Citation
A Qualitative study of the health-seeking behaviors of undocumented immigrant youth adults

Material Information

Title:
A Qualitative study of the health-seeking behaviors of undocumented immigrant youth adults
Creator:
Vasquez, Trishia J.
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English

Thesis/Dissertation Information

Degree:
Master's ( Master of science)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Humanities and Social Sciences, CU Denver
Degree Disciplines:
Social sciences
Committee Chair:
Burciaga, Edelina M.
Committee Members:
Swartz, Omar
Lippert, Adam
Horton, Sarah B.
Thomas, Deborah S. K.

Notes

Abstract:
Existing literature on the health and health care access of undocumented immigrants in the United States has provided essential insight into how immigration status operates to erode the health of undocumented people at a faster pace than their documented counterparts. At the same time, research on the relationship between immigration status and one’s decision to engage with formal health care systems remains scarce. The purpose of this qualitative study is to explore how undocumented immigration status influences the health-seeking behaviors of undocumented immigrant young adults (ages 18-25) in a metropolitan area of Colorado. Federal health care policies and unfavorable state health care policies (also known as structural stigma, or restraining societal level conditions and policies) contribute to disparities in health care access and quality of care for undocumented immigrants. Yet little is understood about how anti-immigrant sentiment and health policy status quo at the federal, state, and local levels impact the day-to-day health-seeking behaviors of undocumented young adults. Drawing on qualitative data collected from in-depth, in-person, semi-structured interviews with undocumented immigrant young adults in an urban locale of Colorado, this study examines why undocumented immigrant young adults may or may not seek formal health care, and it exposes how health care policies at the federal, state, and local levels contribute to issues of health inequality among undocumented immigrant young adults and position them as less deserving health citizens. The evidence presented suggests that immigrant-focused policies are relevant to understanding the health-seeking behaviors of undocumented immigrant young adults and therefore deserve the attention of immigration scholars interested in comprehending and ultimately reducing health inequalities among the undocumented immigrant population in the United States.

Record Information

Source Institution:
University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
Copyright Trishia J. Vasquez. Permission granted to University of Colorado Denver to digitize and display this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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Full Text
A QUALITATIVE STUDY OF THE HEALTH-SEEKING BEHAVIORS OF
UNDOCUMENTED IMMIGRANT YOUNG ADULTS
by
TRISHIA J. VASQUEZ B.S., Colorado State University-Pueblo, 2000
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 Social Science Social Science Program
2019


TRISHIA J. VASQUEZ ALL RIGHTS RESERVED


Ill
This thesis for the Master of Social Science degree by Trishia J. Vasquez has been approved for the Social Science Program by
Edelina M. Burciaga, Chair Omar Swartz Adam M. Lippert Sarah B. Horton Deborah S.K. Thomas
Date: May 18, 2019


IV
Vasquez, Trishia J. (M.S.S., Social Science Program)
A Qualitative Study of the Health-Seeking Behaviors of Undocumented Immigrant Young Adults
Thesis directed by Assistant Professor Edelina M. Burciaga
ABSTRACT
Existing literature on the health and health care access of undocumented immigrants in the United States has provided essential insight into how immigration status operates to erode the health of undocumented people at a faster pace than their documented counterparts. At the same time, research on the relationship between immigration status and one’s decision to engage with formal health care systems remains scarce. The purpose of this qualitative study is to explore how undocumented immigration status influences the health-seeking behaviors of undocumented immigrant young adults (ages 18-25) in a metropolitan area of Colorado. Federal health care policies and unfavorable state health care policies (also known as structural stigma, or restraining societal level conditions and policies) contribute to disparities in health care access and quality of care for undocumented immigrants. Yet little is understood about how anti-immigrant sentiment and health policy status quo at the federal, state, and local levels impact the day-to-day healthseeking behaviors of undocumented young adults. Drawing on qualitative data collected from in-depth, in-person, semi-structured interviews with undocumented immigrant young adults in an urban locale of Colorado, this study examines why undocumented immigrant young adults may or may not seek formal health care, and it exposes how health care policies at the federal, state, and local levels contribute to issues of health inequality among undocumented immigrant young adults and position them as less deserving health citizens. The evidence presented suggests that immigrant-focused policies are relevant to understanding the health-seeking behaviors of


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undocumented immigrant young adults and therefore deserve the attention of immigration scholars interested in comprehending and ultimately reducing health inequalities among the undocumented immigrant population in the United States.
The form and content of this abstract are approved. I recommend its publication.
Approved: Edelina M. Burciaga


VI
TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION..........................................................1
II. BACKGROUND............................................................5
III. LITERATURE REVIEW....................................................12
The Role of Immigration Status and the Health Care Experience....................13
Health and Well-Being of Young Adults............................................15
Health and well-being of Latino young adults...................17
Health-Seeking Behaviors of Undocumented Immigrants..................19
Andersen’s Behavioral Model of Health Services Use...................21
Structural Stigma and Health of Undocumented Immigrants..............25
Health Citizenship...................................................27
IV. METHODS AM) DA I A.....................................................29
Interview and Analysis Methods.......................................29
Sample: Description of Participants..................................31
V. FINDINGS...............................................................35
Structural Level Stigma as a Contributing Factor to Health Outcomes..36
The Role of Undocumented Status and Other Social Positions in Shaping Health Care
Access and Utilization...............................................42
Less Deserving Health Citizens as a Result of Their Form of Health Care Coverage.49
VI. DISCUSSION AND CONCLUSIONS.............................................54
VII. LIMITATIONS AND FURTHER RESEARCH......................................60
Study Limitations....................................................60
Recommendations for Further Research.................................61


REFERENCES


Vlll
LIST OF TABLES
TABLE
1. Demographic characteristics of the sample, overall............................................32
2. Factors that influence the utilization of health facilities...................................33


IX
LIST OF FIGURES
FIGURE
1. Figure 1. Phase 5: A Behavioral Model of Health Services Use Including Contextual and Individual Characteristics....................................................24
2. Figure 2. Image of a Colorado Driver's License for those individuals who either cannot demonstrate lawful presence in the U.S. or can only demonstrate temporary lawful presence in the U. S.......................................................................39


CHAPTERI
INTRODUCTION
Few issues in the United States today are more controversial than immigration. The 2016 U.S. presidential election, and significant actions on immigration taken by the Trump Administration, have further polarized the issue of immigration in the U.S. in political and public debates at both the state and federal levels. The Pew Research Center estimated that the undocumented immigrant population in the United States in 2016 was 10.7 million, down from a high of 12.2 million in 2007 (Passel & Cohn, 2018). This group includes all foreign-born noncitizens who enter the U.S. without legal permission and valid documents, including individuals who overstay their legal immigrant visas. Some undocumented immigrants can obtain a “quasi-legal” status in the U.S. by attaining work authorization by means of applying for an adjustment to lawful permanent status (Department of Homeland Security, 2019a), by being granted Temporary Protected Status (legal status to immigrants from countries that have suffered natural disasters, prolonged unrest, or conflict) (Department of Homeland Security, 2019b), or by being a recipient of Deferred Action for Childhood Arrivals (DACA). Passel and Cohn estimate that the three “quasi-legal” groups account for as much as about 10% of the undocumented population in the U.S. (Passel & Cohn, 2018). Although the number of unauthorized immigrants in the U.S. fell to its lowest level in more than a decade, studies have shown that the age distribution of the undocumented immigrant population in the U.S. is considerably different from that of the legal immigrant or U.S.-bom population, and is reflective of a younger working-age population (Passel & Cohn, 2009). Specifically, in the U.S., the undocumented immigrant population consists of smaller shares of children and smaller shares of the elderly, and a much higher percentage of people between ages 18-3 9 (Passel & Cohn, 2009; Migration Policy


2
Institute, 2019). The age composition of the undocumented immigrant population in the U.S. is critical to this research because studies have identified that age is the sole individual-level demographic characteristic that impacts health most significantly (Cagney, 2006; Marshall, 2011). Undocumented young adults, in particular, come of age in a society full of uncertainty and distress, which may lead to a number of negative emotional and behavioral outcomes causing health concerns for this population.
Immigration research related to health care access and utilization and the general health of undocumented immigrants largely provides snapshots of drivers of health disparities and barriers to care, including lower rates of health insurance, less utilization of health care services, and lower quality of care than U.S.-bom populations. Due to challenges to conducting large-scale studies on the health status and health care access among the undocumented immigrant population, researchers know little about the health and well-being of undocumented immigrants in the U.S. Furthermore, existing studies about access and use of health care services among undocumented immigrants in the U.S. have rarely addressed the health care needs of undocumented immigrant young adults and the challenges they face in not only accessing care, but also their health care experiences when utilizing health care services (for exceptions, see Vega, Rodriguez, & Gruskin, 2009; Artiga & Ubri, 2017; Sudhinaraset, To, Ling, Melo, & Chavarin, 2017; Philbin, Flake, Hatzenbuehler, & Hirsch, 2018).
Young adulthood (roughly spanning the ages of 18-26) is a distinct and important period in the life course. During young adulthood, the choices people make around education, employment, and relationships have consequential and long-lasting implications for economic security, health, and well-being. In addition, young adulthood is a life course stage where health and health behaviors undergo major changes. Harris, Gordon-Larsen, Chantala, & Udry, have


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identified that across all sex and race/ethnic groups, there are significant increases in health risk and health disparities from adolescence into young adulthood (Harris, Gordon-Larsen, Chantala, & Udry, 2006). Specifically, they found that there are noteworthy increases in health risk during transition from adolescence to adulthood, including an increase in the percentage of young adults who get no exercise, report asthma, report a decline in breakfast consumption, are obese, need but cannot afford medical care, use cigarettes and marijuana, had any sexually transmitted diseases (STDs), and reported binge drinking (Harris et al., 2006).
In an era of increased legislation related to immigration at the federal, state, and local levels, and the fact that young adults make up the largest portion of the undocumented immigrant population in the U.S., it is critical for researchers to understand how undocumented immigrant young adults access and use health care services and how they experience health care in a state like Colorado where state and local level health care policies stimulate negative attitudes and beliefs toward undocumented immigrants and exclude them from Medicaid and the state’s children’s health insurance program (House Bill 06S-1023, 2006). This research advances the discussion regarding undocumented immigrants' vulnerability to inadequate health care in the U.S. Drawing from 12 semi-structured in-depth interviews, I examine the relationship between structural stigma, specifically policies and laws that stimulate stigma processes by intentionally restricting the health care access of undocumented immigrants, and the health-seeking behaviors of undocumented immigrant young adults in a metropolitan area of Colorado. This research explores Colorado’s state-level immigrant-focused health care policies around public (Medicaid and CHP+) and private (school mandated insurance plans and Kaiser Permanente Colorado Bridge Program) insurance programs and national immigration policies that affect the health-


4
seeking behaviors of undocumented immigrant young adults, with a focus on their: (1) Perceived health status; (2) Access and utilization of health care services; and (3) Health experiences.
In this thesis, I explore how national and state-level immigrant-focused health care policies, immigration status, socioeconomic status, and health citizenship converge at the stage of young adulthood to shape disparities in health and to create barriers to health care access and utilization at the system and individual levels for undocumented immigrant young adults. I show that structural stigma produces health inequalities among undocumented immigrant young adults, and that immigration status is important for understanding the health-seeking behaviors among this group during different developmental stages of the life course, specifically adolescence and young adulthood. Equally important, I show that health care coverage does not necessarily equate to a sense of health equality among this population. This study contributes to the broader literature on health care access and utilization patterns among the undocumented population by examining when and how immigration status plays a role in factors that impact health-seeking behaviors of undocumented young adults in a metropolitan area of Colorado.


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CHAPTER II BACKGROUND
Although the Patient Protection and Affordable Care Act (ACA) of 2010 was responsible for the expansion of health care coverage for a large number of eligible uninsured individuals living in the U.S., including naturalized citizens and lawfully present immigrants, undocumented immigrants remain ineligible for assistance, although they are disproportionately poor, nonwhite, and non-English speaking. The ACA explicitly excludes undocumented immigrants from purchasing health insurance coverage through the Health Insurance Marketplace and it excludes undocumented immigrants from benefiting from any Medicaid expansions carried out by the states (Patient Protection and Affordable Care Act, 2010). Essentially, undocumented immigrants are not eligible for federal health care coverage, including Medicare, nonemergency Medicaid, or the Children’s Health Insurance Program (CHIP) (ACA, 2010). However, while federal law generally bars undocumented immigrants from being covered by Medicaid, states set individual eligibility criteria within federal minimum standards and federal funding limitations (ACA, 2010). For instance, states like New York and California consider DACA recipients to be eligible to sign up for low-cost health care options like state-funded Medi-Cal in California (California Department of Health Care Services, 2019) and Medicaid in New York. In New York specifically, DACA recipients are considered to be Permanently Residing Under Color of Law (PRUCOL) and their Medicaid access is paid for exclusively by the state of New York (New York City Health Insurance Link, 2019).
In the state of Colorado, undocumented immigrants, including DACA recipients, are not eligible to enroll in Health First Colorado (Colorado's Medicaid Program), the state’s public health insurance program for low-income people, or the Child Health Plan Plus (CHP+), nor are


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they eligible to buy health insurance through Connect for Health Colorado, Colorado’s Health Insurance Marketplace (Colorado Department of Health Care Policy and Financing, 2019a; Colorado Department of Health Care Policy and Financing, 2019b; Johnson, 2017). A 2016 study by the Pew Research Center estimated that 190,000 undocumented immigrants comprised 34 percent of the immigrant population in Colorado, and 3.4 percent of the total state population in 2016 (Pew Research Center, 2019). In 2015, there were an estimated 104,201 uninsured undocumented adult (ages 19-64) immigrants in Colorado, accounting for one in four uninsured Coloradans overall (Johnson, 2017).
In extraordinary circumstances, low-income undocumented immigrants living in Colorado may qualify for Emergency Medicaid which covers labor, deliveries, and acute care, but does not provide follow-up or long-term care that may be needed after a health emergency.
In addition to Emergency Medicaid, other sources of health care available to undocumented immigrants in Colorado include services from Federally Qualified Health Centers (FQHCs), which use a sliding scale fee and cannot turn someone away because of their immigration status or income, and emergency room care as per the Federal Emergency Medical Treatment and Active Labor Act (EMTALA) (Zibulewsky, 2001). Under EMTALA, hospitals are required to stabilize and treat individuals, regardless of their insurance status, ability to pay, or immigration status (Burger, 2006; Zibulewsky, 2001). Care accessed through FQHCs and emergency departments is referred to as “safety-net” health care because such facilities are exclusive providers of critical health care services such as inpatient behavioral health services and dental and vision care for our country’s most vulnerable populations, including the uninsured, the underinsured, and residents of rural and underserved communities. Researchers have identified that safety-net facilities, including hospitals and community based clinics, frequently have lower


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and more shallow quality of care than non-safety-net facilities (Werner, Goldman, & Dudley, 2008; Culhane-Pera et al., 2018; Getrich, C. M., Garcia, J. M., Solares, A., & Kano, M., 2018).
In addition to the aforementioned health care services available to undocumented immigrants, a small number of undocumented immigrants can obtain health insurance through private employers, and those who are in college often have the option of obtaining health insurance through a student health plan. Many universities across the nation offer such plans for students who do not have health insurance (Braverman, 2018; Metropolitan State University of Denver, 2019); however, this can add barriers to the continuation of educational pathways for undocumented immigrants because some universities and colleges require students to have and show proof of some form of health insurance and others simply did away with their student health insurance plans after the passing of the Affordable Care Act. For example, the Auraria Campus, in Denver, Colorado is home to three educational institutions: the Community College of Denver, Metropolitan State University (MSU Denver) of Denver, and the University of Colorado Denver. All three institutions have different student health insurance requirements. MSU Denver requires all students who are taking more than nine credit hours to have health insurance coverage and they can meet the University requirement by fulfilling one of two options: (1) Students can accept automatic enrollment in the University-sponsored Student Health Insurance Plan (SHIP)-enrollment is automatic when a student registers for nine or more credit hours in the Fall or Spring semester or (2) students insured by an outside federally compliant health plan can submit an online health insurance waiver form by the published semester deadline to opt-out of the University sponsored SHIP (Metropolitan State University of Denver, 2019). On the contrary, as of August 2016, the University of Colorado Denver (CU Denver) no longer offers an optional health insurance plan for domestic (non-international)


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students because of the “more affordable” insurance options via the market (University of Colorado Denver, 2019). Like CU Denver, the Community College of Denver does not offer a health insurance plan for students, but rather encourages students to use health care services via the student Health Canter at Auraria because of its affordability (Community College of Denver, 2019). Unfortunately, the health insurance policies adopted by CU Denver and the Community College of Denver after the passing of the Affordable Care Act are restrictive of all students, including undocumented students.
Lastly, there are a few public or charitable health care coverage programs that are available to undocumented immigrants. A well-known program in Colorado was the Kaiser Permanente Colorado Bridge Program. The Bridge Program was designed to help those who are uninsured with no access to other health coverage options to pay for the standard Kaiser Permanente Individuals and Families Healthcare Plan (KPIF) (Colorado Bridge, 2019). To be eligible, one had to: (1) live within the Kaiser Foundation Health Plan of Colorado service area based on county zip code (2) have income at or below 300 percent of the Federal Poverty Level (FPL) (3) be under the age of 30 years at time of the effective date of the Kaiser Permanente plan (4) not have access to any other public or private health coverage including, but not limited to (Colorado Bridge, 2019):
- Health First Colorado (Colorado's Medicaid Program)/CHP+
- Connect for Health Colorado
- Medicare
- Job-based health coverage
Unfortunately, without warning, in October of 2018, the Kaiser Permanente Colorado Bridge Program stopped accepting new applications, and most insured patients, many who were


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undocumented young adults, lost their health care coverage as of December 31, 2018 (Colorado Bridge, 2019). The abrupt cancellation of the Colorado Bridge Program is important to note for this particular study because it highlights the precarity of health care coverage for undocumented young adults in Colorado. In addition, the Colorado Bridge Program as a public or charitable form of health coverage illustrates how different forms of health care coverage can add to experiences of health inequity (Andaya, 2017) for the undocumented population.
Although available, health care options for undocumented young adults living in Colorado are sparse, and costs associated with care and the lack of knowledge about eligibility requirements can be additional deterrents for someone needing to seek care. The Colorado Health Institute reported that a quarter of Colorado’s uninsured population were undocumented immigrants, with extensive variation across the state (Johnson, 2017). For example, more than a third of the uninsured adult population in Adams, Arapahoe, and Denver counties were undocumented immigrants (Johnson, 2017).
The health and well-being of undocumented immigrants cannot be disconnected from the political and social environment. This study is important because it contributes to the understanding of the interconnectedness of structural stigma, discrimination, and health. Our current political environment around immigration has created a sense of constant hypervigilance and fear among the undocumented immigrant population in our country. Persistent systematic and social discrimination take a toll on the mental and physical health of undocumented immigrants and their loved ones, in turn increasing their risk of poor health (Artiga & Ubri,
2017; Philbin, Flake, Hatzenbuehler, & Hisrch, 2018; Hatzenbuehler, 2018; Elejalde-Ruiz,
2018).


