 2012:404). Rodgers and ONeill state, "In particular, sociologists, anthropologists and geographers alike are increasingly raising questions about both the cultural and the political assumptions built into the design of infrastructure and the social consequences of its day-to-day (mal)functioning...Infrastructure shapes how people relate to the city and each other, affecting where and how people and things move across time and space (2012:403). Drawing from Benson, Fischer and Thomas, structural violence, and arguably infrastructural violence, is described by three key features (404). The most significant feature is described as, "in modern societies and capitalist economies, suffering tends to impact poor and marginalized groups adversely because of the uneven distribution of material, social and symbolic capital (404). Infrastructural violence, using this feature description, focuses on not only the allocation of physical resources, but also the arrangement of groups in a landscape (i.e. city planning), the function of physical aspects of the environment (e.g. roads, fences, etc.), architecture, and barriers (403-405). An example of infrastructural violence includes the arrangement of, "...suburbs, city centers and squatter settlements (405). Vulnerable groups and privileged groups are often organized in different patterns in a landscape, deepening social class disparities between groups.
Reports indicate colonias typically are found a significant distance from urban centers and lack basic infrastructure (i.e. running water, electricity, safe and sanitary housing, adequate sewage, public transportation, and more importantly, medical facilities). Lack of such necessary infrastructure creates a great burden on a vulnerable population, compared to those in urban centers. In addition, aid following flooding

events illustrates the theory of infrastructural violence. As most colonias do not have the necessary funding or resources to manage flooding conditions and/or repair the damages caused by flooding events, they must rely on nearby urban centers and local/state governments for aid (Tyx 2016). However, little aid has been provided to colonias in the past, though it is well documented that these areas are high risk and high damage areas (Tyx 2016). This lack of infrastructure and support further illustrates that colonias as prime victims of infrastructural violence as well as other forms of structural violence.
To this authors knowledge, there have been no studies directly examining the physical factors preventing colonia residents from accessing healthcare. However, previous research and personal communications have revealed the importance of spatial factors in shaping health in marginalized communities. This study will attempt to catalog the various physical barriers to health care access described by colonia residents in Hidalgo County, Texas through the use of semi-structured interviews as well as ArcGIS.
Review of Health Problems in the Colonias
Researchers have shown that many of the health conditions found in the colonias are directly connected to structural and environmental conditions. For example, cholera, typhoid, and hepatitis A are known to spread via fecal-oral transmission. The presence of these diseases is a result of the inadequate sewage systems typically found in the colonias (Anders et al. 2010). Due to the flooding of the borderlands, often the sewage systems rupture, causing sewage to flow into the streets of the communities (Collins et

al. 2010). As there is little support for colonias outside of the community, correcting this reoccurring issue often fails or is not performed adequately.
In addition to inadequate sewage systems, the lack of potable is thought to contribute to the poor health of residents in the colonias (Anders et al. 2010; Davidhizar 1999). Residents report traveling large distances in order to fill large storage containers with potable water (Davidhizar 1999). The source of the potable water is known to be contaminated in many cases with disease- causing pathogens (Personal Communication, August 2013). Due to the limited supply of fresh drinking water, many turn to river water or wells to supply water for personal hygiene purposes. According to Davidhizar, "Contaminated water conditions frequently exist, however, and when river water and shallow well water are used for personal hygiene, outbreaks of dysentery and hepatitis A occur" (1999:302).
Obesity and obesity-related health conditions are prevalent among residents in the colonias (Meyer et al. 2013). According to Meyer et al., "Relationships between diabetes and obesity/overweight, hypertension, and high cholesterol are supported...for which Mexican-American adults and children are at escalated risk of diagnosis, especially those living in colonias and other new-destination immigrant communities... (2013:2). Thought to be primarily due to decreased levels of physical activity among residents, research has suggested that physical activity is often limited due to physical infrastructural inadequacies (Meyer et al. 2013).
The living conditions in many colonias along with the health of residents can be described as substandard. Despite the fact that while the majority of the population in colonias are US citizens, 65% lack health insurance, and others who are entitled to

health service, often cannot access them. This has resulted in poor health across the
board in unincorporated communities.

Using a structural violence theoretical framework, this study attempted to determine the barriers impeding access to healthcare for colonia residents. The study utilized qualitative and quantitative research methods in order to investigate obstacles found in select unincorporated communities. The principal investigator conducted data collection in El Paso County, Texas, specifically targeting colonias in the immediate area surrounding El Paso. Data were collected in Agua Dulce, Dairyland, College Park Addition, San Elizario, and El Paso between August 2016 and January 2017.The Colorado Multiple Institutional Review Board (COMIRB) approved the study and all research methods and analyses in July 2016, with changes to the study approved in December 2017.
Participants from two distinct populations were recruited for the study (n=16). Population 1 (n=6) consisted of medical professionals, community leaders, and other experts in El Paso, Agua Dulce, and San Elizario. Population 2 (n=10) included current residents of Agua Dulce, Dairyland, and College Park Addition. Members of Population 1 were interviewed in August 2016 and January 2017. Participants of Population 2 were interviewed in January 2017.
Population 1 was recruited using publicly available contact information, local contacts, and snowball sampling. Population 2 was recruited through local contacts and snowball sampling. Participants from both groups were asked to engage in semi-structured interviews lasting approximately one hour. In order to protect the confidentiality of participants, no signatures were required to confirm consent. Instead,