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For instance, chronic fear and anxiety can weaken the immune system and can cause cardiovascular damage, gastrointestinal problems such as ulcers and irritable bowel syndrome, and decreased fertility (University of Minnesota, n.d.). Chronic fear and anxiety can also lead to faster ageing and in some cases early death (University of Minnesota, n.d.). Other consequences of long-term fear and anxiety can lead to mental health issues such as fatigue, clinical depression, and post-traumatic stress disorder (University of Minnesota, n.d.). If undocumented immigrants avoid the health care system because of fear of deportation, a fear of being labeled as “illegal” or “unauthorized,” a fear of being treated differently because of their status, and or lack of ability to pay, the impact goes beyond the individual and infiltrates society as a whole; it becomes a matter of public health.
Socioeconomic background, immigration status (i.e., refugee, documented, undocumented, DACA), English proficiency, health literacy, residential location, and marginalization are among the important factors that must be considered when examining the impact of the undocumented immigrant population on public health systems and personal medical services. Because health in general is a complex issue, the science underpinning this research must integrate information and epistemologies from many disciplines including, anthropology, economics, law, medicine, political science, psychology, public health, and sociology, among others. By using an interpretivist qualitative approach through in-depth interviews this study captures the lived health care experiences and perceived health care needs of 12 undocumented immigrant young adults in Colorado. The end result of the research provides an understanding of the impact of structural stigma on health, quality of life, and wellbeing for this community. Ultimately, the research provides evidence that there is an urgent need to improve access to care, increase health insurance coverage options, and improve health


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services for the undocumented immigrant population in Colorado in order for them to believe that they are worthy health citizens so they can acquire and maintain good health (Horton, 2004; Andaya, 2017).


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CHAPTER III LITERATURE REVIEW
The number of undocumented immigrants living in the U.S., coupled with the cost to each state to provide certain public benefits and services to undocumented immigrants regardless of their legal status, has prompted researchers to study how undocumented immigrants access and use health care services. Available studies have, by and large, found that immigration status is an important determinant of health care access and patterns of health care utilization (Berk, Schur, Chavez, & Frankel, 2000; Ortega et al., 2007; Nandi et al., 2008; Raymond-Flesch, Siemons, Pourat, Jacobs, & Brindis, 2014; Hacker, Anies, Folb, & Zallman, 2015). Although studies have reported on the health care needs and numerous barriers to health care access of undocumented immigrants, much of what we know is based on research conducted in immigrant-friendly states (states that have laws that make it easier for undocumented immigrants access to jobs, higher education, health care, and driver licenses) such as California (Plascencia, Leyva, Pena, & Waheed, 2013; Raymond-Flesch et al., 2014; Horton, 2016) and New York (Nandi et al., 2008; Stump, 2016), and in states that are not necessarily immigrant-friendly but host a large undocumented population where presumably there is more infrastructure set up to serve the immigrant population. This includes states such as Texas (Kullgren, 2003; Heyman, Nunez, & Talavera, 2009), and Florida (Ku & Freilich, 2001), where about half of the undocumented immigrant population live (Passel & Cohn, 2017). Unfortunately, less is known about the health care experiences and barriers to care for undocumented immigrants in states where the size of the undocumented immigrant population is fairly low and state policies around health care access are unfavorable toward this group. Furthermore, too little attention has been paid to undocumented immigrant young adults’ specific health needs, health utilization patterns, barriers to care, and health experience (Stump, 2016). As a general pattern, most of the literature has focused on


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barriers to health care for undocumented immigrants through the policy arena, in the health care system, and at the individual level (Hacker et al., 2015). I show that the effects of inadequate health care access for undocumented young adults is best examined through a structural level stigma framework. Structural stigma can produce harm and cause significant health consequences for undocumented immigrants in the U.S. throughout the life course (Hatzenbuehler, 2018).
To understand the complexities of health care access and utilization amongst undocumented young adults, I bring the growing field of research about undocumented young adults into conversation with the health disparities literature. Specifically, I will review Everett Cherrington Hughes’ concept of “master status” as it relates to the role of immigration status and the health care experience, discuss young adults’ health and well-being in general, specifically highlighting information about the health and well-being of Latino young adults, summarize the literature on health-seeking behaviors of undocumented immigrants, revisit Ronald Andersen’s behavioral model of health services use, assess the consequences of structural stigma on the health of undocumented immigrants, and examine the concept of health citizenship.
The Role of Immigration Status and the Health Care Experience
Social determinants of health include multifaceted, integrated, and intersecting social structures and economic systems that are responsible for most health inequities in the U.S. (Centers for Disease Control and Prevention, 2014). Previous studies have demonstrated that immigration status (legal/documented or undocumented) as a social construct contributes to immigrants' vulnerability to inadequate health care access and utilization in numerous ways including: socioeconomic background; limited English proficiency; limited health literacy; and stigma and marginalization (Castaneda et al., 2015; Martinez et al., 2015; Young & Pebley,


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2017). Castaneda et al. argue that simply being an immigrant limits behavioral choices and directly impacts and alters the effects of other social positions, including race/ethnicity, gender, and socioeconomic status, because immigrant status places individuals in uncertain and positions with institutions, including health services (Castaneda et al., 2015). Such scholarship supports current research by immigration scholars around the effect undocumented status has on higher educational pathways through the lens of Everett Hughes’ concept of “master status” (Enriquez, 2017; Valdez & Golash-Boza, 2018; Gonzales & Burciaga, 2018). Hughes describes the “master status” as a primary status or social position (formal or legal) that determines a person’s place in society (Hughes, 1945). Although Hughes’ scholarship was intended to address status contradictions in professional and occupational positions (Hughes, 1945), immigration scholars have identified that undocumented status overshadows many other social positions (Castaneda et al., 2015; Enriquez, 2017; Valdez & Golash-Boza, 2018; Gonzales & Burciaga, 2018) and over the life course it can become a principal attribute driving one’s personal identity and life experiences.
Drawing from previous scholarship pertaining to the concept of “master status,” immigration status as a social determinant of health, and undocumented status as a social construct that shapes educational pathways for undocumented immigrant young adults, my findings will address how and when undocumented immigrant status can create disparities in health and health outcomes for undocumented immigrant young adults. Specifically as it relates to health, I will show that undocumented status as a “master status” evolves over the course of life, and that once undocumented immigrant young adults become responsible for their own health care (age of 18), immigration status becomes one of many social positions that contributes to inequities that shape the health care experience of undocumented young adults.


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Health and Well-Being of Young Adults
Research suggests that young adulthood (spanning the ages of roughly 18-26) is an important and critical time of life (Mulye, et al., 2009; Park, Scott, Adams, Brindis, & Irwin, 2014; National Research Council and Institute of Medicine, 2015). During young adulthood, people usually complete their high school education, start or complete college, start working in the “real-world,” join the military, develop relationships, and pursue other activities that help set them on a pathway to a healthy and productive adult life (Mulye et al., 2009; National Research Council and Institute of Medicine, 2015). However, young adulthood can also be a challenging time for people (Park et al., 2014; Mulye et al., 2009). Although young adults are generally healthy (National Research Council and Institute of Medicine, 2015), some important health and social problems either start or peak during these years (Harris et al., 2006; Mulye et al., 2009; Balocchini, Chiamenti, & Lamborghini, 2013; Park et al., 2014; National Research Council and Institute of Medicine, 2015). Mulye et al. (2009) indicate that rates of homicide, unintentional injury (i.e., motor vehicle crashes, fires and burns, falls, drowning, poisoning, choking, suffocation, and animal bites), substance use, drinking and driving, and sexually transmitted infections, peak during young adulthood. In addition, research indicates that risky adolescent sexual behaviors, including multiple sex partners, having had an STD, and having had an intended or unintended birth, increase risk of negative reproductive health outcomes in young adulthood (Scott et al., 2011). Scott et al. (2011) point out that young adult male and females endure a disproportionate burden of STDs and unintended childbearing (women aged 20-24 have the highest unintended childbearing rate) as a result of adolescent sexual risk behaviors.
Young adulthood is a critical developmental period during which key tasks in the transition to independent adulthood need to be accomplished, including taking responsibility for


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one’s own health. As young adults acquire more privileges of adulthood, they lose support from institutions and safety net programs, including health care programs that serve adolescents, and they often face challenges as they transition from the child health care system to the adult health care system (Mulye et al., 2009). Before the passing of the ACA, young adults were only allowed to stay on their parents’ health insurance until they turned 19, or 23 for full-time college students, or got married. Under current law, parents can add or keep their children on their health insurance policy until they turn 26 years old and can join or remain on their parent's plan even if they are married, not living with their parents, attending school, not financially dependent on their parents, or eligible to enroll in their employer’s health insurance plan (ACA, 2010). Having access to health care as a young adult helps decrease social and economic challenges at a time when young adults are expected to take on adult responsibilities and obligations. Unfortunately for undocumented immigrant young adults, since they are excluded from federal health care coverage programs, they are excluded from the health care overhaul related to rules for legal citizen children and young adults. As the research has firmly established in other areas of the transition to adulthood, health care benefits can significantly protect against unmet health care needs for young adults in general (Marshall, 2011). As a result of being excluded from critical health care services and coverage options, undocumented young adults have to navigate the tumultuous transitions to adulthood without the same benefits and opportunities as citizens. Consequently, undocumented immigrant young adults face an increased risk of poor health outcomes, negative health care provider attitudes, and unnecessary disability and premature death due to the lack of access to comprehensive, quality health care services (Hardy, 2004; Mulye et al., 2009; Andaya, 2017; Healthy People 2020, 2018).


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Health and well-being of Latino young adults. As reported by the Migration Policy Institute (MPI), “in 2017, 44 percent of U.S. immigrants (19.7 million people) reported having Hispanic or Latino origins” (Zong, Batalova, & Burrows, 2019).1 Between 2012 and the end of 2016, based on MPI estimates, Mexicans and Central Americans were estimated to account for roughly two-thirds (67 percent or 7.6 million) of the undocumented immigrant population in the U.S. (Zong, Batalova, & Burrows, 2019). Insufficient access to health care services, the social and economic environment, and structural barriers to health can cause significant health disparities among Hispanic/Latino immigrants. Many studies related to racial and ethnic disparities in health care access and utilization frequently identify Hispanics/Latinos as one of the most disadvantaged ethnic groups in the U.S. (Callahan, Hickson, & Cooper, 2006; Paz & Massey, 2016; Dillon, Ertl, Corp, Babino, & De La Rosa, 2018). Furthermore, research by Callahan, Hickson, and Cooper pointed out that Central/South American and Mexican young adults without U.S. citizenship were the most likely Hispanic/Latino groups to be uninsured (63% and 73%, respectively) and the majority of noncitizens also lack a usual source of health care and had no contact with a professional health care provider within a one year period of time (Callahan, Hickson, & Cooper, 2006).
Although Hispanics/Latinos have lower deaths than whites from most of the 10 leading causes of death, they experience more deaths from diabetes and chronic liver disease, and similar numbers of deaths from kidney diseases (Centers for Disease Control and Prevention, 2015). The CDC also specifies that place of national origin (where one was bom) for Hispanic/Latinos makes a difference. For instance, cancers related to infections (cervical, stomach, and liver) are
1 It should be noted that Hispanic and Latino are ethnic categories, and are separate from racial categories. Hispanic/Latino ethnic groups include any person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of racial identification (United States Census Bureau, 2019).


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more common among Hispanics/Latinos born outside of the U.S. (Centers for Disease Control, 2015). Although there is no assurance in cancer prevention, there are things that one can do to lower the risk of cancers related to infections. For instance, one can decrease the risk of developing liver cancer by getting a vaccination for Hepatitis B, which is the most common risk factor for liver cancer (Hepatitis B Foundation, 2019). In respect to cervical cancer, the American Cancer Society acknowledges that this disease can be stopped from developing by finding and treating precancerous conditions before they become true cancers, and by preventing the precancerous conditions all together (American Cancer Society, 2019). The Pap test (or Pap smear) and the human papillomavirus (HPV) test are specific tests used during screenings for cervical cancer, and the HPV vaccine can protect young people against infection “with the HPV subtypes most commonly linked to cancer, as well as some types that can cause anal and genital warts” (American Cancer Society, 2019). According to the National Institutes of Health (NIH), nearly all cases of cervical cancer are caused by particular types of HPV (NIH, 2019). There are more than 100 types of HPV, of which more than 40 can be transmitted through intimate skin-to-skin contact by having vaginal, anal, or oral sex with someone who has the virus (NIH, 2019).
Along with physical health, Hispanics/Latinos are no different from the rest of the population when it comes to prevalence of mental health conditions. Generally speaking, mental health conditions are common among adolescents and young adults - 1 in 5 live with a mental health condition (National Alliance on Mental Illness, 2019). Previous studies have identified that young adults from urban, socio-economically disadvantaged communities report high rates of adverse childhood experiences which can be linked to depressive symptoms, antisocial behavior, and drug use during the early transition to adulthood (Schilling, Aseltine, & Gore, 2007). Although U.S.-bom Hispanics/Latinos are at significantly higher risk than immigrant


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Hispanics/Latinos for major depressive episode, social phobia, post-traumatic stress disorder, any anxiety disorder, alcohol dependence, alcohol abuse, drug dependence, drug abuse, and any disorder (Alegria et al., 2008), recent research identified that undocumented Mexican immigrants are an at-risk population for mental disorders, particularly depression and anxiety disorders, mostly because of the stress from living as an undocumented person in the U.S. (Garcini Pena, Galvan, Fagundes, Malcarne, & Klonoff (2017). There are notable mental health implications of being an undocumented person living in the U.S. For instance, stigma can contribute to barriers to health care access and utilization for the undocumented population. There are both psychological and behavioral responses to stigma including, maladaptive or counterproductive, coping behaviors as a way to deal with stress (i.e., drinking and smoking), and maladaptive emotion regulation strategies such as rumination (deep or constant thought about something) and suppression (the conscious deliberate exclusion from consciousness of a thought or feeling) (Hatzenbuehler, Phelan, & Link, 2013). Lack of knowledge and perceived stigma may increase the length of delay in accessing health care among the undocumented immigrant population. Health-Seeking Behaviors of Undocumented Immigrants
Although the literature suggests that immigrants in general have better health status and lower rates of risky health behaviors compared to U.S.-born citizens (Stephen, Foote,
Hendershot, & Schoenborn, 1994; Gordon-Larsen, Harris, Ward, & Popkin, 2003; Antecol & Bedard, 2006), factors such as limited access to quality health care, low income and occupational status, and legal status may erode the health advantage of undocumented Hispanic/Latino immigrants at a faster pace than their documented counterparts (House, Kessler, & Herzog,
1990; Derose, Escarce, & Lurie, 2007; Nandi et al., 2008). Sociodemographic characteristics including, age, ethnicity, sex, socioeconomic status (three indices including, income, education,


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and occupation), marital status, and family size, are important predictors of undocumented immigrants’ health and influence both access to care and utilization of services.
Throughout the literature, it is suggested that undocumented immigrants in the U.S. underutilize the health care system and spend less than other immigrants and U.S. native bom individuals on health care (Mohanty et al., 2005; Goldman, Smith, & Sood, 2006; Nandi et al., 2008; Rodriguez, Vargas Bustamante, & Ang, 2009; Stimpson, Wilson, & Su, 2013). The degree to which undocumented immigrants experience barriers in access to care in the U.S. hinges on the country’s structure and organization of our health care system and social and political policies related to immigration. Hacker et al. identified that barriers to care for undocumented immigrants are experienced in the policy arena, within the health care system, and at the individual level (Hacker et al., 2015). At the policy level, a commonly cited mechanism for excluding undocumented immigrants from the health care system and health care services are laws and policies that limit or exclude undocumented immigrants from accessing health insurance (Ortega et al., 2007; Raymond-Flesch et al., 2014; Hacker et al., 2015). At the health system level, barriers to care include external resource constrains, such as work conflicts and high costs associated with care (Horton & Stewart, 2011), discrimination from health care providers on the basis of documentation status, and bureaucracy including complex paperwork and systems (Raymond-Flesch et al., 2014; Hacker et al., 2015). At the individual level, barriers to care include a lack of health care literacy, fear of deportation, shame and stigma, language and cultural barriers, and a lack of knowledge of complex health policies at the federal, state, and local levels around rights to health care (Garces, Scarinci, & Harrison, 2006; Ortega et al., 2007; Nandi et al., 2008; Raymond-Flesch et al., 2014; Hacker et al., 2015). The cumulative effects of these systematic barriers contribute to major health disparities among the undocumented


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immigrant population in the U.S. and lead to delays in seeking formal health care services and contribute to unequal access to formal health care services and negative health care experiences. Many undocumented immigrants in the U.S. approach formal medical care as a last resort; that is, they seek formal medical care only when everything else doesn’t work (Garces, Scarinci, & Harrison, 2006; Raymond-Flesch et al., 2014). When undocumented immigrants finally do seek formal medical care, it is typically accessed at FQHCs, safety-net hospitals, or they wait until their conditions are dire enough to seek medical care through an emergency department (Raymond-Flesch et al., 2014; Sommers, 2013). As noted previously, safety-net facilities, including hospitals and community based clinics, frequently have lower and more shallow quality of care than non-safety-net facilities because they are often overwhelmed and busy (Werner, Goldman, & Dudley, 2008; Culhane-Pera et al., 2018; Getrich, C. M., Garcia, J. M., Solares, A., & Kano, M., 2018). This particular health system barrier to care contributes to negative health care experiences among the undocumented immigrant population as a result of perceived discriminatory practices by the health care system and health care practitioners. There are blatant public health implications of disparities in care for undocumented immigrants in the U.S. Inadequate access to health care and treatment for undocumented immigrants living in the U.S. due to exclusionary policies and laws can lead to high costs associated with chronic diseases, spread of infectious diseases, and negatively affect disease control efforts and interventions.
Andersen’s Behavioral Model of Health Services Use
At some point in time, every person will need to access medical care. Access to health care services, including dental and vision care, is critical to good health, yet undocumented immigrants in the U.S. face a variety of access barriers specifically due to their immigration


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status. With the exception of emergency medical care, in the U.S. undocumented immigrants are not eligible for federally funded public health insurance programs, including Medicare, Medicaid, and CHIP (ACA, 2010). Most medical care for undocumented immigrants in the U.S. relies on a fragmented system of safety-net providers, including public and not-for-profit hospitals, FQHCs, and migrant health centers. The ways in which undocumented immigrants interact with the health care system in the U.S. illustrates a gap in Ronald M. Andersen’s healthseeking behavior model.
The concept of the health-seeking process has evolved with time (Chrisman, 1977). Various anthropological, psychological, and sociological models have been used to explain health-seeking behaviors among populations all over the world (Chrisman, 1977; Poortaghi et al., 2015). MacKian defines health-seeking behavior as “the factors which enable or prevent people from making healthy choices, in either their lifestyle behaviors or their use of medical care and treatment” (MacKian, 2003). In the broadest sense, health-seeking behavior includes all behaviors associated with establishing and maintaining a healthy physical state and a healthy mental lifestyle. Andersen’s Behavioral Model of Health Services Use was specifically constructed to explain and describe health-seeking behaviors and it is one of the most widely used conceptual frameworks for understanding why and when people seek out health care services (Andersen, 1995).
Andersen’s Behavioral Model of Health Services Use was initially developed in the late 1960’s and it primarily focused on the family as the unit of analysis (Andersen, 1995). Consequently, as health policy and the external environment (including physical, political, and economic components) have become important factors in influencing how researchers understand the concept of health services utilization, there have been four revisions (Phase 2-


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1970s; Phase 3-1980s-1990s; Phase 4-1990s; Phase 5-2000s) of the model (Andersen, 1995; Andersen, 2008). Now in the fifth phase (2000s), the model stresses that understanding health services use is best achieved by focusing on contextual and individual determinants (Andersen, 2008). According to the current model, contextual determinants of health services utilization include health system organization, provider-related factors, and community characteristics (Andersen, 2008). The model suggests three reasons for health-seeking behaviors: (1) people are predisposed to use health care services because of their demographics, social context, and beliefs, (2) factors such as health policies, finances, and organization of the health care system enable or hinder use of services, and (3) people’s immediate need for care (Andersen, 2008). Phase 5 of the model includes feedback loops to demonstrate that outcomes can affect health behaviors, predisposing, enabling, and need variables both contextually and individually, and additionally, health behaviors can influence predisposing, enabling, and need variables both contextually and individually (Andersen, 2008). Also added in phase 5 of the model is the process of the health care experience. This pertains to provider behavior and attitudes during the delivery of medical care (Andersen, 2008). For example, the quality of doctor-patient trust and communication can influence whether or not patients acknowledge health problems, understand their treatment options, and modify their behavior accordingly. Phase 5 of the Behavioral Model of Health Services Use is shown in Figure 1.


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Figure 1. Phase 5: A Behavioral Model of Health Services Use Including Contextual and Individual Characteristics.
Contextual Characteristics
Health
Individual Characteristics Behaviors Outcomes
Reprinted from National Health Surveys and the Behavioral Model of Health Services Use, by Ronald Andersen, July 2008, retrieved from doi:10.1097/MLR.0b013e31817a835d Copyright 2008 by Lippincott Williams & Wilkin.
Although Phase 5 of Andersen’s Behavioral Model of Health Services Use is more comprehensive and stresses the importance of contextual and individual characteristics in promoting access for defined populations, contextual characteristics of the current model can be expanded to include structural stigma as a factor inhibiting health-seeking behavior. Hatzenbuehler and Link define structural stigma as “societal-level conditions, culture norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized” (Hatzenbuehler & Link, 2014). Structural level stigma is embedded in multiple institutions, including law and social policies (Hatzenbuehler, n.d.). For instance, federal, state, and local level health care policies, allow for scrutiny of people suspected of being undocumented (Toomey et al., 2014; Rhodes et al., 2015), and social policies and state laws that allow undocumented immigrants to obtain a driver's license or some type of driving permit


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which is required to be marked in particular ways to distinguish it from the licenses of those with legal status (Colorado Department of Revenue, 2019), can invigorate stigma processes and produce harm to mental and physical health (Link & Hatzenbuehler, 2016).
Structural Stigma and Health of Undocumented Immigrants
Research concerning the causes and consequences of stigma has flourished since Goffman’s classic work on stigma in his 1963 publication entitled Stigma: Notes on the Management of Spoiled Identity. Goffman defined stigma as “an attribute that is deeply discrediting” (Goffman, 1963, p. 3). and by definition “the person with a stigma is not quite human” (Goffman, 1963, p. 5). Goffman’s point about stigma and the relationship to people being “not quite human” describes the perceptions of undocumented immigrants in the U.S. by some individuals (Cowan, Martinez, & Mendiola; 1997; Pearson, 2010). To illustrate, when people identify undocumented immigrants as “illegal,” used as an adjective, this stereotypes all undocumented immigrants as deviant and less deserving. Recognizing that there are notable health implications of social devaluation, recent scholars have identified several other elements of stigma at the individual level, including micro level interactions, and at the macro level i.e., structural stigma (Hatzenbuehler & Link, 2014).
Hatzenbuehler and Link define structural level stigma as “societal4evel conditions, culture norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized” (Hatzenbuehler & Link, 2014, p. 2). Their research documents the extensive health consequences of structural stigma across the life course (Hatzenbuehler, n.d.; Link & Hatzenbuehler, 2016; Philbin, Flake, Hatzenbuehler, & Hisrch, 2018; Hatzenbuehler, 2018). Hatzenbuehler and Link indicate that social policy can contribute to stigma processes in three different ways: by invigorating the social production of stigma and producing harm; by


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interrupting stigma processes and mitigating harm; and by, ignoring the interests of stigmatized groups (Hatzenbuehler, n.d.; Hatzenbuehler & Link, 2014; Link & Hatzenbuehler, 2016; Hatzenbuehler, 2018). Structural forms of stigma are conceptualized as objective rather than subjective evaluations assessed at the individual and interpersonal levels (Hatzenbuehler, 2018). This is critical to immigration research because several scholars have suggested that laws and policies are forms of structural stigma that shape social/cultural norms and attitudes toward the stigmatized group (Kreitzer, Hamilton, & Tolbert, 2014; Philbin, Flake, Hatzenbuehler, & Hisrch, 2018; Hatzenbuehler, 2018). For undocumented immigrants, structural stigma is a risk factor for poor health because federal, state, and local level policies that invigorate or ignore access to health care and related services for this group undermine health through psychological and physiological factors, and such policies can undermine health interventions (Hatzenbuehler, n.d.).
Hatzenbueheler proposes that when structural level stigma occurs, interpersonal and individual stigma mechanisms are more likely to be openly conveyed and acted upon (Hatzenbuehler, 2018). Hatzenbuehler et al. (2013) indicate that many psychological and behavioral processes are drastically altered by stigma. For example, the experience of structural level stigma can lead to maladaptive coping behaviors (i.e., drinking, smoking) and maladaptive emotion regulation strategies (i.e., rumination or suppression) (Hatzenbuehler, Phelan, & Link, 2013). Such behaviors lead to negative consequences for both mental and physical health. Stress is another mechanism through which structural level stigma can lead to adverse health outcomes. Stress is the physiological demand placed on the body when one must adapt, cope, or adjust to threatening or challenging events (Nevid & Rathus, 2003). Undocumented immigrants in particular have to deal with isolation from peers, the struggle to pursue an education, fears of


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detention and deportation, the lack of access to health care, and the trauma of separation from family and loved ones (APA, 2012).
Structural stigma has robust health consequences for undocumented immigrants living in the U.S., and it is a considerably understudied cause of health inequalities amongst this group. It is imperative to examine structural forms of stigma and prejudice as social determinants of health and longevity among undocumented immigrants in the U.S., and in particular, in states with unfriendly or hostile health care policies related to access to care for this group. As noted, laws and policies that directly affect members of stigmatized groups can invigorate the effect of stigma on life chances. For undocumented immigrants, structural level stigma related to laws and social polices around immigration and health care access play a distinct role in inequalities related to mental and physical health and the health care experience of undocumented immigrants.
Health Citizenship
Medical anthropologists use the notion of “health citizenship” to examine the way people are included socially, politically, economically, or are marginalized or excluded from the health care system (Redden, 2002; Horton, 2014; Petryna & Follis, 2015; Andaya, 2017). A growing body of literature has elaborated on this concept by discussing how federal and state health care policies shape immigrants’ perceptions of their rights with respect to health and health care (Horton, 2014; Horton, 2016; Andaya; 2017). Horton’s scholarship examines patterns of health utilization among the undocumented immigrant population as a result of negative federal and state policies that affect access to health care services for the undocumented population and their children (Horton, 2014; Horton; 2016). Andaya adds to the concept of “health citizenship” by addressing how different forms of health coverage can contribute to experiences of heath


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inequality by making some people, particularly immigrants, feel like they are less worthy of health care (Andaya, 2017). As a consequence, Andaya identifies that certain individuals may experience better health care and respect during their health encounter because of judgement about citizenship and moral worth (Andaya, 2017). Furthermore, both Horton’s and Andaya’s research highlights the importance of immigrants being seen as less deserving because of the forms of health coverage available to them (Horton, 2014; Horton, 2016; Andaya, 2017). Each addresses the difference between inclusion of immigrants in health care, and the reproduction of social structures that contribute to unequal health care experiences within certain forms of health care coverage (Horton, 2014; Horton, 2016; Andaya, 2017).
Horton and Andaya’s research regarding health citizenship is of particular interest to this study, because many of the participants were insured as a result of an employee-based plan, a school health care plan, or private health insurance through the Colorado Bridge Program. I present evidence that inclusion in health care coverage does not necessarily result in equity in health care access and utilization for undocumented immigrant young adults. In fact, structural level stigma and health systems barriers to care can shape health care provider attitudes which directly contribute to the patient experience, making many undocumented immigrant young adults feel as though they are less deserving health citizens.


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CHAPTER IV METHODS AND DATA
Qualitative research is a method of analysis engaged in by scholars in many different academic disciplines, including the social sciences, behavioral sciences, health sciences, medicine, human geography, and public health. Qualitative research has numerous benefits as a method of inquiry for immigration research and for health care research with social and cultural dimensions. Qualitative research focuses on participant viewpoints and stories; it can uncover significant issues that can later be studied using more structured methods (i.e., quantitative design methods); it can provide insight into cultural activities that might otherwise be missed via a quantitative approach; and such methods are suitable for accessing implied, taken-for-granted, intuitive understandings of a culture (Tracey, 2013). The Colorado Multiple Institutional Review Board (COMIRB) under the auspices of the University of Colorado Denver approved all protocols for the research. Verbal informed consent was obtained from each participant and anonymity of participation was guaranteed.
Interview and Analysis Methods
The study design consisted of in-depth, in-person, semi-structured interviews with undocumented immigrant young adults ages 18-25. In addition to semi-structured interviews, in order to satisfy the principle of triangulation and increase the validity of the study’s conclusions, I complemented the qualitative study with a web based questionnaire consisting of 32 questions. Each study participant completed the questionnaire before participating in the interview. Interviews were conducted from October 2018 through November 2018 in Denver, Colorado. I initiated convenience sampling by recruiting participants from multiple organizations that support undocumented immigrant young adults, including local health organizations and clinics,


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the University of Colorado Denver, and Metropolitan State University of Denver. Participants were recruited until I reached a point of sampling saturation, meaning the data collected started to become repetitive and I was no longer getting any new participants from any of the outreach destinations to volunteer. All participants received a $20 incentive in the form of a gift card for being interviewed. Interviews were conducted in a private space on the Auraria Campus in Denver, CO, and lasted approximately 50-90 minutes. All participants chose to be interviewed in English and identified a pseudonym to protect confidentiality.
Interviews were directed by a semi-structured interview guide that included questions to map each participant’s migration story, perceived health (physical, mental, oral, and eye) status, access to and utilization of health care services, and barriers to care. Interviews were recorded and sent to Rev.com, a professional freelance transcription service, for verbatim text transcription. Transcripts were analyzed manually on hard-copy printouts. Using Microsoft Word, codes were directly added to the data. In addition, analytic memo writing was used to reflect on code choices, understand emerging patterns and themes, and theory assessment. These processes revealed four main inhibiting predictors of health-seeking behavior among the participants: structural stigma, health system barriers to care (i.e., bureaucratic obstacles and safety net health care), individual barriers to care (i.e., low social economic status (SES), lack of social capital, low health literacy), and social location of undocumented status. I systematically coded for the inhibiting predictors and developed a process-based analysis by reviewing each transcript to identify patterns of how and when each inhibiting predictor affected participants’ health-seeking behaviors including health care usage, health-related expenditures, and patterns of
access and utilization.


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Sample: Description of Participants
Immigration research involves complex human interactions that can rarely be studied or explained in simple terms. In order to understand how Colorado’s health care policies around public insurance programs (Medicaid and CHP+) and our country’s immigration policies affect the health-seeking behaviors of undocumented immigrant young adults, I elected to speak with individuals currently living in the state without permanent legal status (i.e., not a citizen, permanent resident, or hold a student visa). Study participants identified as undocumented, DACA, DACAmented, ASSET student, and DREAMer. Participants also had to be between the ages of 18-25 and have arrived in the U.S. before their 16th Birthday.
Twelve undocumented immigrant young adults between the ages of 18-25 completed the interview and the web based questionnaire. All 12 participants identified their place of national origin as Mexico. They are all 1.5 generation immigrants, meaning they arrived in the U.S. as children and adolescents. 50% of the participants arrived before the age of four, another 33% arrived between ages 4-6, and 17% arrived between the ages of 7-12. All but one person identified their gender as female; one individual identified as male. Participants lived in Colorado an average of 16 years, and 100% of participants completed high school in Colorado. Eleven participants were currently attending a four-year university, and one participant attended a four-year university and completed a Bachelor’s degree. In regards to employment status, 50% of participants identified as a full-time employee, 25% identified as a part-time employee, and the remaining 25% of participants were either self-employed or unemployed. All but two participants (83%) indicated they had some form of health insurance at the time of the interview. Various types of health insurance were identified; private insurance, specifically the Colorado


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Bridge Program through Kaiser Permanente2, student health insurance, and employee based health insurance. More than half of the participants (58.33%) indicated having an existing need to access a doctor or specialist about their health at the time of the interview. The demographic characteristics of the sample are provided in Table 1.
Table 1
Sociodemographic characteristics of participants (N=12)
Total Participants 12
N %
Age Range=19-25 years Mean =21.42 years
Age Upon Arrival in U. S. Range=0 (months)-17 or older
0 (months)-3 years 6 50
4 years-6 years 4 33.33
7 years-12 years 2 16.67
Place of National Origin
Mexico 12 100
Length of T ime in the U. S. Range=10-21 years Mean =16.05 years
Length of Time Lived in Colorado Range=5-21 years Mean =15.83
Gender Identity
Female 11 91.67
Male 1 8.33
Sexual Orientation
Heterosexual or straight 10 90.91
Bisexual 1 9.09
Employment Status
Full-Time 6 50.00
Part-T ime 3 25.00
Self-Employed 1 8.33
Unemployed 2 16.67
Student Status
Full-Time 9 75.00
Part-T ime 2 16.67
Not a student 1 8.33
High School Graduate 12 100.00
Current Immigration Status
Deffered Action for Childhood Arrival (DACA) 10 83.33
Undocumented 2 16.67
Insurance Status
Insured 10 83.33
Uninsured 2 16.67
Existing Need to Access a Doctor or Specialist About a Health Concern
Yes 7 58.33
No 5 41.67
2 Effective October 1, 2018, the Colorado Bridge Program was cancelled unexpectedly.


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Additionally, the web based questionnaire added a deeper understanding of the healthseeking behaviors of the participants. When asked to rank what influences the utilization of health facilities, participants identified cost of services and immigration status as the number one and number two influences of utilization of formal health facilities. Table 2 provides a ranking of items that influence health care utilization from most important to least important by the participants.
Table 2
Factors that influence the utilization of health facilities from most important to least important; 1 being the most important and 5 being the least important (N=12)
# Field 1 2 3 4 5 Total
1 the cost of services 75.00% 9 25.00% 3 0.00% 0 0.00% 0 0.00% 0 12
2 the distance to health facilities 0.00% 0 0.00% 0 16.67% 2 25.00% 3 58.33% 7 12
3 immigration status 16.67% 2 58.33% 7 16.67% 2 8.33% 1 0.00% 0 12
4 cultural beliefs 0.00% 0 0.00% 0 25.00% 3 33.33% 4 41.67% 5 12
5 level of education/health literacy 8.33% 1 16.67% 2 41.67% 5 33.33% 4 0.00% 0 12
Participants were also asked to self-rate their physical, mental, and overall health using a 5 point Likert scale that ranged from “excellent” to “poor.” 58% (7 of the 12) of the participants indicated that their physical health was “good” and 68% (8 of the 12) indicated that their overall health was “good” at the time of the interview. When asked about mental health, 50% of the participants indicated that in general their mental health was “fair” at the time of the interview. Moreover, participants were asked if they had an existing need to access a doctor or a specialist about their health at the time of the interview and to comment on their response. Seven of the participants said “yes.” Comments included “I have a hole in my heart and I need an echo but it is too expensive,” to “I haven’t seen a real doctor in years so I should probably see where I am at


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with my overall health.” One participant indicated “Yes, I need to see someone soon because I’ve had previous surgery on my head for an abnormal growth, and it is growing back; bigger now, so I should probably go in and get it checked.”


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CHAPTER IV FINDINGS
My analysis suggests that undocumented status, along with structural level stigma and perceived quality of care, directly affect the health-seeking behaviors of undocumented immigrant young adults. More specifically, in relationship to health care access and utilization, undocumented young adults often do not experience the inequalities of the health care system created by their immigration status until they are in need of formal health care after they turn 18 years of age. Participants were largely safeguarded from health inequalities due to their own immigration status during childhood and adolescence because they were at the will of their parents’ consent to medical treatments. Additionally, since undocumented immigrant children and adolescents have access to K-12 education, they are afforded some of the same health care access as their citizen counterparts. Colorado is one of many states across the country that locates health care clinics on school properties to provide primary, behavioral, and oral health services, particularly for low-income children and youth, regardless of immigration status (Colorado Department of Public Health & Environment, 2018).
Data analysis yielded three themes consistently influencing participants’ health-seeking behaviors: (1) structural stigma, specifically health care related laws and policies and driver’s license-related polices, as a contributing factor to adverse health outcomes; (2) the role of undocumented status and other social positions in shaping health care access and utilization; (3) position in the health care system as less deserving health citizens because of their form of health care coverage. These three themes describe factors at the structural, health care system, and individual level, that interact together to shape health-seeking behaviors among the undocumented immigrant young adult population.