verbal consent was obtained in front of a witness. A copy of the consent form was offered to participants. Participants were informed of the purpose of the study, potential risks, potential benefits, and compensation prior to the interview. All answers given during the interviews were hand recorded on paper. Recording devices were not used in order to better protect participant confidentiality. No identifying information was collected during the course of the interviews. Any volunteered sensitive information (e.g. documentation status) was not recorded by the principal investigator. For Spanish-speaking participants, a local contact provided translation services at the standard rate of $20 per hour. Following the completion of the interviews, the principal investigator conducted inductive and deductive coding of the recorded results.
Spatially-referenceable results from the semi-structured interviews were used in conjunction with publicly available online resources including state, county, city, and street shapefiles, healthcare facility locations, and colonia locations. The Texas Parks and Wildlife Department provided city and county shapefiles (n.d.). All state and country boundaries were downloaded from the ArcGIS webpage (2013, 2012, 2012). The road networks utilized in the network analyses were provided by ArcGIS (2014. A shapefile depicting the location of healthcare facilities was generated using the Google Earth application and publicly available addresses. All points in Google Earth were saved as a KML and converted to a shapefile in ArcMap. Only facility locations mentioned in interviews were used in this process. A layer containing the location of all colonias included in the study was generated using information from the Colonias Internet Viewer provided by the Attorney General of Texas webpage (n.d.). The El Paso County Rural Transit provided public transportation routes (n.d.). However, data were

not available for download from the website. Instead, the PI, using the locations of the bus stops and routes, digitized a standard transportation map in the GIS. All features were projected into a North American 1983 Geographic Coordinate System (GCS) and the Albers Equal Area Conic projection, to maintain consistency. In order to preserve the confidentiality of participants, a single point, unassociated with any addresses, was placed in each colonias. All shapefiles were used in the construction of the geodatabase. Using ESRI software, including ArcMap 10.2.2, the principal investigator created a network dataset (Figure 2). The generated network dataset was used to perform network analyses including; Closest Facility and Service Area. Following the completion of the network analyses, the results were used to generate maps depicting spatial/physical barriers to healthcare access (Figures 6 and 7). Two additional maps showing the locations of all medical facilities identified by participants and public transportation routes in the colonias were also generated (Figures 5 and 8).
This study of colonias required the researcher to examine hidden and vulnerable populations. Researchers must be aware of the ethics of autonomy and informed consent, which can be difficult to navigate when working with vulnerable populations. Cooper et al. conducted a study examining Hispanic migrant farm workers exhibiting variable documentation status, English competency, minimal education, and lower socioeconomic status (2004:29). Residents of colonias are often described as having similar characteristics and thus must be considered a vulnerable population entitled to additional protections. The vulnerability of colonia residents is addressed in the research design of this study. Similar to Cooper et al. (2004), in order to maintain the autonomy and informed consent of participants, participants were fully informed of the

benefits and potential risks of the study. Participants were not influenced by monetary incentives, but instead, the researcher provided food packages (Cooper et al. 2004). In addition, the power dynamic of the study was closely monitored to ensure that it did not play a major role in influencing participants to begin or continue the study. All participants were given the opportunity to drop out of the study at any point in the process. Culturally competent translators were present throughout the course of the study, when participants were non-English speakers, to avoid any miscommunication (Cooper et al. 2004).
Not only are colonia residents considered vulnerable by ethical standards, but they may also be considered a hidden population. According to Singer, hidden populations include "...groups that reside outside of institutional and clinical settings and whose activities are clandestine and therefore concealed from the view of mainstream society and agencies of control (Watters & Biernacki, 1989, p. 417), as well as from local community-based organizations (1999:125). Oftentimes, researchers describe hidden populations as difficult to identify, recruit, and study (1999:126-127). To address difficulties in locating and recruiting participants, participants were located using trusted, local contacts and/or snowball sampling. To address difficulties in performing qualitative and ethnographic interviews, the principal investigator performed unobtrusive interviews with few risks and did not require participants to attend multiple sessions. Furthermore, the use of publicly accessible data further minimized the impact of the study on participants.

Participants (n=16) from Population 1 (n=6) and Population 2 (n=10) were interviewed in August 2016 and January 2017, fulfilling the predetermined threshold (N=15) and satisfying all inclusion criteria. Members of Population 1 (n=6) included medical professionals (n=2), and community leaders and other experts (n=4) found in Agua Dulce, El Paso, and San Elizario. Participants were asked a total of 12 questions throughout the course of the interview (See Figure 4 and Figure 5). Members of Population 2 (n=10) consisted of residents of colonias found in the El Paso area including Agua Dulce, Dairyland, and College Park Addition. Sixty percent of participants came from Agua Dulce, twenty percent from Dairyland, and twenty percent from College Park Addition.
Participants described various barriers impeding residents from EL Paso, TX colonias from accessing healthcare, and more importantly, quality healthcare. Primary barriers described by residents in the community include transportation, income, law enforcement, insurance status and the distance to nearby medical facilities. Factors such as trust in medical providers and the insurance system/representatives were not significantly cited as a barrier to healthcare access, though they could be influential in selecting providers. The primary barriers described by professionals in the community included insurance status, transportation, a lack of nearby facilities, and income.
Aspects including ICE, local law enforcement, and language were considered by some as significant barriers while others determined them to be insignificant. Because residents emphasized the importance of law enforcement but generally did not report language

as a barrier, it will be omitted from the discussion. However, future work should include
questions pertaining to language barriers in colonias.
Scholarly literature often tends to analyze barriers individually, separating elements from one another. However, this study determined numerous barriers were interrelated and compound upon one another. As such, each section of the Results, while providing analysis of each of the barriers described by participants, will also elaborate on their interrelatedness. The Results below will enumerate the main barriers that respondents reported in their interviews and, where relevant, illustrate how the GIS analysis further illuminates the findings from the interviews. Moreover, it will highlight three unanticipated concerns that respondents emphasized when discussing health care access: the reliability of private transportation, traffic tickets, and the lack of in-network providers. These three emergent themes highlight the convergence of these barriers, illustrating that they cannot be examined in isolation.
Fifty percent of residents and local experts cited access to reliable transportation, private and public, as a primary barrier to healthcare in El Paso colonias. Seven participants indicated that they had access to a private car, 4 utilized carpooling, 1 used public transportation, 1 utilized Project Amistad, and 2 cited walking as their primary mode of transportation. While the majority of residents interviewed utilized private transportation ranging from personal vehicles to carpooling with family or friends, a number said public transportation was necessary for themselves or other residents in the community.

GIS analysis reveals that there is an apparent gap in public transportation coverage in El Paso colonias. Between Agua Dulce, Dairyland, and College Park Addition, there is a single bus stop available for commuters in Agua Dulce (Figure 8). In San Elizario, a participant revealed there are no known public transportation routes available for residents. Project Amistad is available to eligible residents with Medicaid in order to travel between their place of residence and medical facilities for care. For those without consistent private transportation or who are ineligible for Project Amistad, the lack of public transportation impedes some residents from seeking nonemergency medical care. This is particularly significant for residents in San Elizario, where there are no bus stations available, and in Agua Dulce, Dairyland, and College Park Addition, with minimal number of public transportation options.
Reliability of Private Vehicles
Several respondents mentioned that the reliability of the source of their private transportation was a significant factor in accessing health care. Respondents stated in the interview that when the vehicle would not start or broke down while traveling in the past, they were unable to reach scheduled appointments. When the reliability of a private vehicle was not in question, participants reported that having access to a car benefited their daily lives, including in the pursuit of healthcare.
Access to transportation is not solely an independent barrier. Instead, it is interrelated with other factors, such as income. Maintaining a vehicle is key to ensuring its reliability. In one interview, a participant stated that although they owned a vehicle, they were often unable to afford gas, preventing them from seeking care. Another participant indicated that many colonia residents are unable to afford insurance, a

drivers license, or even a private vehicle, which is due to limited income, a common phenomenon in Texas colonias (Texas Secretary of State n.d.). Another participant stressed that low-income coupled with high utility bills leaves little money for medical care or transportation. Factors such as low income and a lack of public transportation, have created a compounding effect, impairing the ability to seek medical care. Although most respondents reported having private vehicles, their low incomes in turn led to a oft-expressed concern with the reliability of their transportation.
Locations and Distance to Healthcare Facilities
Both populations involved in the study cited a lack of nearby medical facilities as a barrier to healthcare access. The majority of participants reported traveling more than 10 miles to receive specialized care (Figure 7), which translated into between 10 minutes to over an hour to reach providers for both primary and specialized care. Four of the participants stated it took on average up to 10 minutes to reach a facility, 2 reported 10-20 minutes, 5 reported 30-40 minutes, 1 reported 40-50 minutes, 4 reported 50 minutes or more, and 1 claimed it could take anywhere from 10-40 minutes depending on traffic. Typically, only residents in Agua Dulcewhere a clinic reopened in 2015-were required to travel 10 minutes or less. A total of eight residents and six experts claimed having a medical facility close to the colonias was beneficial in increasing the rate of visits in non-urgent situations.
The severity of this scarcity was demonstrated using Geographic Information Systems (GIS), specifically using Closest Facility and Service Area network analyses (Figure 5, 6 and 7). In the colonias outside of El Paso and Horizon City, there is only one community medical clinic found in Agua Dulce, Clinica Guadalupana (Figure 5 and 6).

According to news reports, this facility was initially established in 1995 and closed in 2010 due to financial hardship (Cortes Gonzales 2015). Under the supervision of new management, the clinic reopened in 2015 (Cortes Gonzales 2015). In San Elizario, participants reported a lack of medical facilities, with some residents seeking care in Fabens (Figure 5, 6 and 7). A participant from San Elizario noted a lack of emergency rooms nearby, which has resulted in delayed responses of emergency medical care. In Agua Dulce, Daiiyland, College Park Addition and San Elizario, there are no known facilities offering more specialized services, outside of one prenatal care facility in Horizon City, within 10 miles (Figure 7). Typically, only those living near and seeking care at Clinica Guadalupana were required to travel 10 minutes or less.. Those with access to transportation were willing to travel farther for care, but still reported positive experiences with the reopening of Clinica Guadalupana. One participant spoke of a public clinic being constructed in Horizon City, approximately six miles from the facility. However, the facility is not estimated to open until late 2017 and will only offer limited services. While this development will be beneficial to residents nearby, it will not address the shortage of specialist facilities within a reasonably distance.
One primary compounding factor related to the distance or location of nearby facilities: access to public or private transportation. In most colonias (except for San Elizario), there is only one clinic within walking distance. But as one participant stated, the colonias have poor walkability, due to a lack of sidewalks and stray or uncontained dogs. Walking is infeasible for many residents due to factors such as age and physical health. The GIS analysis shows that public transportation in Agua Dulce is possible, with Route #30 stopping in the community (Figure 8). While the bus stops in Horizon City

and on the outskirts of the greater El Paso area, the stops are not within walking distance of any listed medical facilities, forcing residents to transfer to at least one additional route. Residents who have previously utilized public transportation report being forced to travel and wait for seven or more hours to receive care, due to transfers, limited bus schedules, and high walk-in volumes at other facilities.
In addition to transportation, the distance/location of medical facilities is further impacted by law enforcement. Participants indicated during interviews that the willingness to travel a longer distance to their providers was negatively influenced by law enforcement (i.e. traffic stops, checkpoints, etc.). A more in-depth review of the relationship between law enforcement and distance/location will be discussed in the following section.
Law Enforcement
While some variation was present in the results of the study, it is apparent that law enforcement poses a significant barrier for many residents in the colonias. However, the majority of participants in Agua Dulce, Dairyland, College Park Addition, and San Elizario indicated that a fear of ICE was not a significant factor when seeking healthcare, with only one resident and four experts claiming otherwise. Instead, the most influential groups associated with immigration and law enforcement mentioned by participants included local police, state police, Border Patrol, and in some cases, local sheriff departments. According to one participant, local law enforcement is, "...not a barrier to health but a barrier to everything. As a result, some residents are afraid to so much as look outside of their homes. Five participants expressed a fear of checkpoints and routine traffic stops performed by local and state police and Border Patrol agents.