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Structural Level Stigma as a Contributing Factor to Health Outcomes
Stigma scholars have identified that stigma at all levels (individual, interpersonal, and
structural)3 plays an important role in producing health disparities among marginalized
populations (Hatzenbuehler, Phelan, & Link, 2013; Hatzenbuehler & Link, 2014; Hatzebuehler,
2018). For this study, health care related laws and policies at the federal, state, and local levels
and driver’s license-related polices at the state level interfered with the participants ability to
access and utilize formal health care services. In particular, the restrictions created by such laws
and policies produce health systems bsrriers and individual barriers to care.
Philbin et al. identified that health care related policies include laws and policies that
govern access to health care services and coverage, requirements that health care professionals
participate in cultural competency training, and polices that require health care providers to
report undocumented immigrants (Philbin, Flake, Hatzenbuehler, & Hisrch, 2018). Limited by
their ability to pay for health care services due to federal and state level policies that make them
ineligible for Medicaid and ACA expansion benefits, and their immigration status,
undocumented immigrants tend to access formal health care as a last resort (Garces, Scarinci, &
Harrison, 2006; Raymond-Flesch et al., 2014). Additionally, when undocumented immigrants do
access care, it tends to be through safety net options such as the emergency department and
safety net clinics (Raymond-Flesch et al., 2014; Sommers, 2013). Elbe describes the ease of
access to health care services on a scale from 1-10:
Two. I always have to look really hard for services. I would have to do hours of research to find the cheapest option usually, and the option that I know undocumented people are safe to go to, and I have to call various places. So I wouldn't call that accessible.
3 As defined by Hatzenbuehler, individual level stigma refers to how individuals engage in responding to stigma. Interpersonal stigma is the interactional process that occurs between the stigmatized and the non-stigmatized. Structural level stigma is defined as “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources and well-being of the stigmatized” (Hatzenbuehler, 2018, p. 106).


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Ellie identifies how structural factors like SES and the unequal allocation of power and resources contribute to health disparities among undocumented young adults. Ellie noted that there is a lack of knowledge amongst the undocumented community about where to go to access good care and even how to go about scheduling an appointment. Participants who avoided the formal health care system often named cost of services and difficulty of access, specifically the ability to locate culturally sensitive providers and services in general, as reasons why they did not access care. Participants who did access care through safety net options described these facilities as being overwhelmed and busy and suggested that practitioners participated in inequitable treatment practices. Layla recounted a time when she visited a student-run free clinic to address issues she was having with her stomach:
I went right at the time that they opened. I was there for like I swear... six hours until 10 p.m. They saw me and I was like, "I have this pain. Oh my god. I have this pain." It doesn't go away ... and I still have it to this day. They [the practitioners] were just like "Oh" and eventually someone just came in to talk with me.. .and they were like, "Urn so you told us you're a student. Maybe you're just stressed." I was just like, "No. Something is wrong." Eventually...they did the stool test and I took my stool in a bag to the lab on the big campus. They never followed up with me so I kept e-mailing them and no one would reply. I eventually went back [to the clinic] again when I had more time and.. .they said everything came back normal so maybe it was just something you had ate that week or something. I said it's still here.
Tired of being dismissed by the health care system as an undocumented young adult, Layla chose not to go back to the clinic, and at the time of the interview she was still trying to locate a doctor that she could afford and would acknowledge her symptoms. Claudia also experienced unfair treatment at a safety net dental clinic. She went to the clinic because she had been experiencing pain with her wisdom teeth and she wanted to get an estimate on wisdom teeth removal. Claudia explains that the treatment she experienced at the low cost dental clinic was different then her experience at the private Orthodontist office:


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Yeah, the services could have been better. I think a lot of it, they have a lot of Latino community come in, and so they kind of treat them a bit different, and they give them all these prices, because they know that they don't have insurance for oral care, so it's just...
I don't know, I think it's a different vibe compared to when I was going to my orthodontist, I felt a lot different. I was treated like a normal patient, but at this Latino dentist [office], I don't know, it's different.
Although Layla and Claudia both sought necessary health care services, Layla for treatment, and Claudia for preventative care, the frustrating delays and the dismissal of their symptoms by health care providers discouraged them from reaching out for additional health care services and following up on their care.
Bureaucratic obstacles including Identification cards (ID’s), specifically driver licenses, and medical office forms, also led some participants to experience health systems barriers to care. The Colorado Road and Community Safety Act (CO-RCSA SB 13-251) of 2013 “authorizes the issuance of a Colorado driver license, instruction permit, or identification card to those individuals who either cannot demonstrate lawful presence in the U.S. or can only demonstrate temporary lawful presence in the U.S.” (CO-RCSA SB13-251, 2013; Colorado Department of Revenue, 2019). While SB13-251 is a positive development for many undocumented individuals living in Colorado, the law has already had unintentional consequences as it relates to program backlog. As of 2019, there are three Department of Motor Vehicle Offices in Colorado (Westgate, Grand Junction, and Colorado Springs) that are available to process first time applicant appointments and renewal appointments, and an additional location in Aurora that can process renewal appointments only (Colorado Department of Revenue, 2019). Hatzenbuehler demonstrates that structural level stigma can be both intentional (i.e., laws that prohibit undocumented immigrants from receiving public benefits) and unintentional (Hatzenbuehler, 2018). Although not intentional, SB 13-251 can contribute to health systems barriers to care for undocumented immigrant young adults. As demonstrated in Figure 2 below (Colorado


39
Department of Revenue, 2019), SB 13-251 requires card images to display a “blackbox” with the wording “NOT VALID FOR FEDERAL IDENTIFICATION, VOTING, OR PUBLIC BENEFIT PURPOSES.”
Figure 2. Image of a Colorado Driver's License for those individuals who either cannot
demonstrate lawful presence in the U.S. or can only demonstrate temporary lawful presence in
the U.S.
DL
DRIVER LICENSE
SAMPLE
DL ADULT NON REAL ID 1881 PIERCE ST LAKEWOOD . CO 80214-1249 3 DOB 4a Iss
04/24/1976 08/27/2015
4d Customer Identifier 4b Exp 15-239-1250 DD
12345678917
16 Sex M
18 Eyes PNK
19 Hair UNK
04/24/2018
Previous Type A
16 Hgt 5‘-4"
17 Wgt 201 lb
F "4/24/^1^
9a Endorsements
12 Restrictions NONE
9 Vehicle Classifications R

Reprinted from Colorado Department of Revenue, Division of Motor Vehicles, Card Images, 2019. [PDF], Retrieved from
https://www.colorado.gov/pacific/sites/default/files/251CardImages.pdf.
Several participants described feeling uneasy and embarrassed about having to provide their driver’s license at time of check in at a medical appointment. Adeline describes how she feels when she is asked to present her driver’s license and or social security card4 at medical appointments:
I definitely feel nervous when the social starts with different [number] 8, either like they [health care staff] are wondering why it starts with an 8 or why my ID, when they see my ID or they're checking it. I feel like they're like, "Hey, can I check your ID to check you
4 Once an approval of Deferred Action for Childhood Arrivals and an application to work in the United States is approved, DACA recipients may be eligible for a Social Security number.


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in?" It has no federal use or no federal benefits, and I've had people question that and then they start thinking, "Who are you? Where are you coming from?" They're like, "Oh, I've never seen that. What kind of card is this?"
Adeline identified that her driver’s license and social security card were labels of her
undocumented status and that before she was insured her willingness to seek out health care was
affected because she was afraid and embarrassed and didn’t feel safe to share these items with
health care staff. Like Adeline, Layla identifies also experiencing scrutiny by reception staff in
health care settings:
I've been afraid to give somebody my ID because it has a black line across it, and so, yeah, I get questions asked about that all the time.. .when I check in at the clinic... Sometimes the receptionist can be so loud and they ask me about these things in front of the whole office.
At the health systems level, the driver’s license alone operates as a form of stigma. It contributes
to status loss by means of labeling undocumented people as less human and reliable, possibly
discouraging undocumented immigrant young adults from seeking health care.
Furthermore, participants pointed to bureaucratic medical paperwork as another health
systems barrier to care. Most new patient intake forms require people to complete patient data,
including current address, phone number, occupation, social security number, and payment
information. Such forms are necessary in health care to help with the initial evaluation of the
patient profile, analyzing treatment results, and for planning treatment protocols (Thomas, 2009).
Nonetheless, for the undocumented community, these documents can be another form of
unintentional stigma. As an undocumented person, K.S.G. recalled feeling nervous when she was
asked to complete paperwork at the medical office:
When I went to see a health care provider and I was asked to provide my social security number. I got uncomfortable, because when I was filling my insurance paperwork.. .and I was asked to give my social security number, I was just like ... I would say, my tone changed because I was like, "I don't have one." It's just really uncomfortable.. .and at the time it is one reason why I am not seeing a doctor right now.


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Being that this was the first time K.S.G. had to complete such paperwork for herself, her experience with having to provide such detailed information made her feel apprehensive and scared. This particular situation occurred when K.S.G. was 18; she had scheduled a doctor’s appointment for her achy knee. Although insured through her school’s health insurance program, the overall experience led K.S.G. to avoid seeking out formal medical care for almost three and half years in her young adult life.
Unlike K.S.G., Claudia and her family effectively try to avoid delaying medical care; however, for her and her family this means making tough decisions about what information to disclose on medical intake forms and how to report the information. Specifically, Claudia spoke about the importance of seeking out health care services in a timely manner, but because of her mother’s status and cost of services, she indicated that her mother has work-around solutions to such forms:
As an undocumented person she [Claudia’s mother] is very afraid when she fills out these forms. She uses her middle name on the forms most of the time and then it switches to her first name other times. She switches things because she has all these hospital bills and all these medical bills that she owes. She's really, really afraid that her name is out there, and no social security number at all that's designated with her name.
Although Claudia indicated that she has never put the wrong birthday or a made-up social
security number on a medical form because of fear and the possibility of not being considered for
an amnesty program, she said she does “worry about whether they [bill collectors] will come
after” her for the payment of her family’s unpaid medical bills now that she is “old enough.”
Claudia specified that she is very scared that her mom will get in trouble and possibly deported
because of her decisions to alter such paperwork. As a result, Claudia said she only goes to the
doctor when she can afford to pay for it in full.


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Out of the 12 participants that I interviewed, all were clear about the role structural level stigma plays in their health-seeking behaviors. Yet, the participants also made it clear that there are additional reasons beyond laws and policies that dissuade them from accessing and utilizing formal health care.
The Role of Undocumented Status and Other Social Positions in Shaping Health Care Access and Utilization
Life-course scholarship focuses on individual development as being a life-long process. At every stage of the life course,5 events mark shifts and trajectories of new roles. Colorado, like many other states, has determined that individuals are to be treated as adults at the age of 18, with some exclusions, such as drinking and purchasing alcohol, renting cars, and paying for hotel rooms (Colorado Judicial Branch, n.d.). Additionally, Colorado state law specifies that “the age of competence in regard to a minor’s body and the body of his issue, is 18 years or older” (Conway, 2017). Essentially, this law refers to medical consent to care. In Colorado, unless a minor aged 15 or older is emancipated and living apart from their parents and managing their own financial affairs, or is legally married, or has children of their own, most of the time6, parental consent is required for medical treatment until the age of 18 (Conway, 2017).
Addressing medical consent is important for this particular study because up until the age of 18, the respondents in this study experienced the health care system through the lens of their parents’ immigration status, low SES, and cultural beliefs about health and illness, and were at the will of their parents’ decisions about health care access and utilization. I contend that the participants in
5 The stages of the life course are most commonly categorized as childhood, adolescence, adulthood, and old age (Greene, Wheatley, & Aldava, 1992).
6 In Colorado, many laws allow a minor to consent to medical treatment that address medical situations in which a minor may be less likely to seek treatment if parental consent were required (i.e., reproductive health, pregnancy, sexually transmitted infections, drag use, and mental health services) (Conway, 2017).


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this study started to feel their own immigration status, cultural beliefs about health and illness, and low SES as individual barriers to health care access and utilization once they turned 18, and tried, or needed to, seek out their own health care. Additionally, since undocumented immigrant children and adolescents are afforded many of the same benefits as their U.S. bom and legal counterparts, such as access to K-12 education and school-based health clinics and medical vouchers, they are unprepared to transition into the adult health care system at the age of 18. Systems such as school-based health clinics, school nurses, sports programs, and health care vouchers, substitute as forms of safety-net care for undocumented immigrant children and adolescents. Conversely, once young undocumented people graduate out of these systems they are left to navigate the adult health care system on their own without the supplementary opportunities of health care access and coverage afforded to their U.S. born and legal counterparts.
Social and cultural factors can influence health beliefs and health-seeking behaviors (Kreuter & McClure, 2004; Thomas, Fine, & Ibrahim, 2004). In particularly for Hispanics/Latinos, cultural influences such as male dominance, female modesty, and the practice of keeping problems within the family can lead to health risks (Galanti, 2003; Caballero, 2011). For traditional Hispanics/Latinos, loyalty to the extended family is more important than the needs of the individual, a concept known as familismo (Galanti, 2003; Caballero, 2011). For this study, cultural beliefs about health and illness, parents’ socioeconomic status, and parents’ immigration status contributed to the overall health and health-seeking behaviors of the participants as children and adolescents. As Layla explains, being undocumented, not having money, and trying to handle things within the family, can lead to future health consequences:
The scariest part and I still have pain from it, physical pain from it today, is when I broke
my collarbone in high school playing volleyball. We didn't have health insurance and my


44
parents are undocumented... I remember that night I was crying and begging them [parents], "Please you have to take me to the hospital.” They were like, "No, we can't. We can't. We don't have health insurance. We don't have money." I'm like, "Oh my god, oh my god, oh my god." They took me to this lady's house. She's a chiropractor. She was like, "Here, let me touch it." She was like, "Oh I can't really feel ...." Then she tried to put it back into place. It was the most insane pain ever. That's when she told my parents, "Okay, this is going to be the cheapest way to get this taken care of. You have to go to this place and get x-rays. Take the x-rays and then go to the hospital. That way you don't get charged for the x-rays at the hospital." They took me to this place. The x-rays were $60.00 and I took the x-rays and they definitely showed that my collarbone was broken ... I was so angry at my parents for this. They finally took me to Children’s Hospital and the bill came to $10,000.00 for a sling and some Vicodin. They are still paying on it and the bill collectors call all the time.
Breaking her collarbone and having to beg her parents to take her to the hospital was a traumatic experience for Layla. In fact, Layla highlighted that this particular experience caused a rift in her relationship with her parents for about two years. Layla recalled as a child being told that because of “culture,” her parents immigration status, and the family’s financial situation, that if there was nothing “really wrong,” then there was no need to seek out health care services. She indicated that when she broke her collarbone that her parents waited to take her to the hospital first and foremost because of expense, then because of their immigration status, but also because they believed her injury would “heal on its own” and “probably was not a big deal.” Like Layla, Alex’s parents’ immigration status, health beliefs, and financial situation played a role in his health-seeking behaviors as a child and adolescent. Alex described that “if there was ever anything wrong health wise” as a child, his family chose to take him to a Curandero7 because “they practiced better care and they are not expensive.” Alex said he had never been to a “real doctor” as a child except for when he broke his arm and “they had to go.” He indicated that he was taught that you didn’t “need to seek out professional care unless something is really wrong because it costs too much.” Alex also talked about his parents’ immigration status as being a
7 a traditional native healer or shaman


45
deterrent from seeking out formal health care as a child because “of the paperwork and they don’t have socials” and because he would be the one who would “have to deal with talking to adults and then being worried about translating right.”
Some participants highlighted the value of the health-seeking behaviors that they were taught by their family. Yasmin, a former pre-med student, specified that when she gets sick, she consults with her family first because family resources and referrals are more trustworthy and affordable:
So I got bacterial pneumonia like almost two years ago, and obviously I didn't have healthcare insurance back then but my mom contacted my aunts in Mexico and my aunts were like, I'm really good friends with my doctor here, I'm gonna ask them. They asked them, and then they contacted my mom and they're like she needs to take this type of medication, antibiotics.. .It's funny 'cause I didn't even need a doctor but like, I was already diagnosed [by] the third person. So my mom went to our secret Hispanic pharmacy on Colfax for medication that's been imported from Mexico. I got my antibiotics for way cheaper, and like in three days I was fine.
Yasmin indicated that her aunts’ connections to doctors in Mexico and also knowing about the
“Hispanic pharmacy”8 9 have been forms of “life-savers” for her because “doctors in Mexico are
more reliable and can refer you to the right medication” and “the Hispanic pharmacy has cheaper
medication and you don’t need a prescription” and the people at the pharmacy understand her
“culture more.” Although Yasmin highlighted family connections and knowing where to buy
“cheap” medication as assets that shape her health-seeking behaviors, such practices may be a
result of low health literacy and can lead to poor health outcomes and increased rates of
hospitalization and less recurrent use of preventative services (Berkman, Sheridan, Donahue,
Halpern, & Crotty, 2011). 8 9
8 It should be noted that buying antibiotics without a doctor’s prescription in Mexico is a “cultural norm.”
9 In Denver and in Aurora there have been news reports of local grocery stores that serve the Hispanic/Latino community selling antibiotics that should be dispensed by a licensed pharmacist. Some of these pills can be purchased for as little as 90 cents each (Denver CBS4, 2016).