Residents reported missing or postponing appointments in instances where local law enforcement was active on nearby roads.
There was variability among the colonias as to what agencies were most active in immigration enforcement. In colonias closest to El Paso, participants did not express great concern over encounters with the local sheriff. Collaborations between the sheriff department and immigration enforcement were rarely enforced, reducing the potential repercussions during encounters. In San Elizario, participants indicated that ICE and other law enforcement agencies were a greater barrier for residents, due to inconsistently enforced partnerships. The presence of increased numbers of checkpoints and law enforcement agents dispersed in areas near unincorporated colonias near the border is proving to be a significant barrier for some residents, forcing them to delay or forgo medical treatment in non-emergency situations.. Due to laws pertaining to obtaining drivers licenses, the fear of discovery, costs associated with tickets, and other repercussions, some residents report an obstacle to accessing care. Traffic Tickets
While some local law enforcement, such as the current sheriff in El Paso, do not implement immigration rules (i.e. contacting immigration enforcement), there are other repercussions impacting residents. Some residents reported traffic tickets as the most important concern they had in attempting to drive to access health care. As many throughout the community have limited financial resources, having to pay tickets for driving without a license or for routine offenses, poses an additional financial barrier. If a resident is required to pay a fine, there is less money available for medical care in the

future. Therefore, barriers associated with law enforcement are compounded by other obstacles including income and the distance/location to facilities.
Concern with traffic tickets varied according to the location of facilities and the distance to and from facilities. Some participants expressed little fear of law enforcement due to the fact that their providers were within a short distance from their place of residence, decreasing the probability of being pulled over or encountering a checkpoint. Participants required to drive greater distances to see a provider cited a greater risk of coming across law enforcement agents. This was discouraging for some residents in the community, resulting in the decision to potentially delay or forgo care. Income
Approximately 81% of participants cited low-income as a barrier to healthcare in the colonias. The majority of residents do not earn enough income to pay for all necessary resources and services, including medical care. Costs of care, for insured and uninsured residents, are often greater than what can be afforded. For example, treatments not covered through insurance or only partially covered will result in higher out-of-pocket expenses. A participant in San Elizario claimed self-medication is a common phenomenon in Texas colonias in order to avoid the cost of a medical visit. Many participants reported seeking care in Mexico, as costs in Juarez are much lower compared to care in the US.
Insurance status and type were cited by participants to also be interconnected with income. While the majority of participants were insured, many claimed high out-of-pocket expenses for out-of-network providers or treatments. Meanwhile, lack of insurance itself carries a price. Mandates under the Affordable Care Act require all

eligible residents/citizens in the US to be covered by insurance. Those opting out of an insurance policy are required to pay fines. Uninsured participants discussed financial difficulties stemming from health insurance or difficulty in paying for the penalty for refusing insurance, resulting in some residents forgoing frequent medical care, as their financial resources are further strained. Such problems further complicate the relationship between insurance and income, placing undue burdens on low-income households.
In order to mitigate the high costs of care, many medical facilities have instated financial aid programs. Typically, such programs function using a sliding scale based on income, payment plans, or by offering discounts on treatments or medications for low-income and/or uninsured patients. Select locations offer additional aid programs on a case-by-case basis. Many residents, with and without insurance, reported that financial aid programs were beneficial for colonia residents. However, not all facilities in the area provide similar programs and not all services are adequately discounted. This is particularly problematic for those who have insurance, but are not covered under their current policies or if a provider is out-of-network.
Income is interrelated not only with insurance but also with transportation. Participants stated that residents are often unable to purchase or maintain private vehicles due to high costs and low-income. One participant claimed they could not afford to pay for gas due to high utility bills and financial resources. This prevented them from seeking non-emergency medical care. Another participant indicated they were often unable to travel due to an unreliable vehicle and a lack of financial resources to replace or repair it at the time.

Finally, law enforcement barriers also compounded income barriers. According to participants in El Paso colonias, if an immigrant is ticketed for driving without a license or for other minor offenses, due to limited income and the cost of the ticket, they are unable to afford medical care afterwards. Due to the absence of public transportation, this barrier is significant for those with private vehicles.
Insurance Status
Approximately 60% (n=6) possessed medical insurance while 40% were uninsured (n=4). Of the uninsured, 3 received financial aid through medical facilities. Of those insured, two had both Medicare and Medicaid, one had Medicaid alone, one with only Medicare, one was covered through the Marketplace under the ACA, and one was covered through their place of employment. A total of 8 participants indicated medical insurance to be an obstacle to accessing quality medical care in the colonias.
Participants without medical insurance coverage reported greater barriers to care than insured participants. Partially compounded by the costs of penalty fees under the Affordable Care Act, residents often have been unable to receive quality, affordable medical care. However, most of the uninsured participants cited access to beneficial financial aid programs through their providers. Sliding scale, payment plan, and discount programs were cited by residents, medical professionals, and other experts to be successful in helping low-income and/or uninsured residents gain access to high quality care. While participants cited some financial difficulty, in spite of participating in aid programs, it was clear they would be entirely unable to receive care without aid entirely. No resident claimed to forgo care entirely, with the minimum being seen once a year.