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In addition to cultural and parental influence, the participants’ health-seeking behaviors
as children and adolescents were influenced by the availability of school-based safety-net
systems. Many of the participants described ease of access to preventative care services as
children because of their welcome participation in the K-12 education system. Monroe, a college
graduate, explains that the last time she went to the dentist was when she was in middle school:
Oh my gosh, I haven’t been to the dentist in years because the last time I ever went was when I got my root canal and I was actually getting help through, was it my middle school or high school, I don't know. I think it was my middle school or high school, they would give me a voucher for me to be able to go and get that help and ever since I got out of school, I don't get that help anymore. So it's been a bunch of years that I've been to the dentist... Sometimes my root canal bothers me a little bit when I chew on that side but I don’t know where to go get help.
Monroe said she understood the severity of putting off dental work, but because she was not
aware of where to go to get treatment, and because her “teeth really don’t bother [her] all the
time,” she indicated she would “wait it [the pain] out.” Monroe also acknowledged that the last
time she received standard immunizations like the flu shot was in middle school:
I actually got those through the school most of the time. Elementary and middle school -they really cared about getting our shots, which that's the only reason why I had access to do that. It was like a mandatory thing to be able to go into school and to stay in school so you had to go get these immunizations.
Many of the female participants also described that they were able to learn about and
receive contraception through voucher programs or school-based clinics. Bernadette spoke about
who and where she would go as an adolescent for reproductive health information:
Well, for the longest time, I didn't have [health] insurance, so I didn't know where to go and I didn’t have any resources. So mainly when I was in high school, I turned to Denver Health Clinic for birth control, and just kind of working with those people from Denver Health. They had a clinic school based at my school, so that was the only place that I knew where to go to get my birth control.
Likewise, Ana recalled being able to get birth control from her school-based health clinic to treat her polycystic ovarian syndrome:


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A recurring problem that I had in high school was that I wasn't getting my period regularly and so my mom was really worried and I was really worried. So, I went to the school-based clinic and they diagnosed me with something called, polycystic ovarian syndrome, which I still have, but it's better now. I think that the main concern at the time was that I had to take birth control... so that I could get my period regularly. The biggest concern was that I needed to have access to it and the school-based doctor was able to help and I continued to get birth control there until I graduated.
Having access to preventative care services such as health screenings, immunizations,
and reproductive health services via school-based health centers and voucher programs is critical
in reducing educational gaps and advancing health equity among the young adult undocumented
immigrant population. Yet, such services are only a stopgap for this population until they turn 18
years of age. Because of their immigration status and formal exclusion from recent health care
reform, undocumented immigrant young adults have a much harder time than their U.S. born and
legal counterparts with the transition from the pediatric health care system to the adult health
care system. Most of the participants in this study stopped important health screenings, wellness
visits, immunizations, and contraception as a result of not knowing where to go and how to
locate providers and services once they graduated from high school.
It is at this point, respectively at the age of 18, when undocumented young adults are
forced to transition into the adult health care system, where there is little to no support for them,
that the respondents’ own undocumented status, socioeconomic status, and cultural beliefs about
health and well-being started to play a role in their health-seeking behaviors. Although 10 out of
the 12 participants were DACAmented (having DACA status), their cultural beliefs about health
and illness, legal exclusion from the health care system, and fears of being “found out”
contributed to their ability to navigate the health care system and their ability to engage in
appropriate self-care and disease management. Elbe, a full-time student with school-based health


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insurance, talked about a serious medical condition that she had been putting off because of cost and her immigration status:
The doctors found some problems the last time I went for a physical for birth control. They found a whole in my heart and... said I needed to get an echo done but that’s expensive and... I mean, just being undocumented, it just limits opportunities for anything so much that sometimes it's just not even worth looking or trying to get help with something like this, because it's not going to work out based on past experiences.
Similarly, Sophia, insured by her employer at the time of the interview, spoke about not using
her health care coverage because her health concerns were not that serious and because she
didn’t know where to go to get care. Furthermore, Sophia had concerns about cost of services
and her immigration status:
I have health insurance through my employer. Do I use it? No. I don’t really have major health issues, and if I did, I don’t know where to go and I don't ask friends for referrals just because they're obviously not in my situation without documentation. The places they will refer me to will cost me an arm and a leg if I go. So I don’t know... .Because of my immigration status wherever I go I’ll be treated differently. Maybe they won't like recommend certain things that would be beneficial for me, just 'cause they know my status and they assume certain things.
Likewise, Itzel identified that the reason she doesn’t seek out health care as often as she knows she should, is because she has to decide what is more important; “do I get my health checked, or pay for rent? Do I go check my health or do I help buy food for my family?” Similar to Itzel, all except one participant described having to pick and choose between accessing health care services and paying for day-to-day needs such as food, transportation, rent, and even college tuition. Notably, dramatic health disparities related to low socioeconomic status exist among poor Americans and legal immigrants in the U.S.; however, public benefit programs exist to help eligible low income individuals cover basic expenses like food, housing, health care, and even tuition and fee costs. Regrettably, under federal law, undocumented immigrants are not eligible


49
to receive public benefits such as Supplemental Nutrition Assistance Program (SNAP),10 regular Medicaid, Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), and federal financial aid for college tuition (Broder, Moussavian, & Blazer, 2015; USA.GOV, 2019). Essentially, the participants’ undocumented status paired with their own socioeconomic status and cultural beliefs about health and illness reinforced their legal exclusion from the health care system, and further contributed to barriers to health care access and utilization.
Less Deserving Health Citizens as a Result of Their Form of Health Care Coverage
The participants who were able to succeed at navigating the structural barriers to care, and their multiple individual barriers to care, including cultural beliefs about health and wellbeing, immigration status, and socioeconomic status, experienced new barriers to care at the health systems level once they obtained health care coverage.
Health economists argue that health insurance is not created equal and that many insured individuals can’t access health care when they need it as a result of limited access to relatively few providers and the terms under which insurance is available (Schansberg, 2014).
Furthermore, anthropologists argue that health care coverage does not necessarily equal better health, but rather it may position certain people as being “less deserving health citizens because of their form of health coverage” (Andaya, 2017, p. 105). Though insured, as undocumented immigrant young adults from low socioeconomic and low health literacy backgrounds, the 10 participants who had health insurance coverage at the time of their interview, came face-to-face with the limits of their health insurance coverage. Adeline compares how she was treated when
10 SNAP was formerly known as the Food Stamp Program.


50
she had student health insurance verses how she was treated as a consumer of the Colorado Bridge Program:
I went to the health center on campus a couple of times, but it was always a little uncomfortable, just because it was more like, "Oh, you really don't have health insurance. You have school insurance. You're just here for that [school]." I think that the one time I went the health center was more for my acne at the time and I got an acne prescription, but I feel like the provider wasn't helpful at all. She didn’t tell me what the medicine does. It was more like, "Well, this is going to help your skin," and I was just like, "Okay." I used it once, I think. On the other hand, now that I have Kaiser through the Bridge Program, I feel like since I started going [there], I was more exposed to what my real health was and how I was supposed to sustain it and better it.
Undoubtedly, Adeline felt more deserving as a patient when she accessed health care services
through the Bridge Program; however, she mentioned being scared about the program’s
unexpected cancellation: “It’s unfair and it is probably because of who is insured... People who
are insured by the program are like me, young and undocumented, so why should they [Kaiser]
care.” Adeline reconciled with her limited access to health care services after the announcement
of the end of the Colorado Bridge Program, and focused instead on how she was going to
schedule more appointments while she still had health care coverage.
Adeline’s positive sentiment over having a “better” source of health care coverage was
not felt by all of the participants. In fact, 8 of the 10 insured respondents felt like the type of
insurance coverage they had limited their access to seeing doctors they wanted, like specialists,
and they also felt like the type of coverage contributed to how they were treated when seeking
health services and to who treated them during their health encounters. Layla recalled being
diagnosed with depression and anxiety by her primary care physician:
Well, the first time I went to the doctor, was because I had already had the Bridge Program, but I wasn’t using it. I wouldn't go to the doctor at all, because I didn't know what to do, or how to get a doctor or whatever the whole process was. Just the process of finding a doctor in my network I guess is overwhelming... It wasn't until I started having panic attacks... and I was just really sad and crying all the time, that I was just like, okay, maybe I should call. I made an appointment, and they were like, oh, you need to be seen


51
by PCP. She [doctor] is nice, but I wasn’t able to get into see her [the doctor] for three weeks and I was told by her I could see a Psychiatrist I think. I want to do that but I haven’t been able to get into see someone cause it takes time, like four weeks before or something, before they can get me in.
Layla was certainly grateful and excited that she was able to see, as she explained, a “real doctor” for the first time as an adult; however, she really wanted to see someone who could help her with her mental health issues. She was overwhelmed by how long she would have to wait to see a specialist and was scared that she wasn’t going to get the help she needed before the Bridge Program ended. Like Layla, others described being appreciative that they had health care coverage and a regular provider, but they also expressed difficulty in understanding their health conditions and treatment options because they didn’t feel their provider cared about them. Claudia emphasized this point by talking about the treatment she received when she went to Kaiser for an issue with her stomach:
Now that I have Kaiser... I try to go to the doctor like every three to four months, just because I'm taking medication for my stomach issues. And this is weird to me because I am not all about the medication just because I am very skeptical, but that is what my doctor said I needed. He also prescribed me antidepressants. I don’t think I need them because I am not sure how my IBS [Irritable Bowel Syndrome] is connected with depression, but he [the doctor] said stress can cause IBS. And so I think the medication has been making me feel okay, but I think it's just covering everything else. I think they just want more money from me. It is frustrating because I don’t think I need all of these pills, but the doctor is the expert, right?...He said I need them [the pills].
Like Layla, Claudia was grateful that she had access to see a doctor regularly, but she was
clearly frustrated by how she was treated by her provider. More specifically, she described her
doctor as being “arrogant” and indicated that she felt that her doctor was just providing “orders,”
and that he never really explained why he put her on anti-depressants. She talked about only
using the “pills” (anti-depressants) when she needs them because she didn’t necessarily know
why she was taking them and additionally, they cost too much.


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Furthermore, other insured respondents conveyed feeling discriminated against simply
because of who was treating them. When I interviewed Sofia, she was insured by the Colorado
Bridge Program. She was upset about all the steps she had to go through to make an
appointment, only to be seen by a physician assistant (PA):
Now that I have Bridge, I decided I needed to see a doctor because I was paying for it. I was frustrated because I didn’t know where to start or how to schedule an appointment... Sometimes these things just get so tedious I wouldn't know what I was selecting and for what, but I'd still wanted to do it [see a doctor]. So then I finally got an appointment scheduled and it wasn’t even with a doctor, it was a PA. I don’t really know the difference, but I thought I was going to see a doctor. She was Middle Eastern, so I think that was okay, but I feel sad about the situation.
In spite of the efforts made by Sofia to figure out how to schedule an appointment and with
whom, she was disappointed with the clinical encounter because she felt like she should have
been treated by a physician or told she was going to see a PA instead of a doctor. She indicated
that she scheduled the appointment with a doctor, and not a PA. Others felt Sofia’s ill sentiment
toward the type of provider they saw as an insured person. Bernadette illustrates this point by
describing the number of times she has had to go to Urgent Care and the Emergency Department
because she hasn’t been able to see her doctor at Kaiser:
I've been with a provider for the past two years, but it is really hard to get in to see her.. .1 usually see her PA or a nurse. I am paying for my insurance and because I don’t feel like I've been seen by the doctor enough.. .1 [go] to the urgent care, I've been to the ER, and it's been covered by my insurance, so that is okay.. .1 have access to a doctor either way. I prefer to see a doctor and not a PA or a nurse.. .because I am paying for it.
Like Bernadette, many of the participants highlighted feeling offended when they arrived at their
appointments only to discover that they were going to be seen by a nurse or a physician assistant
and not a doctor. The truth is, people don’t always need to be seen by a doctor and it can be
difficult to see a doctor in a timely manner. Nevertheless, whatever the motivation was for why
some of the participants saw other providers besides a doctor at their health visits, the


53
consequence for this group was that they did not feel like they were worthy health citizens. Those that were part of the Bridge Program perceived that they were being treated differently than other Kaiser patients because of the type of health coverage that they had; one participant described the Bridge Program as being “charity care” for undocumented immigrants.
Thus on the one hand, the participants recognized the importance of having health care coverage resulting in their ability to access and afford health care. On the other hand, the participants also recognized that they did not experience a sense of health equality during their health encounters as a result of their perceived quality of care and because of who treated them when they sought out health care services via an in-network facility.


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CHAPTER VI
DISCUSSION AND CONCLUSIONS
Previous research on undocumented immigrants and health care access and utilization and health coverage focuses largely on health disparities and barriers to care and the exclusion from health care reform (Zuckerman, Waidmann, & Lawton 2011; Raymond-Flesch et al., 2014; Hacker, Anies, Folb, & Zallman, 2015; Martinez et al., 2015 ). Furthermore, existing studies about access and use of health care services among undocumented immigrants in the U.S. have rarely addressed the health care needs of undocumented immigrant young adults and the challenges they face in not only accessing health care, but also their overall health care experiences (for exceptions, see Vega, Rodriguez, & Gruskin, 2009; Artiga & Ubri, 2017; Sudhinaraset, To, Ling, Melo, & Chavarin, 2017; Philbin, Flake, Hatzenbuehler, & Hirsch,
2018). Yet, the findings presented in this study draw on the experiences of primarily insured undocumented immigrant young adults. Using the case of undocumented immigrant young adults who have private health insurance, I argue that barriers to care and exclusion from health care reform are not simply the result of being an undocumented person and that immigration status as a sole explanation to these issues does not properly reflect the health-seeking behaviors of undocumented immigrant young adults.
In revisiting Andersen’s current Behavioral Model of Health Services Use, this model highlights the multiple influences on health services' use and, consequently, on health status. The feedback loops show that outcomes, in turn, affect subsequent predisposing factors and perceived need for health care services as well as health behavior. Another possible predisposing component which may be conceptually distinct from those listed in the current model is structural stigma. I emphasize how structural stigma, specifically health care related laws and


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policies and driver’s license-related polices, parental social positions, including undocumented status, culture, and socioeconomic status, participant social positions, including undocumented status, culture, and socioeconomic status, and perceived quality of care, intersect over time to shape health-seeking behaviors of undocumented immigrant young adults. I argue that these elements overlap with each other and heighten health system and individual barriers to care and health care utilization amongst this population. An overarching premise of this research is that when considered alongside one another, structural stigma, parental social locations, social locations of the undocumented young adult, and perceived quality of care, predict the healthseeking behaviors of undocumented immigrant young adults. Furthermore, when looked at simultaneously these inhibiting predictors of health-seeking behaviors among undocumented immigrant young adults enable a broad band of social determinants of health and multiple negative health outcomes for this population.
Use of health services by undocumented immigrant young adults is key to their overall health and well-being. As my research suggests, structural level stigma in the form of health care related laws and policies and driver’s license-related polices, plays an important role in producing health disparities amongst the undocumented immigrant young adult population. In particular, federal and state level policies that limit or restrict access to care, notably contribute to the most damaging aspects of barriers undocumented young adults’ experience. Such policies contribute to when and where undocumented immigrants access care. As such, many undocumented immigrant young adults choose to access formal health care as a last resort (Garces, Scarinci, & Harrison, 2006; Raymond-Flesch et al., 2014). Additionally, when undocumented immigrants do access care, it tends to be through safety net options such as the emergency department and safety net clinics (Raymond-Flesch et al., 2014; Sommers, 2013).


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Furthermore, state driver’s license policies, a policy specifically aimed at improving overall public safety, contributes to the stigmatization of undocumented immigrant young adults. The information required to be on a driver’s license of an undocumented immigrant serves as a label of immigration status which can lead to an individual being treated differently prior to and during a health encounter. Such policies can dissuade undocumented immigrant young adults from seeking formal medical attention until they’re seriously ill.
My findings also show that the health-seeking behaviors of undocumented immigrant young adults are further shaped by their health beliefs and their experience within the health care system. First, parental social positions, including undocumented status, culture, and socioeconomic status, influence the health-seeking behaviors of undocumented immigrant young adults at an early age. If parents fear doctor’s visits or signing up for health benefits could leave them and their children susceptible to deportation, it is more likely that they will forgo care not only for themselves, but for their children as well. Thus, the urge to access care is often outweighed by parental immigration status. Undocumented children and adolescents are at the will of their parent’s decisions about health care access and utilization. Furthermore, cost of care contributes to why parents who are undocumented choose to delay or not to take their children to see a doctor. Such behaviors contribute to negative attitudes around the necessity of care. Specifically, undocumented immigrant children are taught that formal health care should be used as a last resort. Unfortunately, delaying care can lead to worse health and more costly care, which means that future care could be more difficult to access due to cost.
At the age of 18, undocumented immigrant young adults experience their own barriers to care as a result of their own social positions. Immigration status, low socioeconomic status, and cultural beliefs about health and illness reinforce their legal exclusion from the health care


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system, and further contribute to system and individual barriers to health care access and utilization. Undocumented immigrant young adults have to navigate an increasingly more complex health care environment without the support systems afforded to their U.S. born and legal counterparts. As a result, many undocumented immigrant young adults lack the ability to navigate the health care system, including knowing how to complete complex health care paperwork and locating providers and services. Additionally, because of their low socioeconomic status, undocumented immigrant young adults are less likely to be able to afford preventative care services and engage in appropriate self-care and disease management. Such behaviors can have long-term effects on health.
Finally, even after undocumented immigrant young adults obtain health care coverage, their health-seeking behaviors are further influenced as a result of new barriers to care at the health systems level. Although being included in the health care system can provide a sense of security and comfort, it can also lead to further health inequalities. The types of health care coverage available to undocumented immigrant young adults can contribute to negative health care experiences. There has been recent scholarly inquiry into the Medicaid expansion and whether it positions people “as less deserving health citizens because of their form of health coverage” (Andaya, 2017). As I demonstrate, experiences of health inequality for the undocumented immigrant young adult population are the consequences of how one is treated and by whom during the health care encounter. For insured undocumented immigrant young adults, their quasi-inclusion in the health care system, and perceived negative health care experiences, ultimately shapes their sense of self as less deserving health citizens. Furthermore, as highlighted, the fact that health care coverage can be taken away at any time undermines the


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extent to which undocumented immigrant young adults can experience equality in the health care system.
In order to better understand that the health and well-being of undocumented immigrant young adults cannot be disconnected from the political and social environment, the general public, health care professionals, and policymakers will need to develop an understanding of the complexity of federal eligibility provisions and states’ choices in extending or further restricting health care coverage for undocumented immigrants. Furthermore, our current political environment around immigration has created a sense of constant hypervigilance and fear amongst the undocumented immigrant population in our country. Persistent structural and social stigma take a toll on the mental and physical health of undocumented immigrants and their loved ones, in turn increasing their risk of poor health and diminished access and utilization of health care.
Core values of public health include promoting health care equity, quality and accessibility, valuing every life, and preventing harm (CDC Foundation, 2019). Regardless of political and social positions on immigration, the reality that undocumented immigrant young adults have significant unmet health needs, and the sheer number of undocumented immigrants between the ages of 18-39 living in the U.S., indicates that it is imperative to understand and address barriers to health care utilization for this group because the impact goes beyond the individual and local community. Unequal access to care and unequal care during the health encounter harms undocumented immigrant patients, their families, the health care providers who treat them, and the entire country. Limited access to health services, and lower health care utilization among undocumented immigrants because of health beliefs, low SES, and fear of


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being stopped by police and potential deportation, infiltrates society as a whole and it becomes a matter of public health.