The majority of participants were insured through Medicare, Medicaid, private insurance, or work insurance. While the majority of uninsured participants cited their lack of insurance as a barrier to care, some insured participants indicated that quality care was still potentially beyond reach. Distance and the lack of medical facilities impeded access of insured participants to healthcare. As was noted in the interviews, the type of insurance plan hindered policyholders from accessing certain treatments or providers. One participant, covered through their employer, was unable to seek care from a specialist, as their policy did not cover the provider, who was the only one within a reasonable distance who could provide that care. Due to high costs, paying for the treatments or appointments out-of-pocket would have been unrealistic due to limited financial resources.
In-Network Providers
Locating in-network providers was cited by multiple participants to be a challenge due to a limited number of facilities in the area. This is particularly problematic in cases of residents who required specialized care. As was discussed, for the El Paso colonias and San Elizario, there are little to no medical facilities offering specialized care within 10 miles, outside of a single womens health clinic in Horizon City (Figure 7). Residents seeking specialized care must travel 10 miles or more to receive treatment from a provider, especially when locating in-network providers. The frequent concern with locating in-network providers illustrates the convergence of barriers to health care such as insurance, transportation, and distance. Compounded by the lack of public transportation and variable private transportation (see

Transportation), even insured residents often have difficulties seeking care covered by
health insurance.

Scholarly literature often tends to analyze barriers individually, separating elements from one another. However, this study illustrates how these multiple barriers intersect in ways that compound each other. As Heyman et al. (2009) have argued, intersecting barriers create "web of effects that are qualitatively more constraining than either single barrier alone.
This study has illuminated transportation, the location of nearby facilities, law enforcement, income, and insurance as the main barriers to accessing health care that residents of colonias face. Three important concerns that arose during interviews illuminate the intersection of these barriers in unanticipated ways: the reliability of private transportation, traffic tickets, and the availability of in-network providers. These concerns are powerful symbols of the multiple forms of vulnerability that residents in colonias face, highlighting the interaction of multiple barriers. Transportation
The reliability of vehicles and its impact on mobility has not been discussed in previous colonias literature. According to Syed et al., evidence has indicated that access to transportation, specifically private, poses as a significant barrier to healthcare utilization in other communities (2013:977). Syed etal. reported those without access to a vehicle often missed vital appointments, such as for cancer treatments, or delayed seeking care (Syed et al. 2013:977). They stated, "...walking or using public transportation to receive medical care was an independent predictor of not having a regular source of care... (2013:977). Residents in colonias with private vehicle access

often cited more frequent care compared to other residents without access to vehicles. According to Stuber and Bradley, access to transportation not only impacts seeking medical care, but also prevents approximately one-third of Medicaid applicants from reaching a Medicaid office or other locations to obtain documentation required to apply (2005:294). Minorities, including Hispanics, are documented to experience unequal access to transportation compared to Whites, placing colonia residents at a greater disadvantage (Syed etal. 2013:988).
Location of Nearby Facilities
Current research has attempted to examine the relationship between adverse heath outcomes, utilization of care, and the lack of nearby medical facilities. According to Nemet and Bailey, there is a strong relationship between the distance to a facility and the frequency of patient visits (2000:1205). The greater the distance between a medical facility and the patients place of residence, the fewer visits they will make to that facility (Nemet and Bailey 2000). It was stated, "People who had to travel more than 10 miles to their physician tended to go to their physicians less frequently than those who had to travel shorter distances (Nemet and Bailey 2000:1202). This study supports resident claims that while the distance/location of medical facilities does not always impede care, it is beneficial to have facilities nearby, minimizing travel costs. According to Figure 7, the majority of medical facilities used by participants are 10+ miles from any of the sampled communities. While many residents expressed that they, overall, were able to seek care at least once a year for non-emergency care, some also expressed a desire for closer facilities.

Law Enforcement
Multiple studies have shown law enforcement to be a hindrance to migrant populations healthcare access (Park et al. 2000; Akins 2013; Alexander and Fernandez 2014; Castaneda 2015; Horton 2014; Maldonado et al. 2013). According to researchers, law enforcement poses a serious barrier for undocumented immigrants and mixed-status families in the border region (Park et al. 2000; Akins 2013; Alexander and Fernandez 2014; Castaneda 2015; Horton 2014; Maldonado et al. 2013; Heyman et al. 2009). Heyman et al. state, "The border region has a dense web of immigration law enforcement, including inspections at official ports of entry from Mexico into the United States, Border Patrolling close to the international boundary between ports of entry, fixed interior checkpoints on highways leading away from the border region and mobile patrols through urban and rural areas near the border (2009:11). In El Paso, between 2005 and 2006, the local sheriff participated in checkpoints and the removal of undocumented immigrants by Border Patrol (Heyman 2009:11).
The testimony of participants in this study confirmed decreased access to healthcare resulting from decreased mobility. In addition, this obstacle is compounded by additional factors, such as income and distance. Nevertheless, participants in this study indicated that they were more concerned about potential encounters with local law enforcement and sheriffs than with the Border Patrol or ICE. In order to fully understand the scope of these relationships and the severity at which residents are impacted by law enforcement, additional research is required. In addition, current legislation must be examined in order to understand the severe impact on health in unincorporated communities in El Paso County.

Income and Cost of Care
High costs for medical treatments and income are frequently cited as barriers to quality care for any population, including immigrants. According to Meropol et al., the high costs of cancer diagnosis and treatments have shown to prevent patients from seeking care (2017). These claims are supported among immigrant families. Leclere et al. stated immigrants often will delay or forgo preventative care due to financial barriers (1994). Since many immigrants do not receive insurance through employers, they face additional hardships in accessing medical care (Leclere et al. 1994). Minority populations are consistently cited as being underserved due to low socioeconomic status, especially in unincorporated communities (King et al. 2009). Due to rising costs of care, migrant workers have reported turning to self-medication (Horton and Stewart 2012).
This study found that income was a significant barrier to healthcare access. Future research is necessary to determine the comprehensive impact of income on healthcare access for colonia residents. It will be important to explore related factors, including financial aid programs, transportation, and health insurance. From here, the forces driving low-income in unincorporated communities can be studied and addressed, to better improve healthcare access.
Current literature indicates the importance of health insurance for low income and immigrant populations in the US (Carrasquillo and Pati 2004; Meropol et al. 2017; Leclere et al. 1994; Bergmark et al. 2010; Edberg et al. 2011; DeVoe et al. 2007). According to Meropol et al. and Leclere et al., many immigrant and low-income

populations will postpone or forgo medical treatments, even life-saving procedures, due to high costs and a lack of health insurance coverage (2017; 1994). According to Carrasquillo and Pati, approximately half of all recent immigrants in the US lack health insurance coverage (2004). Such findings are supported by the results of this study. Residents reported that their lack of insurance coverage resulted in significant barriers to healthcare utilization. Residents reported seeking care in Juarez, Mexico, seeking only urgent or emergency care, and self-medication.
The results of this study indicated the importance of medical insurance for colonia residents, illustrating a barrier for some. Insurance coverage generally enabled residents to receive affordable, quality care. Financial aid programs enabled low-income and uninsured individuals or families to receive care, due to high costs that could be covered through insurance. Due to the financial aid programs available, barriers are mitigated. However, residents still report barriers associated with travel and income for out-of-pocket costs. Further research will be required to understand the relationship between these variable and the apparent disparities found in colonias.

Healthcare is a complex subject to comprehend, with no single explanation or solution for improving healthcare access. This holds particularly true for immigrant populations and colonia residents. Research indicates greater disparities in health and unequal access to care among these minority populations. Colonia residents alone contract preventable or curable illnesses including tuberculosis, measles, mumps, typhoid, hepatitis A, cholera, dysentery, etc. at a much higher rate than the rest of the state and nation (Lewis 2015; Anders etal. 2010; Davidhizar 1999; Meyer etal. 2013; Mier et al. 2008; Mier et al. 2013; Ortiz et al. 2004). In addition, other conditions such as depression, hypertension, obesity, diabetes, etc. are much more prevalent in these communities (Anders et al. 2010; Davidhizar 1999; Meyer et al. 2013; Mier et al. 2008; Mier et al. 2013; Ortiz et al. 2004). Immigrant populations across the world similarly experience poorer health overall as well as access to care, resulting from decreased income and employment, insurance access, legal status, mobility, etc. (Derose et al. 2007; Heyman et al. 2009; Marshall et al. 2006 Bollini and Siem 1995; Huang et al.
2005; Park et al. 2000; Akins 2013; Alexander and Fernandez 2014; Castaneda 2015; Horton 2014; Maldonado et al. 2013).
Utilizing a structural and infrastructural violence framework, this study attempted to record and understand barriers inhibiting access to quality healthcare in unincorporated colonias in El Paso County, Texas. Specifically focusing on the communities of Agua Dulce, Dairyland, College Park Addition, and San Elizario, this study illustrated some of the primary barriers faced by some residents. The majority of

barriers are supported by previous literature in migrant populations, while others are not widely studied in colonias.
Five primary barriers described by participants around the El Paso area included; transportation, a lack of spatial access to nearby medical facilities, law enforcement, income, and insurance status and type. Additional minor barriers, not handled in the discussion here, included language, trust in the state and federal government, and discrimination by medical providers. While these barriers are well documented to impede access to medical care, they were insignificant for the participants recruited in the study.
Though the majority of participants owned a private vehicle or had access via another residents vehicle, transportation was widely cited as a barrier to care. Public transportation was highly limited in all areas, with a single bus passing through Agua Dulce (Figure 8). With limited run throughout the day and operating on a first-come-first-serve basis, and requiring additional transfers, participants indicated a need for additional public transportation options. Lastly, while many reported owning a vehicle, some did not have the means to maintain the vehicle, restricting mobility.
Spatial access to nearby medical facilities was considered to be a significant barrier in the colonias. Members of both populations attributed access difficulties to distance. As was shown in the Closest Facility and Service Area analyses, there are a limited number of medical facilities found within 10 miles, a threshold established in other research resulting in decreased care (Mattson 2010). Specialized facilities tended to be clustered in central El Paso, 10 or more miles from the colonias. General and preventative care, though found within 1-5 miles from the colonias, was limited due to

resources and the capabilities of the facilities (Figure 7). San Elizario medical facilities, including an emergency room, were not found less than 10 miles. Additional facilities, particularly specialized and emergency facilities, must be constructed within 10 miles of all of the sampled areas. Participants are hopeful that the addition of a small hospital at the end of 2017 in Horizon City will be beneficial to the population.
Law enforcement was somewhat contested as a barrier to care, but was significant for participants in the study. Residents, when reporting law enforcement as a barrier, were typically more fearful of border patrol, state police, and local sheriffs and police than of Immigration and Customs Enforcement. The presence of checkpoints in nearby areas was reported to deter residents from seeking care. Routine traffic stops were also reported to pose a partial barrier for some residents due to the cost of tickets and further repercussions. A fear of the local sheriffs office is mixed among participants due to the inconsistent collaboration between immigration enforcement and the local sheriff. Fear of law enforcement was potentially independent of documentation status, with participants indicating residents with and without documentation to share a similar concern. Current legislation has been documented to impact the health of residents, through threats to mobility and a fear of discovery at medical facilities (Park etal. 2000; Akins 2013; Alexander and Fernandez 2014; Castaneda 2015; Horton 2014; Maldonado etal. 2013). This studys results reinforce the claim that migrant populations are negatively affected by enforced immigration policies. Additional research is required, especially due to changing political realities in 2017.
Income was widely claimed as a barrier among all of the sampled communities. According to multiple sources, colonia residents, on average, live below the federal

poverty level and struggle to pay for medical care, directly and indirectly. Low-income families or individuals, including immigrants, experience health disparities disproportionally compared to other populations/communities. While many participants were covered by insurance, it was often not adequate coverage, requiring out-of-pocket expenses. For those uninsured, financial aid programs in the region helped alleviate costs. However, residents are still required to pay for the remaining balance. Such requirements are difficult for those with limited financial resources. This study did not initially include questions pertaining to income. Future research should examine not only the impact of income on healthcare access, but also the root causes of the high level of poverty and unemployment in Texas colonias.
Lastly, insurance status was claimed by some participants to be a barrier for colonia residents in accessing quality care. In spite of the commonly held notion that insurance eliminates obstacles to care, the results of this study show that access does not function in such a manner. Participants with insurance, while reporting the benefits, also discussed instances in which insurance would not cover certain procedures or treatments or in which locating an in-network provider was problematic. These situations are particularly significant due to the limited number of facilities nearby. Barriers are more prominent among those without insurance. Due to high costs and limited resources, many colonia residents engage in self-medication, travel to receive care in Mexico, and/or delay seeking care. While financial aid programs attempt to assist those without insurance, residents and participants report financial difficulty. Additional research is required in order to further examine the impact of financial aid programs and insurance status for colonia residents.