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CHAPTER VII
LIMITATIONS AND FURTHER RESEARCH
There are important gaps and knowledge about the health-seeking behaviors of undocumented immigrant young adults. In this section I will highlight limitations of my own research and areas to guide future research on this topic.
Study Limitations
Although my research methodology attempted to conduct a broad review of healthseeking behaviors of undocumented immigrant young adults in the Denver metropolitan area, limitations remain. While undocumented immigrants from Mexico and Central America contribute to the largest numbers of the undocumented population in the U.S., due to new migration patterns, the number of undocumented immigrants from the Caribbean, South America, Asia, Eastern Europe, and Africa has increased (Migration Policy Institute; 2019). Trends in health-seeking behaviors for undocumented immigrant young adults from these regions is not reflected in this study (see for example Gonzales & Burciaga, 2018). The authors point out that certain ethnic communities feel a sense of stigma and shame as a result of their undocumented status, making it much harder to recruit and interview people from certain regions of national origin (Gonzales & Burciaga, 2018).
Furthermore, a possible methodological limitation exists with the sample size. Although sampling saturation was met for this study, for publication purposes, it would be ideal to have a larger sample size and perhaps a comparative sample. For example, adding a comparison sample of undocumented young adult males and females, or U.S. born and legal counterparts could add to the context of the research problem. It should be noted that because of fear of arrest, deportation, or exclusion from qualification for amnesty if it becomes available, undocumented


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immigrants in general avoid talking about their immigration status, making it harder to understand their specific health care access and utilization experiences.
Also, despite the fact that males represent more than half (53%) of the undocumented immigrant population in the U.S. (Migration Policy Institute; 2019), many feel vulnerable about sharing their story. For this study, it should be noted that men in general are less likely to speak about their health and participate in risk mitigating behaviors (see for example Courtenay, 2000). Because only one of the study participants identified as male, I cannot speak confidently about the undocumented immigrant young adult male narrative regarding health-seeking behaviors.
Furthermore, because the study is based on self-reported data it is limited by the fact that it cannot be independently verified. The data may contain several potential sources of bias including: (1) selective memory bias; (2) telescoping bias (recalling events that occurred at one time as if they occurred at another time; (3) attribution bias (attributing positive events and outcomes to one's own agency, but attributing negative events and outcomes to external forces); and, (4) exaggeration. Such limitations can serve as an important opportunity to identify new gaps in the literature and to describe the need for further research.
Recommendations for Further Research
It is suggested that future research on health-seeking behaviors of undocumented young adults include a more diverse narrative around gender, region of birth, and geographic location.
Gender is a crucial factor that impacts health and well-being. Gender perspectives are important in contemporary immigration research on health care access and utilization because gender socialization among undocumented Hispanic/Latino immigrants may play a role in the willingness to seek out and utilize health care (Nunez et al., 2016). For undocumented immigrant Hispanic/Latino males, the concept of machismo defines beliefs and expectations around the role


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of men in society. Nunez et al., describe machismo as “positive and negative aspects of masculinity, including bravery, honor, dominance, aggression, sexism, sexual prowess, and reserved emotions...” (Nunez et al., p. 3, 2016). For undocumented immigrant Hi spanic/Latino females the concept of marianismo, defines the values and expectations regarding female gender roles. Marianismo stresses the role of women as family- and home-centered; it influences passivity, selflessness, and modesty (Nunez et al., 2016). The association between the construct of machismo and marianismo and health-seeking behaviors of undocumented Hispanic/Latino males and females remains unclear. Nunez et al. identify that most of the existing literature on male gender roles in general has been attained from college students and non-Hispanic White male and female populations, and has not always reflected cultural aspects of gender roles (Nunez et al., 2016). Thus future research should draw on the differences and similarities of health-seeking behaviors among male and female undocumented immigrant young adults.
Most research on undocumented immigrants and health in the U.S. has focused primarily on Hispanic/Latino immigrants, especially those from Mexico. We know that immigrants in general tend to have better health and mortality profiles than their native bom counterparts, especially from the same racial/ethnic group (Markides & Rote, 2015). However, more data are required to systematically examine whether the relationship between health-seeking behaviors and structural stigma, undocumented status, culture, and SES, operates similarly or differently among undocumented immigrants from different nationalities. Due to new migration patterns in the U.S., it is important to conduct future research on the health and health-seeking behaviors of undocumented immigrants from the Caribbean, South America, Asia, Eastern Europe, and Africa. Disaggregating results by nativity will allow researchers to determine whether certain undocumented groups are disproportionately affected by structural stigma and their social


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locations, including undocumented status, culture, and SES. Assessing nativity and healthseeking behaviors among undocumented immigrants in the U.S. is particularly important because undocumented immigrants from certain underserved sub-groups (i.e., those who speak fair/poor English, low education levels, those who are experiencing acculturative stress) are more likely to experience negative health outcomes.
Place and neighborhood context and health are inherently linked. In order to encompass the full breadth of health-seeking behaviors of undocumented immigrant young adults, it is important to replicate this research in rural communities and furthermore, in states that have restrictive laws directed at undocumented immigrants.
According to the 2010 Decennial Census, almost 60 million people, about 19 percent of the population, lived in rural areas of the U.S. (United States Census Bureau, n.d.). Health disparities research has emphasized that people who live in rural communities are at risk for poorer health compared to urban and suburban residents (Warshaw, 2017; Centers for Disease Control and Prevention, 2017). Furthermore, people who live in rural communities often encounter barriers to health care that limit their ability to obtain the care they need (Rural Health Information Hub, 2019). Future research should examine whether the health-seeking behaviors of undocumented immigrant young adults are similar or different in rural vs. urban locales.
As mentioned in the literature review, much of what we know about the health care needs and barriers to care for undocumented immigrants, is based on research conducted in immigrant-friendly states (states that have laws that make it easier for undocumented immigrants to access jobs, higher education, health care, and driver licenses). There is a growing body of research on state-level differences in migration control and their effects on US migration patterns (Leerkes, Leach, & Bachmeier, 2012; Ellis, Wright, & Townley, 2016). Such research suggests that state-


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level and local-level hostile immigration policies arose mostly after 2007 and are disproportionately found in places where the rates of foreign-bom population growth are high, but also where they are mostly Hispanic/Latino (Leerkes, Leach, & Bachmeier, 2012; Ellis, Wright, & Townley, 2016). Adapting earlier research on Latino migration by Leerkes, Leach, and Bachmeier, Ellis, Wright and Townley’s research classifies states into two groups: "hostile states," which have enacted laws that are restrictive in some way (i.e., Ariz., Ark., Colo., Conn., Fla., Ga., Md., Miss., Mo., N.C., Nev., Okla., Ore., S.C., Tenn., Texas, Utah, and Va.) and all others, which the authors refer to as "non-hostile states" (Ellis, Wright, & Townley, 2016). State-level and local-level statutes around immigration enforcement have intended and unintended health consequences for undocumented immigrants. Future work should therefore examine whether there is a difference in health-seeking behaviors amongst undocumented immigrant young adults living in “hostile-states” verses “non-hostile states.” Additionally, more work is needed on the health-seeking behaviors of undocumented immigrant young adults who live in a sanctuary city (a city where city level laws tend to protect undocumented immigrants from deportation or prosecution, despite federal immigration law) located in an exclusionary or “hostile” state.
Finally, more work is needed in the areas of policy and public health programming. Future investigation should examine how educational programming around health and health care access might improve the health of undocumented immigrants and lessen health disparities. For example, culturally sensitive health literacy interventions could be developed for undocumented children, adolescents, young adults and their families. Additionally, a comprehensive website dedicated to information about health, health care access, and health care resources, could be developed for local communities and states. To make informed choices,


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people need accessible and accurate information. Thus, the accessibility of information about health and health care resources is important in ensuring undocumented immigrants can make choices about their health and can do so in an informed way.
Furthermore, in order to improve health care services and access to care for undocumented immigrants, more research is needed around how health care services are coordinated and when, where, and by whom patients are referred. Patient navigation is an internationally utilized, culturally grounded, and multi-layered strategy that is used to enhance patients’ collaboration with the health care team and system in order to help decrease existing health care disparities (Natale-Pereira, Enard, Nevarez, & Jones, 2011). Patient navigators were first used at a public hospital in Harlem, New York in the early 90’s as health care advocates for poor black women who were diagnosed with breast cancer (Freeman, 2012). Patient navigation has evolved into an effective approach to help improve health outcomes amongst vulnerable populations (economically disadvantaged, racial and ethnic minorities, the uninsured and underinsured, low-income children, the elderly, the homeless, and those with HIV, other chronic health conditions, and or severe mental illness), by reducing barriers to timely diagnosis and treatment of cancer, chronic diseases, and infectious diseases (Natale-Pereira, Enard, Nevarez, & Jones, 2011; Freeman, 2012). For undocumented immigrants, a patient navigator could help with care coordination, they could provide general health literacy information (educational pamphlets, resources, etc.), and they could provide information about appropriate health care screenings by age and gender. At a minimum, a patient navigator could develop and provide health information about risks associated to behavior (smoking, unsafe sex, etc.) in multiple languages.


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A QUALITATIVE STUDY OF THE HEALTH SEEKING BEHAVIORS OF UNDOCUMENTED IMMIGRANT YOUNG ADULTS by TRISHIA J. VASQUEZ B.S., Colorado State University Pueblo, 2000 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 Social Science Social Science Program 20 19

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ii © 2019 TRISHIA J. VASQUEZ ALL RIGHTS RESERVED

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iii This thesis for the Master of Social Science degree by Trishia J. Vasquez h as been approved for the Social Science Program b y Edelina M. Burciaga , Chair Omar Swartz Adam M. Lippert Sarah B. Horton Deborah S.K. Thomas Date: May 18, 2019

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iv Vasquez , Trishia J. ( M.S . S. , Social Science Program ) A Q uali tative Study of the Health Seeking Behaviors of Undocumented Immigrant Young Adults Thesis directed by Assistant Professor Edelina M. Burciaga ABSTRACT E xisting literature o n the health and health care access of undocumented immigrants in the United States has provided essential insight into how immigration status operates to erode the health of undocumented people at a fa ster pace than their documented counterparts. At the same time, research formal health care systems remains scarce. The purpose of this qualitative study is to explore how undocumented immigration status influences the h ealth seeking behaviors of undocumented immigrant young adults (ages 18 25) in a metropolitan area of Colorado . Federal health care policies and unfavor able state health care policies ( also known as structural stigma, or restraining societal level conditions and policies ) contribute to disparities in health care access and quality of care for undocumented immigrants . Yet little is understood about how anti immigrant sentiment and health policy status quo at the federal, state , and lo cal level s impact the day to day health seeking behaviors of undocumented young adults . Drawing on qualitative data collected from in depth, in person, semi structured interviews with undocumented immigrant young adults in an urban locale of Colorado , this study examines why undocumented immigrant young adults may or may not seek formal health care, and it expose s how health care policies at the f ederal, state, and local levels contribute to issues of health inequality among undocumented immigrant young adu lts and position them as less deserving health citizens. The evidence presented suggests that immigrant focused policies are relevant to understanding the health seeking behaviors of

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v undocumented immigrant young adults and therefore deserve the attention of immigration scholars interested in comprehending and ultimately reducing health inequalities among th e undocumented immigrant population in the U nited States. The form and content of this abstract are approved. I recommend its publication. Approved: Edelina M. Burciaga

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vi TABLE OF CONTENTS CHAPTER I. .......1 II. BACKGROUND III. LITERATURE REVIEW .. 12 The Role of Immigration Status and the Health Care Experience Health and Well Being of Young Adults . 15 Health and well being of Latin o young adults Health Seeking Behaviors of Undoc Behavioral Model of Health Services Use Structural Stigma and Health of Undocumented Immigrants Health ... ... 27 IV . METHODS AND DATA Interview and Analy sis 29 Sample: Description of Participants V. FINDINGS Structural Level Stigma as a Contributing Factor to Health Outcomes The Role of Undocumented Status and Other Social Positions in Shaping Hea lth Care Access and Utilization Less Deserving Health Citizens as a Result of Their Form of Health Care Coverage .. 49 V I . DISCUSSION AND CONCLUSIONS ...54 VII. LIMITATIONS AND FURTH Study ... 60 61

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vii ..66

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viii LIST OF TABLES TABLE 1. Demographic characteristics of the .. 32 2. Factors that influence the utilization of health facilities

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ix LIST OF FIGURES FIGURE 1. Figure 1. Phase 5: A Behavioral Model of Health Services Use Including Contextual and Individual Characteristic 2. Figure 2. Image of a Colorado Driver's License for those individuals who either cannot demonstrate lawful presence in the U.S. or can only demonstrate temporary lawful presence in the 9

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CHAPTER I INTRODUCTION Few issues in the United States today are more controversial than immigration. The 2016 U.S. presidential election , and significant actions on immigration taken by the Trump A dministration, have further polarized the issue of immigration in the U.S. in political and public debates at both the state and federal levels. The Pew Res earch Center estimated that the undocumented immigrant population in the United States in 2016 was 10.7 million, down from a high of 12.2 million in 2007 (Passel & Cohn, 2 018 ). This group includes all foreign born non citizens who enter the U.S. w ithout legal permission and valid documents , including individuals who overstay their legal immigrant visas . Some undocumented immigrants can obta status in the U.S. by attaining work authorization by means of applying for an adjus tment to lawful permanent status (Department of Homeland Security, 2019a) , by being granted T emporary Protected Status ( legal status to immigrants from countries that have suffered natural disasters, prolonged unrest, or conflict ) (Department of Homeland Security, 2019 b ) , or by being a recipient of Deferred Action for Childhood Arrivals (DACA). Passel and Co hn estimate that the three quasi group s account for as much as about 10% of the undocumented population in the U.S. (Passel & Cohn, 2018). Altho ugh t he number of unauthorized immigrants in the U.S. fell to its lowest level in more than a decade , s tudies have shown that the age distributio n of the undocumented immigrant population in the U.S. is considerably different from that of the legal immigrant or U.S. born population , and is reflective of a younger working age population (Passel & Cohn, 2009). Specifically, in the U.S . , the undocumen ted immigrant population consists of smaller shares of children and small er shares of the elderly, and a much higher percentage of people between ages18 39 (Pass el & Cohn, 2009; Migration Policy

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2 Institute, 2019 ). The age composition of the undocumented imm igrant population in the U.S. is critical to this research because studies have identified that age is the sole individual level demographic characteristic that impacts health most signi ficantly (Cagney, 2006 ; Marshall, 2011 ). Undocumented young adults, in particular, come of age in a society full of uncertainty and distress, which may lead to a number of negative emotional and behavioral outcomes causing health concerns for this population. Immigration research related to heal th care access and utilization and the general health of undocumented immigrants largely provides snapshots of drivers of health disparities and barriers to care, including lower rates of health insurance, less utilization of health care services, and lowe r quality of care than U.S. born populations. Due to challenges to conducting large scale studies on the health status and health care access among the undocumented immigrant population, researchers know little about the health and well being of undocument ed immigrants in the U.S. Furthermore, existing studies about access and use of health care services among undocumented immigrants in the U.S. have rarely addressed the he alth care needs of undocumented immigrant young adults and the challenges they face i n not only accessing care , but also their health care experiences when utilizing health care services (for exceptions, see Vega, Rodriguez, & Gruskin, 2009; Artiga & Ubri , 2017; Sudhinaraset, To, Ling, Melo, & Chavarin, 2017 ; Philbin, Flake, Hatzenbuehler , & Hirsch, 2018). Young adulthood (roughly spanning the ages of 18 26 ) is a distinct and important period in the life course . During young adulthood, the choices people make around education, employment, and relationships have consequential and long last ing implications for economic security, health, and well being . In addition, young adulthood is a life course stage where health and health behaviors undergo major changes. Harris, Gordon Larsen , Chantala, & Udry , have

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3 identified that a cross all sex and race/ethnic groups, there are significant increases in health risk and health disparities from adolescence into young adulthood ( Harris, Gordon Larsen, Chantala, & Udry, 2006 ). Specifica lly, they found that there are noteworthy increases in health risk during transition from adolescence to adulthood, including an increase in the percentage of young adults who get no exercise, rep ort asthma, report a decline in breakfast consumption, are obese, need but cannot afford medical care, use cigar ettes and marijuana, had any sexually transmitted disease s ( STDs ), and reported binge drinking ( Harris et al. , 2006 ) . In an era of increased legislation related to immigration at the federal, state, and local level s , and the fact that young adults make up the largest portion of the undocumented immigrant population in the U.S., it is critical for researchers to understand how undocumented immigrant young adults access and use health care services and how they experience health care in a st ate like Colorado where state and local level health care policies stimulate negative attitudes and beliefs toward undocumented immigrants and exclude them from Medicaid and am (House Bill 06S 1023, 2006). This research advances the discussion regarding undocumented immigrants' vulnerab ility to inadequate health care in the U.S . Drawing from 12 semi structured in depth interview s, I examine the relat ionship between structural stigma , specifically policies and laws that stimulate stigma processes by intentionally restricting the health care access of undocumented immigrants, and the health seeking behaviors of undocumented immigrant young adults in a metropolitan area of Colorado . This research level immigrant focused health care policies around public (Medicaid and CHP+ ) and private (school mandated insurance plans and Kaiser Permanente Colorado Bridge Program ) insurance programs and national immigration policies that affect the health -

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4 seeking behaviors of undocumented immigrant young adults, with a focus on their : (1) Perceived health status ; (2) Access and utilization of health care services ; and (3) Health experiences . In this thesis, I explore how national and state level immigrant focused health care policies, immigration status, socioeconomic status, and health citizenship converge at the stage of young adulthood to shape disparities in health and to create barriers to health care access and utilization at the system and individual levels for undocumented immigrant young adults . I show that structural stigma produces health inequalities among undocumented immigrant young adults, and that immigration status is importan t for understanding the health seeking behaviors among this group during different developmental stages of the life course, specifically adolescence and young adulthood. Equally important, I show that health care coverage does not necessarily equate to a s ense of health equality among this population. This study contributes to the broader literature on health care access and utilization patterns among the undocumented population by examining when and how immigration stat us plays a role in factors that impact health seeking behaviors of undocumented young adults in a metropolitan area of Colorado.