Colonia residents are victims of both structural and infrastructural violence,
chiefly regarding healthcare access. Farmer (2004; 2006) and Rodgers and ONeill claim that the social and physical world can function as machinery of oppression (2012:404). These forms of violence reinforce oppression, discrimination, and placement in a social order (Rodgers and ONeill 2012). Violence has resulted in excessive health disparities, specifically the elevated rates of preventable or treatable health conditions. Structural violence is apparent in immigration legislation and enforcement, socioeconomic status, eligibility requirements for insurance, among many others. Infrastructural violence is present in the absence or limited access to physical resources such as private transportation and nearby medical facilities. All of the described barriers cause or perpetuate medical conditions in colonia that otherwise would be absent or occur at a lower rate.
This project illustrated the complexity of the subject, highlighting the salience of previously known barriers, as well as revealing new obstacles previously unheard of in colonias, to the best of the Pis knowledge. Such barriers included poor access to transportation, both private and public, and poor spatial access to facilities. This study also revealed compounding and interrelated barriers. For example, limited financial resources can impede acquiring or maintaining a private vehicle, which in turn inhibits mobility and medical care. Income and insurance status were also found to be interrelated, though the relationship between these barriers are documented in previous research. One participant related the high cost of utilities to limited financial resources, which prevented them from affording medical care or the gas required to travel. The limited number of nearby facilities was found to be related to medical

insurance, regarding locating in-network providers, and the potential repercussions from interacting with law enforcement, which increase with distance. Further research is required in order to fully understand the deeper roots of inequality in El Paso County colonias. Reducing the complexity of this documented crisis does not benefit residents, nor would such simplification illustrate the underlying roots stemming from historical and systemic discrimination in the social, legal, economic, and spatial/physical realms.
By utilizing a structural and infrastructural violence framework, this study was able to track historical and current discrimination in colonias. Previous research has shown some barriers and disparities faced by residents, however, have not fully illustrated spatial barriers, discussed those impeding mobility, and have neglected to analyze the relationships between obstacles. To the Pis knowledge, physical/spatial barriers have not been displayed using Geographic Information Systems in El Paso County colonias. The use of a mixed-methods approach using structural and infrastructural violence frameworks have proven to be an effective technique to illustrate barriers to healthcare access in unincorporated communities at the US-Mexico border.
To address barriers presented by participants in the study, participants and the principal investigator recommend not only additional research, but also the construction of additional medical facilities, including laboratories, emergency rooms, specialized clinics, with a greater number of practitioners and hours of operation, increasing the number of public transportation routes and stops, and additional financial aid for colonia residents to help pay for gas, utilities, private transportation, and medical care.

This study attempted to record a comprehensive array of data to create a greater understanding of the barriers faced by colonia residents when seeking healthcare.
While the PI attempted to address every weakness throughout the course of the study, there were a number of limitations warranting discussion.
First, there were a number of variables and elements not recorded during interviews with participants, which could have better informed the results of the study. For example, in order to protect the identity of participants, information including; age, sex, gender, yearly income, employment status, medical history, and documentation status were not asked for or recorded if offered. Any identifiable information published could lead to serious repercussions for participants or their families. The risks associated with such breaches in confidentiality outweighed the benefits of the results.
Regarding the setup of the network dataset and all geospatial analyses performed, the results would have been stronger if time (minutes) was used as the measured cost, rather than distance. Due to the available data in the downloaded road networks, time costs could not be calculated with the network dataset. In addition, minor inaccuracies exist in the generated maps. To protect the identities of participants, a single central point was used to represent all residents in each community. All calculations in the Service Area and Closest Facility analyses were based on those representative points. This led to some inaccuracy and misrepresentation in the visual displays. Finally, there when generating a map depicting public transportation in the colonias, no downloadable spatial data were available. Instead, the PI created linear

features along the known road network as accurately as possible. Minor errors could be present, though minimal. The generated linear features were further manipulated, offset by 1-2 degrees in order to increase the clarity and quality of the visual display.
Furthermore, sampling biases could have potentially impacted the study. By using existing contacts and/or snowball sampling, sampling could not be considered random. Due to a lack of rapport in the community at the onset of the study and limited time for recruitment, this sampling strategy was necessary to complete the data collection. This limitation, however, does not negate the quality or accuracy of the data collected. In future research, the PI will attempt to broaden the scope of recruitment to address sampling bias.
Lastly, the number of participants (N=16), while adequate for the current study, can be considered small for scientific research. By using such a small population, the results cannot be considered entirely representative of a larger population (i.e. all colonias in El Paso County). Future research attempts will increase the sample size from a greater number of communities in the county.

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Figure 1: Process for generating a new network dataset using ArcCatalog.