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5 CHAPTER II BACKGROUND Although the Patient Protection and Affordable Care Act (ACA) of 2010 was responsible for the e xpansion of health care coverage for a large number of eligible uninsured individuals living in the U.S., including naturalized citizens and lawfully present immigrants , undocumented immigrants remain ineligible for assistance , although they are disproportionately poor, non w hite, and non English speaking. T he ACA explicitly excludes undocumented immigrants from purchasing health insurance coverage through the Health Insurance Marketplace and it excludes undocumented immigrants from benefiting fro m any Medicaid expansions carried out by the states ( Patient Prot ection and Affordable Care Act, 2010) . Essentially, undocumented immigrants are not eligible for federal health care coverage, including Medicare , n onemergency Medicaid, or lth Insurance Program ( CHIP ) (ACA , 2010 ) . However, while federal law generally bars undocumented immigrants from being covered by Medicaid , s tates set individual eligibility criteria within federal minimum standards and federal funding limitations ( ACA, 2010). For instance, s tates like New York and California consider DACA recipients to be eligible to sign up for low cost health care options like state funded Medi Cal in California (California Department of Health Care Services, 2019 ) and Medicaid in New York . I n New York specifically, DACA recipients are consider ed to be Permanently Residing Under Color of Law (PRUCOL) and t heir Medicaid access is paid f or exclusively by the s tate of New York (New York City Health Insurance Link, 2019 ). In the state of Colorado , undocumented immigrants, including DACA recipients , are not eligible to enroll in Health First Colorado (Colorado's Medica health insurance program for low income people, or the Child Health Plan Plus ( CHP+ ) , nor a re

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6 they eligible to buy health insurance through Insurance Marketplace ( Colorado Department of Health Care Policy and Financing, 2019 a; Colorado Department of Health Care Policy and Financing, 201 9 b; Johnson, 2017). A 2016 study by the Pew Research Center estimated that 190,000 undocumented immigrants comprised 34 percent of the immigrant population in Colorado, and 3.4 percent of the total state population in 2016 (Pew Research Center, 2019). In 2015, there we re an estimated 104,201 uninsured undocumented adult (ages 19 64) immigrants in Colorado, accounting for one in four uninsured Coloradans overall (Johnson, 2017). I n extraordinary circumstances, low income undocumented immigrants living in Colorado may qualify for Emergency Medicaid which covers labor , deliveries, and acute care, but does not provide follow up or long term care that may be needed after a health emergency . In addition to E mergency Medicaid, other sources of health care available to un documented immigrants in Colorado include services from Federally Q ualified Health Centers (FQHCs), which use a sliding scale fee and cannot turn someone away because of the ir immigration status or income, and emergency room care as per the Federal Emergen cy Medical Treatmen t and Active Labor Act (EMTALA) (Zibulewsky, 2001). Under EMTALA, hospitals are required to stabilize and treat individuals, regardless of their insurance status, ability to pay, or immigration status (Bu rger, 2006; Zibulewsky, 2001). Ca re accessed through FQHCs and emergency departments is referred to as safety net health care bec ause such facilities are exclusive providers of critical health care services such as inpatient behavioral health services and dental and vision care for the uninsured, the underinsured , and residents of rural and underserved communities . Researchers have identified that safety net facilities , including hospitals and community based clinics, frequently h ave lower

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7 and more shallow quality of care than non s afety net facilities ( Werner, Goldman, & Dudley, 2008 ; Culhane Pera et al., 2018; Getrich, C. M., García, J. M., Solares, A., & Kano, M., 2018 ) . In addition to the aforementioned health care services available to undocumented immigrants , a small number of undocumented immigrants can obtain health insurance through private employers , and those who are in college often have the option of obtaining health insurance through a student health plan. Many uni versities across the nation offer such plans for stud ents who do not have health insurance ( Braverman, 2018 ; Metropolitan State University of Denver, 2019) ; however, this can add barriers to the continuation of educational pathways for undocumented immigra nts because some universities and colleges require students to have and show proof of some form of health insurance and others simply did away with their student health insurance plans after the passing of the Affordable Care Act . For example, the Auraria Campus, in Denver, Colorado is home to three educational institutions: the Community College of Denver, Metropolitan State University (MSU Denver) of Denver, and the University of Colorado Denver. All three institutions have different student health insurance requirements. MSU Denver requires all stu dents who are taking more than nine credit hours to have health insurance coverage and they can meet the University requirement b y fulfilling one of two options: ( 1) Students can accept automatic enrollment in the University sponsored Studen t Health Insurance Plan (SHIP) e nrollment is automatic when a student registers for nine or more credit hours in the Fall or Spring semester or (2) s tudents insured by an outsid e federally compliant health plan can submit an online health insurance waiver form by the published semester deadline to opt out of the University sponsored SHIP (Metropolitan State University of Denver, 2019) . On the contrary, a s of August 2016, the Univ ersity of Colorado Denver (CU Denver) no longer offers an optional health insurance plan for domest ic (non international)

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8 students market ( University of Colorado Denver, 2019). Like CU Denver, t he Community College of Denver does not offer a health insurance plan for students, but rather encourages students to use health care services via the student Health Canter at Auraria because of its affordability (Community College of Denver, 2019). Unfortuna tely, the health insurance policies adopted by CU Denver and the Community College of Denver after the passing of the Affordable Care Act are restrictive of all students, including undocumented students. Lastly, there are a few public or charitable health care coverage programs that are available to undocumented immigrants. A well known program in Colorado was the Kaiser Permanente Colorado Bridge Program. The Bridge Program was designed to help those who are uninsured with no ac cess to other health coverage options to pay for the standard Kaiser Permanente Individuals and Families Healthcare Plan (KPIF) (Colorado Bridge, 2019). To be eligible, one had to : (1) l ive within the Kaiser Foundation Health Plan of Colorado servic e area based on county zip code (2) have income at or below 300 percent of the Federal Poverty Level (FPL) (3) be under the age of 30 years at time of the effective date of t he Kaiser Permanente plan (4) not have access to any other public or private health cover age including, but not limited to (Colorado Bridge, 2019) : Health First Colorado (Colorado's Medicaid Program)/CHP+ Connect for Health Colorado Medicare Job based health coverage Unfortunately, without warning, in October of 2018, the Kaiser Pe rmanente Colorado Bridge Program stopped accepting new applications, and most insured patients , many who were

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9 undocumented young adults, lost their health care coverage as of December 31, 2018 (Colorado Bridge, 2019). The abrupt cancellation of the Colorado B ridge Program is important to note for this particular study because it highlights the precarity of health care coverage for undocumented young adults in C olorado. In addition, the Colorado Bridge Program as a public or charitable form of health coverage illustrates how different forms of health care coverage can add to experiences of health inequity (Andaya, 2017) for the undocumented population. Although available, health care options for undocumented young adults living in Colorado are sparse , and costs associated with care and the lack of knowledge about eligibility requirements can be additional deter rent s for someone needing to seek care. The Colorado ed immigrants, with extensive variation across the state (Johnson, 2017). For example, more than a third of the uninsured adult population in Adams, Arapahoe, and Denver counties were undocumented immigrants (Johnson, 2017). T he health and well being of undocumented immigrants cannot be disconnected from the political and social environment. This study is important because it contributes to the understanding of the interconnectedness of structural stigma, discrimination, and health. O ur current political environment around immigration has created a sense of constant hypervigilance and fear among the undocumented immigrant population in our country. Persistent systematic and social discrimination take a toll on the mental and physical health of undocumented immigrants and their loved ones, in turn increasing their risk of poor health (Artiga & Ubri, 2017; Philbin, Flake, Hatzenbuehler, & Hisrch, 2018; Hatzenbuehler, 2018 ; Elejalde Ruiz , 2018).

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10 For instance, chronic fear and anxiety can weaken the immune system and can cause cardiovascular damage, gastrointestinal problems such as ulcers and irritable bowel syndrome, and decreased fertility (University of Minnesota, n.d.). Chronic fear and anxiet y can also lead to faster ageing and in some cases early death (University of Minnesota, n.d.). Other consequences of long term fear and anxiety can lead to mental health issues such as fatigue, clinical depression, and post traumatic stress disorder (Univ ersity of Minnesota, n.d.). If undocumented immigrants avoid the health care system because of fear of deportation , a fear of being labeled as a fear of being treated differently because of their status, and or lack of ability to pay, the impact goes beyond the individual and infiltrates society as a whole; it becomes a matter of public health. Socioeconomic background, immigration status (i.e., refugee, documented, undocumented, DACA), English proficiency, health l iteracy, res idential location, and marginalization are among the important factors that must be considered when examining the impact of the undocumented immigrant population on publ ic health systems and personal medical services. Because health in general is a complex issue, the science underpinning this research must integrate information and epistemologies from many disciplines including, anthropology, economics , law, m edicine, political science, psychology, public health, and sociology , among others. By using an int erpretivist qualitative approach through in depth interviews this study captures the lived health care experiences and perceived health care needs of 12 undocumented immigrant young adults in Colorado. The end result of the research provides an understanding of the impact of structural stigma on health, quality of life, and well being for this community. Ultimately, the research provide s evidence that there is an urgent ne ed to improve access to care, increase health insurance coverage options , a nd improve health

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11 services for th e undocumented immigrant population in Colorado in order for them to believe that they are worthy health citizens so they can acquire and maintain good health (Horton, 2004; Andaya, 2017) .

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12 CHAPTER III LITERATURE REVIEW The number of undocumented immigrants living in the U.S. , coupled with the cost to each state to provide certain public benefits and services to undocumented immigrants regardless of their legal status, has prompted researchers to study how undocumented immigrants access and use health care services. A vailable studies have, by and large, found that immigration status is an important determinant of health care access and patterns of health care utilization (Berk, Schu r, Chavez, & Frankel, 2000; Ortega et al., 2007 ; Nandi et al., 2008; Raymond Flesch, Siemons, Pourat, Jacobs , & Brindis, 2014; Hacker, Anies, Folb, & Zallman, 2015 ). Although studies have reported on the health care needs and numerous barriers to health c are access of undocumented immigrants, much of what we know is based on research conducted in immigrant friendly states (states that have laws that make it easier for undocumented immigrants access t o jobs , higher education, health care, and driver license s) such as California ( Plascencia, Leyva, Pena, & Waheed, 2013 ; Raymond Flesch et al., 2014; Horton, 2016) and New York (Nandi et al., 2008; Stump, 2016), and in states that are not necessarily immigrant friendly but host a large undocumented population wh ere presumably there is more infrastructure set up to serve the immigrant population. This includes states such as Texas (Kullgren, 2003 ; Heyman, Núñez, & Talavera, 2009 ) , and Florida (Ku & Freilich, 2001) , where a bout half of the undocumented immigrant population live (P assel & C ohn , 2017). Unfortunately, less is known about the health care experiences and barriers to care for undocumented immigrants in states where t he size of the undocumented immigrant population is fairly low and state policies around health care access are unfavorable toward this group. Furthermore, too little attention has been paid to undocumented immigrant , health utilization patterns, barriers to care , and health experience (Stump, 2016). As a g eneral pattern, most of the literature has focused on

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13 barriers to health care for undocumented immigrants through the policy arena, in the health care system, and at the individual level (Hacker et al. , 201 5 ). I show that the effects of inadequate health c are access for undocumented young adults is best examined through a structural level stigma framework . Structural stigma can produce harm and cause significant health consequences for undocumented immigrants in the U.S. throughout the life course ( Hatzenbuehler, 2018). To understand the complexities of health care access and utilization amongst undocumented young adults, I bring the growing field of research about undocumented young adults into conversation with the health disparities literature. Sp ecifically, I will r eview Everett Cherrington Hughes master st as it relates to the role of immigration status and the health care experience , discuss being in general, specifically highlighting information a bout the health and well being of Latino young adults, summarize the literature on health seeking behaviors of undocumented immigrants , behavioral model of health services use , assess the c onsequences of structural stigma on the health of undocumented immigrants , and examine the concept of health citizenship . The Role of Immigration Status and the Health Care Experience Social determinants of health include multifaceted, integrated, and intersecting social structures and economic systems that are responsible for most health inequities in the U.S. (Centers for Disease Control and Prevention, 2014). Previous studies have demonstrated that immigration status (legal/documented or undocumented) as a social construct contributes to immigrants' vulnerability to inadequate hea lth care access and utilization in numerous ways including: socioeconomic background; limited English proficiency; limited health literacy; and stigma and marginalization (Castañeda et al., 2015 ; Martinez et al., 2015; Young & Pebley,

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14 2017). Castañeda et al. argue that simply being an immigrant limits behavioral choices and directly impacts and alters the effects of other social positions, including race/ethnicity, gender, and socioeconomic status, because immigran t status places individuals in uncertain and positions with institutions, including health services (Castañeda et al., 2015). Such scholarship supports current research by immigration scholars around the effect undocumented status has on higher educational (Enriquez, 2017 ; Valdez & Golash Boza, 2018; Gonzales & Burciaga, 2018). Hughes determines a per intended to address status contradictions in professional and occupational positions (Hughes, 1945), immigration scholars have identified that undocumented status overshadows many other social positions ( Castañeda et al., 2015 ; Enriquez, 2017; Valdez & Golash Boza, 2018; Gonzales & Burciaga, 2018) and over the life course it can become a principal attribute driving Drawing from previou immigration status as a social determinant of health, and undocumented status as a social construct that shapes educational pathways for undocumented immigrant young adults, my findings will addre ss how and when undocumented immigrant status can create disparities in health and health outcomes for undocumented immigrant young adults. Specifically as it relates rse of life, and that once undocumented immigrant young adults become responsible for their own health care (age of 18), immigration status becomes one of many social positions that contributes to inequities that shape the health care experience of undocum ented young adults.

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15 Health and Well Being of Young Adults Research suggests that young adulthood (spanning the ages of roughly 18 26) is an important and critical time of life (Mulye, et al., 2009; Park, Scott, Adams, Brindis, & Irwin, 2014; National Resea rch Council and Institute of Medicine, 2015). During young adulthood, people usually complete their high school education, start or complete college, start working in hat help set them on a pathway to a healthy an d productive adult life (Mulye et al., 2009; National Research Council and Institute of Medicine, 2015). However, young adulthood can also be a challenging time for people (Park et al., 2014; Mulye et al., 2009). Although young adults are generally healthy ( National Research Council and Institute of Medicine, 2015 ) , some important health and social problems either start or peak during these years ( Harris et al. , 2006 ; Mulye et al., 2009; Balocchini, Chiamenti, & Lamborghini, 2013; Park et al. , 2014; National Research Council and Institute of Medicine, 2015 ). Mulye et al. (2009) indicate that rates of homicide, unintentional injury (i.e., motor vehicle crashes, fires and burns, falls, drowning, poison ing, choking, suffocation, and animal bites ), substance use, drinking and driving, and sexually transmitted infections, peak during young adulthood. In addition, research indicates that risky adolescent sexual behaviors, including multiple sex partners , having had an STD, and having had an intended or unintended birth , increase risk of negative reproductive health outcomes in young adulthood (Scott et al., 2011). Scott et al. (2011) point out that young adult male and females endure a disproportionate b urden of S TDs and unintended childbearing ( women aged 20 24 have the highest unintended childbearing rate ) as a result of adolescent sexual risk behaviors . Young adulthood is a critical developmental period during which key tasks in the transition to inde pendent adulthood need to be accomplished, including taking responsibility for

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16 As young adults acquire more privileges of adulthood , they lose support from institutions and safety net programs , including health care programs that serve adolescents, and they often face challenges as they transition from the child health care system to the adult health care system (Mulye et al., 2009 ). Before the passing of the ACA , young adults were only until they turned 19, or 23 for full time college students, or got married. Under current law, parents can add or keep their children on their health insurance policy until they turn 26 years old and can join or remain on their parent's plan even if they a re married, not living with their parents, attending school, not financially dependent on ACA , 2010 ). Having access to health care as a young adult helps decrease social and ec onomic challenges at a time when young adults are expected to take on adult responsibilities and obligations . Unfortunately for undoc umented immigrant young adults, since they are excluded from federal health care coverage programs, they are excluded from the healt h care overhaul related to rules for legal citizen children and young adults. As the research has firmly established in other areas of the transition t o adulthood, health care benefits can significantly protect against unmet health care needs for young adults in general (Marshall, 2011) . As a result of being excluded from critical health care services and coverage options, undocumented young adults have to navigate the tumultuous transitions to adulthood without the same benefits and opportunities as citizens. Consequently, u ndocumented immigrant young adults face an increased risk of poor health outcomes , negative health care provider attitudes, and unnecessary disability and premature death due to the lack of access to comprehensive, quality healt h care services (Hardy, 2004; Mulye et al., 2009; Andaya, 2017; Hea l thy People 2020, 2018).

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17 Health and well being of Latino young adults. As reported by the Migration Policy Institute (MPI) 2017, 44 percent of U.S. immigrants (19.7 million people) reported having Hispanic or Latino origins Burrows , 2019). 1 Between 2012 and the end of 2016, based on MPI estimates, Mexicans and Central Americans were estimated to account for roughly two thirds (67 percent or 7.6 million) of the und ocumented immigrant population in the U.S. (Zong, Batalova, & Burrows, 2019). Insufficient access to health care services , the social and economic environment, and structural barriers to health can cause significant health disparities among Hispanic/Latino immigrants . Many studies related to racial a nd ethnic disparities in health care access and utilization frequently identify Hispanics/ Latinos as one of the m ost disadvantaged ethnic groups in the U.S. ( Callahan, Hickson, & Cooper, 2006; Paz & Massey, 2016; Dillon, Ertl, Corp, Babino, & De La Rosa, 2018). Furthermore, research by Callahan, Hickson, and Cooper point ed out that Central/South American and Mexican young adults without U.S. citizenship were the most likely Hispanic/Latino group s to be uninsur ed (63% and 73%, respectively) and t he maj ority of noncitizens also lack a usual source of health care and had no contact with a professional health care provider within a one year period of time (Callahan, Hickson, & Cooper, 2006). Althou gh Hispanics /Latinos have lower deaths than whites from most of the 10 leading causes of death, they experience more deaths from diabetes and chronic liver disease, and similar numbers of deaths from kidney diseases (Center s for Disease Control and Prevention , 2015). The CDC also specifies that place of national origin (where one was born) for Hispanic/Latinos makes a difference. For instance , c ancers related to infections (cervical, stomach, and liver) are 1 It should be noted that Hispanic and Latino are ethnic categories, and are separate from racial categories. Hispanic/Latino ethnic groups include any person of Cuban, Mexican, Puerto Rican, South or Central Americ an, or other Spanish culture or origin, regardless of racial identification (United States Census Bureau, 2019).