PI: Sydney Nicole Hutson Protocol Number: 16-1041 Version Date: 06/23/2016
Study Title: Understanding Social, Legal, and Spatial Barriers to Healthcare Access in El Paso County, Texas Colonias : An Examination of Structural Violence Using Mixed Methods
Document Title: Semi-Structured Interview Questions for Medical Personnel
1. Do you treat colonias residents in your practice or are you familiar with colonias healthcare? Please explain?
2. What types of insurance does this facility accept?
3. What services does this facility offer (i.e. emergency, preventative, specialized, etc.)?
4. Do you find that Immigration and Customs Enforcement (ICE) agents impact access to healthcare treatment? If so, how?
5. Do you find that other law enforcement agents impact access to healthcare treatment? If so, how?
6. Do you find that medical insurance impacts access to healthcare treatment or the quality of treatment? If so, how?
7. What recent immigration policies have directly or indirectly impacted healthcare access among colonias residents? Please explain in detail.
8. Do you feel that colonias residents trust medical professionals? Why or why not? Could this impact treatment?
9. Do colonias residents have problems physically accessing your facility (if this can be disclosed)? Provide some examples of the barriers present.
10. Do you think that there are enough facilities to service colonias residents in the immediate area?
11. Are there any other barriers present that prevent colonias residents from accessing healthcare? Please elaborate.
12. Is there anything you want to see change regarding healthcare access in colonias? Please explain.
Figure 2: Survey questions for medical professionals in El Paso County, TX.

PI: Sydney Nicole Hutson Protocol Number: 16-1041 Version Date: 06/23/2016
Study Title: Understanding Social, Legal, and Spatial Barriers to Healthcare Access in El Paso County, Texas Colonias : An Examination of Structural Violence Using Mixed Methods
Document Title: Semi-Structured Interview Questions for Other Community Members
1. What does your agency, organization, group, etc. do within the community?
2. Do you work with the medical field? Describe your interactions?
3. Do you work with colonias residents? Describe your interactions?
4. Do you find that Immigration and Customs Enforcement (ICE) agents impact access to healthcare treatment? If so, how?
5. Do you find that other law enforcement agents impact access to healthcare treatment? If so, how?
6. Do you find that medical insurance impacts access to healthcare treatment or the quality of treatment? If so, how?
7. What recent immigration policies have directly or indirectly impacted healthcare access among colonias residents? Please explain in detail.
8. Do you feel that colonias residents trust medical professionals? Why or why not? Could this impact treatment?
9. Do colonias residents have problems physically accessing healthcare facilities (if this can be disclosed)? Provide some examples of the barriers present.
10. Do you think that there are enough facilities to service colonias residents in the immediate area?
11. Are there any other barriers present that prevent colonias residents from accessing healthcare? Please elaborate.
12. Is there anything you want to see change regarding healthcare access in coloniasl Please explain.
Figure 3: Survey questions for other expert members of the community.

PI: Sydney Nicole Hutson Protocol Number: 16-1041 Version Date: 06/23/2016
Study Title: Understanding Social, Legal, and Spatial Barriers to Healthcare Access in El Paso County, Texas Colonias : An Examination of Structural Violence Using Mixed Methods
Document Title: Semi-Structured Interview Questions for Colonias Residents
1. Are you a resident of a colonial If possible, please indicate which coloniasl
2. Where do you go to access healthcare? How often do you seek treatment?
3. What type of treatment do you receive (i.e. preventative/general, specialized, emergency, etc.)?
4. Do you have health insurance? If so, what type?
5. Do you find that Immigration and Customs Enforcement (ICE) agents impact access to healthcare treatment? If so, how?
6. Do you find that other law enforcement agents impact access to healthcare treatment? If so, how?
7. Do you find that issues associated with medical insurance impacts access to healthcare treatment or the quality of treatment? If so, how?
8. Do you trust medical professionals? Please explain.
9. Do you trust medical insurance representatives or the system? Please explain.
10. Are there affordable medical facilities near you (including emergency, general, specialty, etc.)? Please identify the location and describe how you get there (i.e. what type of transportation) and how long it typically takes.
11. Do you have problems accessing those medical facilities?
1. Are there physical barriers that can prevent you from getting there (i.e. flooding, road conditions)? Please explain.
2. Do you find that distance or time helps or hinders your access to healthcare? Please explain.
3. Do you find that the presence or absence of healthcare facilities nearby helps or hinders your access to healthcare? Please explain.
4. Do you have access to a car during the day? How far/long do you typically drive?
5. Do you have access to public transportation?
6. Do you walk to nearby locations in your community? How far/long do you typically walk?
12. Are there any other barriers that prevent you from accessing healthcare not discussed already? Please elaborate.
13. Is there anything you would change regarding healthcare access in your community? Please explain.
Figure 4: Survey questions for residents of El Paso County, TX colonias.

Utilized Medical Facilities in El Paso County, TX
Homestead Meadows North
Horizon City
College Park Addition
San Elizario
Morning Glory
Homestead Meadows South
Healthcare Facilities
Figure 5: Medical facilities utilized by colonia residents in the larger El Paso, TX area.

Closest Medical Facilities to
Agua Dulce, Dairyland, and College Park Addition
Closest Facility by Distance Measured in Miles
Healthcare Facilities
Figure 6: Closest Facility analysis locating the nearest medical facilities to Agua Dulce, Dairyland, College Park Addition, and San Elizario.

Service Area Analysis of Select El Paso, TX Medical Facilities
From Aqua Dulce, Dairyland, and College Park Addition
Prado Verde
Flomestead Meadows North
Homestead Meadows South
Hggr Horizon City *"rn-
- "^^^^Agua Dulce
Dairyland 9 College Park Addition
'* v Socorro
San Elizario
Morning Glory
10 Miles
Service Area by Distance
1 Miles 5 Miles 10 Miles 15 Miles
m Healthcare Facilities
Figure 7: Service Area analysis of select El Paso, TX medical facilities in relation to distance (miles) to Agua Dulce, Dairyland, College Park Addition, and San Elizario.

El Paso County Rural Transit # 30 Horizon Bus Route
Bus Routes
---- To Colonias d Healthcare Facilities Colonias
----* From Colonias 0 Bus Stops Cities
Figure 8: El Paso County Rural Transit #30 Horizon route to and from El Paso colonias.

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