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18 more common among Hispanics /Latinos bo rn outside of the U.S. (Centers for Disease Control, 2015). Although there is no assurance in cancer prevention, there are things that one can do to lower the risk of cancers related to infections. For instance, one can decrease the risk of developing live r cancer by getting a vaccination for Hepatitis B, which is the most common risk factor for liver cancer (Hepatitis B Foundation, 2019). In respect to cervical cancer, the American Cancer Society acknowledges that this disease can be stopped from developin g by finding and treating precancerous conditions before they become true cancers, and by preventing the pre cancerous conditions all together (Ameri can Cancer Society, 2019). The Pap test (or Pap smear) and the human papillomavirus (HPV) test are specific tests used during screenings for cervical cancer, and the HPV vac cine can protect young people against infection with the HPV subtypes most commonly linked to cancer, as well as some types that c an cause anal and genital 019). According to the National Institutes of Health (NIH), nearly all cases o f cervical cancer are caused by particular types of HPV (NIH, 2019). There are more than 100 types of HPV, of which more than 40 can be transmitted throug h intimate skin to skin contact by having vaginal, anal, or oral sex with someone who has the virus (NIH, 2019). Along with physical health, Hispanics/Latinos are no different from the rest of the population when it comes to prevale nce of mental health conditions. Generally spea king, m ental health conditi ons are common among adolescents and young adults 1 in 5 live with a mental health condition (National Alliance on Men tal Illness, 2019). Previous studies have identified that y oung adults from urban, socio economically di sadvantaged communities report high rates of adverse childhood experiences which can be linked to depressive symptoms, antisocial behavior, and drug use during the early transition to adulthood (Schilling, Aseltine, & Gore, 2007) . Although U.S. born Hispan ics/ Latinos are at significantly higher risk than immigrant

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19 Hispanics/ Latinos for major depressive episode, social phobia , post traumatic stress disorder, any anxiety disorder, alcohol dependence, alcohol abuse, drug dependence, drug abuse , and any disorde r (Alegria et al., 2008), r ecent research identified that undocumented Mexican immigrants are an at risk population for mental disorders, particularly depression and anxiety disorders, mostly because of the stress from living as an undocumented person in the U.S. ( Garcini Peñ a, Galvan, Fagundes, Malcarne, & Klonoff ( 2017 ). T here are notable mental health implications of being an undocumented person living in the U.S. For instance, stigma can contribute to barriers to health care access and utilization for the undocumented population. There a re both psychological and behavioral responses to stigma including, ( deep or constant thought about something ) and

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20

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21 At some point in time, every person will need to access medical care. Access to health care services , including dental and vision care, is critical to good health, yet undocumented immigrants in the U.S. face a variety of access barriers specifically due to their immigration

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22 status. With the exception of emergency medical care, in the U.S. undocu mented immigrants are not eligible for federally funded public health insurance programs, i ncluding Medicare, Medicaid, and CHIP (ACA , 2010 ). Most medical care for undocumented immigr ants in the U.S. relies on a fragmented system of safety net providers, i ncluding public and not for profit hospitals, FQHCs , and migrant health centers. The ways in which undocumented immigrants interact with the health care system in the U.S. illustrates a gap in Ronald M. seeking behavior model. The concept of the health seeking process has evolved with time (Chrisman, 1977 ). Various anthropological , psychological, and sociological models have been used to explain health seeking behaviors among populations all over the world (Chrisman, 1977; Poortaghi et al. , 2015 ) . MacKian defines health or prevent people from making healthy choices, in either their lifestyle behaviors or their use of medical In the broadest sense, health seeking behavior includes all behaviors associated with establishing and maintaining a healthy physical state and a healthy mental lifestyle . A was specifically constructed to explain and describe health seeking behaviors and it is one of the most widely used conceptual framewo rks for understanding why and when people seek out health care services ( Andersen , 1995 ). Behavioral Model of Health Services Use was initiall y developed in the late Andersen, 1995 ). Consequently, as health policy and the external environment (including physical, political, and economic components) have become important facto rs in influencing how researchers understand the concept of health services utilization, there have been four revisions (Phase 2 -

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23 1970s; Phase 3 1980s 1990s ; Phase 4 1990s; Phase 5 2000s) of the model (Andersen, 1995; Andersen, 2008). Now in the fifth phase (2000s) , the model stresses that understanding health services use is best achieved by focusing on contextua l and individual determinants (Andersen, 2008). According to the current model, contextual determinants of health services utilization include health system organization, provider related factors , and community characteristics (Andersen, 2008). The model suggests three reasons for health seeking behavior s: (1) people are predisposed to use health care services because of their demographi cs , social context, and beliefs, (2) factors such as health policies, finances, and organization of the health care system enable or hinder use of services, and (3) immediate need for care (Andersen, 2008). Phase 5 of the model includes feedback l oops to demonstrate that outcomes can affect health behaviors, predisposing, enabling, and n eed variables both contextually and individually, and additionally, health behaviors can influence predisposing, enabling, and need variables both contextually and individually (Andersen, 2008). Also a dded in phase 5 of the model is the process of the health care experience . This pertains to provider behavior and attitudes during the delivery of medical care (Andersen, 2008) . For example, the quality of doctor patien t trust and communication can influence whether or not patients acknowledge health problems, understand their treatment options, and modify their behavior accordingly . Phase 5 of the Behavioral Model of Health Services Use is shown in Figure 1 .

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24 Figure 1. Phase 5: A Behavioral Model of Health Services Use Including Contextual and Individual Characteristics. Reprinted from National Health Surveys and the Behavioral Model of Health Services Use, by Ronald Andersen, July 2008, retrieved from doi:10.1097/ MLR.0b013e31817a835d Copyright 2008 by Lippincott Williams & Wilkin. comprehensive and stresses the importance of contextual and individual characteristics in promoting access f or defined populations, contextual characteristics of the current model can be expanded to include structural stigma as a factor inhibiting health seeking behavior. Hatzenbuehler and Link define structural level conditions, culture norms, and institutional policies that constrain the opportunities, resources, and well being of the institutions , including law and social policies (Hatzenbuehler, n.d.). For instance, f ederal, state , and local level health care policies, allow for scrutiny of people suspected of being undocumented ( Toomey et al., 2014; Rhodes et al., 2015 ), and social policies and state laws tha t allow undocumented immigrants to obt ain a driver's license or some type of driving perm it

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25 which is required to be marked in particular ways to distinguish it from the licenses of those with legal status ( Colorado Department of Revenue, 2019) , can invigorate stigma processes and produce harm to mental and physical health (Link & Hatzenbuehler, 2016). Structural Stigma and Health of Undocumented Immigrants Research concerning the causes and consequences of stigma has flourished since itled Stigma: Notes on the (Goffman, 1963, p. 3 ). not quite ). out stigma and the relationship to people being in the U.S. by some individuals (Cowan, Martinez, & Mendiola; 1997 ; Pearson, 2010). To illustrate, when undocumented immigrants as deviant and less deserving . Recognizing that there are notable health implications of social devaluation, recent scholars have identified several other elements of stigma at the individual level, includin g micro level interactions, and at the macro level i.e., structural stigma (Hatzenbuehler & Link, 2014). societal level conditions, culture norms, and institutional policies that constrain the opportunities, resources, and well , p. 2 ). Their research documents the extensive health consequences of structura l stigma across the life course (Hatzenbuehler, n.d.; Link & Hatzenbuehler, 2016; Philbin, Flake, Hatzenbuehler, & Hisrch, 2018; Hatzenbuehler, 2018). Hatzenbuehler and Link indicate that social policy can contribute to stigma processes in three different ways: by invigorating the social production of stigma and producing harm; by

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26 interrupting stigma processes a nd mitigating harm; and by, ignoring the interests of stigmatized groups (Hatzenbuehler, n.d.; Hatzenbuehler & Link, 2014; Link & Hatzenbuehler, 201 6; Hatzen buehler, 2018). Structural forms of stigma are conceptualized as objective rather than subjective evaluations assessed at the individual and interpersonal l evels (Hatzenbuehler, 2018). This is critical to immigration research because several schol ars have suggested that laws and policie s are forms of structural stigma that shape social/cultural norms and attitudes toward the stigmatized group (Kreitzer, Hamilton, & Tolbert, 2014; Philbin, Flake, Hatzenbuehler, & Hisrch, 2018; Hatzenbuehler, 2018). For undocument ed immigrants, structural stigma is a risk factor for poor health because federal, state, and local level policies that invigorate or ignore access to health care and related services for this group undermine health through psychological and physiological factors, and such policies can undermine health interventions (Hatzenbuehler, n.d.). Hatzenbueheler proposes that when s tructural level stigma occurs, interpersonal and individual stigma mechanisms are more likely to be openly conveyed and acted upon ( Hatzenbuehler, 201 8). Hatzenbuehler et al. (2013) indicate that many psychological and behavioral processes are drastically altered by stigma. For example, the experience of structural level stigma can lead to maladaptive coping behaviors (i.e., drinking, smoking) and maladaptive emotion regulation strat egies (i.e., rumination or suppression) (Hatzenbuehler, Phelan, & Link, 2013). Such behaviors lead to negative consequences for both mental and physical health. Stress is another mechanism through which structural level stigma can lead to adverse health ou tcomes. Stress is the physiological demand placed on the body when one must adapt, cope, or adjust to threatening or challenging events (Nevid & Rathus, 2003). Undocume nted immigrants in particular have to deal with isolation from peers, the struggle to pu rsue an education, fears of

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27 detention and deportation, the lack of access to health care, and the trauma of separation from family and loved ones (APA, 2012). Structural stigma has robust health consequences for undocumented immigrants living in the U.S. , and it is a considerably understudied cause of health inequalities amongst this group. It is imperative to examine structural forms of stigma and prejudice as social determinants of health and longevity among undocumented immigrants in the U.S., and in p articular, in states with unfriendly or hostile health care policies related to access to care for this group. As noted, laws and policies that directly affect members of stigmatized groups can invigorate the effect of stigma on life chances. For undocumen ted immigrants, structural level stigma related to laws and social polices around immi gration and health care access play a distinct role in inequalities related to mental and physical he alth and the health care experience of undocumented immigrants. Heal th Citizenship he al th examine the way people are included socially, politically, economically, or are marginalized or excluded from the health care system ( Redden, 2002; Horton, 2014; Petryna & Follis, 2015 ; Andaya, 2017). A growing body of literature has elaborated on this concept by discussing how federal and state health care their rights with respect to health and health care (Horton, 2014; Horton, 20 utilization among the undocumented immigrant population as a result of negative federal and state policies that affect access to health care services for the undocumented population and th eir addressing how different forms of health coverage can contribute to experiences of heath

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28 inequality by making some people, particularly immigrants, feel like t hey are less worthy of health care (Andaya, 2017). As a consequence, Andaya identifies that certain individuals may experience better health care and respect during their health encounter because of judgement about citizenship and moral worth (Andaya, 2017). Furthermore, research highlights the importance of immigrants being seen as less deserving because of the forms of health coverage available to them (Horton, 2014; Horton, 2016; Andaya, 2017) . Each addresses the difference between inclusion of immigrants in health care, and the reproduction of social structures that contribute to unequ al health care experiences within certain forms of health care coverage (Horton, 2014; Horton, 2016; Andaya, 2017). f par ticular interest to this study, because many of the participants were ins ured as a result of an employee based plan, a school health care plan, or pri vate health insurance t hrough the Colorado Bridge Program. I present evidence that inclusion in health care coverage does not necessarily result in equity in health care access an d utilization for undo cumented immigrant young adults. In fact, structural level stigma and h ealth systems barriers to care can shape health care provider attitudes which directly contribute to the patient experience, making many undocumented immigrant young adults feel as though they are less deserving health citizen s .

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29 CHAPTER IV METHODS AND DATA Qualitative research is a method of analysis engaged in by scholars in many different academic disciplines, including the social sciences, behavioral sciences, health sciences, medicine, human geography, and public health. Qualitative research has numerous benefits as a method of inquiry for immigration research and for health care research with social and cultural dimensions . Q ualitative research focus es on participant viewpoints and stories; it can uncover significant issues that can later be studied using more structured methods (i.e., quantitative design methods) ; it can provide insight into cultural activities that might otherwise be missed via a quantitative approach; and such methods are suitable for accessing implied , taken for granted, intuitive understandin gs of a culture (Trac ey, 2013). The Colorado Multiple Ins titutional Review Board (COMIRB) under the auspices of the University of Colorado Denver approved all protocols for the research. Verbal informed consent was obtained from each participant and anonymity of participation was guaranteed. Interview and Analy sis Methods The study design consisted of in depth, in person, semi structured interviews with undocum ented immigrant young adults ages 18 25 . In additio n to semi structured interviews, in order to , I comple mented the qualitative study with a web based questionnaire consisting of 32 questions. Each study participant completed the questionnaire before particip ating in the interview. Interviews were conducted from October 2018 through November 2018 in Denver, Colorado. I initiated convenience sampling by recruiting participants from multiple organizations that support undocumented immigrant young adults, including local health organizations and clinics,

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30 the University of Colorado Denver, and Metropolitan State University of Denver. Participants were recruited until I reached a point of sa mpling saturation, meaning the data collected started to become repet itive and I was no longer getting any new participants from any of the outreach destinations to volunteer. All participants received a $20 incentive in the form of a gift card for being interviewed. Interviews were conducted in a private space on the Aurar ia Campus in Denver, CO, and lasted approximately 5 0 90 minutes. All participants chose to be interviewed in English and identified a pseudonym to protect confidentiality. Interviews were directed by a semi structured interview guide that included question s to perceived health (physical, mental, oral, and eye) status , access to and utilization of health care services, and barriers to care. Interviews were recorded and sent to Rev.com, a professional freelance transcription service, for verbatim text transcription. Transcripts were analyzed manually on hard copy printouts . U sing Microsoft Word, codes were directly added to the data . In addition, analytic memo writing was used to reflect on code choices, understand emerging patterns and themes, and theory assessment. These processes revealed four main inhibiting predictors of health seeking behavior among the participants: structural stigma, health system barriers to care (i.e., bureaucratic obstacles and safety net health care), individual barriers to care (i.e., low social economic status (SES) , lack of social capital, low health literacy), and social location of undocumented status. I systematically coded for the inhibit ing predictors and developed a process based analysis by reviewing each transcript to identify patterns of how and when each inhibiting predictor a health seeking behaviors including health care usage, health related expenditures, and patterns of access and utilization.

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31 Sample: Description of Participants Immigration research involves complex human interactions that can rarely be studied or explained in simple terms. In order to understand how policies around a ffect the health seeking behaviors of undocumented immigrant young adults, I elected to speak with individuals currently living in the state without perma nent legal status (i.e., not a citizen, permanent resident, or hold a student visa). Study p articipa nts identified as undocumented, DACA, DACAmented, ASSET student, a nd DREAMer. P articipants also had to be between the ages of 18 25 and have arrived in the U.S. before their 16th Birthday. Twelve undocumented immigrant young adults between the ages of 18 25 completed the interview and the web based questionnaire. All 12 participants identified their place o f national origin as Mexico. They are all 1.5 generation immigrants, meaning they arrived in the U.S. as children and adolescents . 50% of the participants arrived before the age of four, another 33% arrived between ages 4 6, and 17% arrived between the age s of 7 12. All but one per son identified their gender as f emale; one individual identified as male. Participants lived in Colorado an average of 16 years, and 100% of participants completed high school in Colorado . Eleven participants were currently attend ing a four year university, and one participant attended a four of participants identified as a f ull time employee, 25% identified as a part time employee , and the remaining 25% of participants were e ither self employed or unemployed. All but two participants (83%) indicated they had some form of health insurance at the time of the interview. Various types of health insurance were identified; private insurance, s pecifically the Colorado

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32 Bridge Program through Kaiser Permanente 2 , student health insurance, and employee based health insurance. More than half of the participants (58 .33 %) indicated having an existing need to access a doctor or specialist about their he al th at the time of the interview. The dem ographic characteristics of the sample are provided in Table 1. Table 1 Sociodemographic characteristics of participants (N=12) 2 Effective October 1, 2018, the Co lorado Bridge Program was cancel led unexpectedly.

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33 Additionally, the web based questionnaire added a d eep er understanding of the health seeking behaviors of the participants. W hen asked to rank what influences the utilization of health facilities, participants identified cost of services and immigration status as the number one and number two influencers of utilization of formal hea lth facilities . Table 2 provides a ranking of items that influence health care utilization from most important to least important by the participants. Table 2 Factors that influence the utilization of health facilities from most important to least importan t; 1 being the most important and 5 being the least important (N=12) Participants were also asked to self rate their physical, mental, and overall health using a 5 point Likert scale that r anged 58% (7 of the 12) of the participants and 68% (8 of the 12) indicated that their overall When asked about mental health, 50% of the participants indicated that Moreover, participants were asked if they had an existing need to access a doctor or a specialist about their health at the time of the interview and to comment on their response . Seve n of the included

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34 One participant indicated

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35 CHAPTER IV FINDINGS My analysis suggests that undocumented status , along with structural level stigma and perceived quality of care, directly affect the health seeking behaviors of undocumented immigrant young adults. More specifically, in relationship to health care access and uti lization, undocumented young adults often do not experience the inequalities of the health care system created by their immigration status until they are in need of formal health care after they turn 18 years of age. Participants were largely safeguarded f rom health inequalities due to their own immigration status during childhood and adolescence because they were at the will of their parents consent to medical treatments. Additionally, since undocumented immigrant children and adolesc ents have access to K 12 education, they are afforded some of the same health care access as their citizen counterparts. Colorado is one of many states across the country that locates health care clinics on school properties to provide primary, behavioral , and oral health serv ices, particularly for low income children and youth, regardless of immigration status ( Colorado Department of Public Health & Environment, 2018). health seeking behavio rs: (1) struc tural stigma, specifically license related polices, as a contributing factor to adverse health outcomes; (2) t he role of undocumented status and other social positions in shaping health care access and utilization; (3) positio n in the health care system as less deserving health citizens because of their form of health care coverage . These three themes describe factors at the structural, health care system, and individual level , that interact together to shape health seeking behaviors among the undocumented immigrant young adult population.

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36 Structural Level Stigma as a Contri buting Factor to Health Outcomes Stigma scholars have identified that stigma at all levels (individual, interpersonal, and str uctural) 3 plays an important role in producing health disparities among marginalized populations (Hatzenbuehler, Phelan, & Link, 2013; Hatzenbuehler & Link, 2014 ; Hatzebuehler, 2018). For this study, health care related laws and policies at the federal, state, and local levels related polices at the state level interfer ed with the participants ability to access and utilize formal health care services. In particul ar, the r estrictions created by such la w s and policies produce health systems bsrriers and indiv idual barriers to care. Philbin et al. identified that health care related policies include laws and policies that govern access to health care services and coverage, requirements that health care professionals participate in cultural competency training, and polices that require health care providers to report undocumented immigrants ( Philbin, Flake, Hatzenbuehler, & Hisrch, 2018 ). Limited by their ability to pay for health care services due to federal and state level policies that make them ineligible for Medicaid and ACA expansion benefits, and their immigration status, undocumented immigrants tend to access formal health care as a last resort ( Gar cés, Scarinci, & Harrison, 2006; Raymond Flesch et al., 2014 ). Additionally, when undocumented immigrants do access care, it tends to be through safety net options such as the emergency department and safety net clinics ( Raymond Flesch et al., 2014; Sommer s, 2013 ). Ellie describes the ease of access to health care services on a scale from 1 10: Two. I always have to look really hard for services. I would have to do hours of research to find the cheapest option usually, and the option that I know undocumente d people are safe to go to, and I have to call various places. So I wouldn't call that accessible . 3 As defined by Hatzenbuehler, individual level stigma ref ers to how individuals engage in responding to stigma. Interpersonal stigma is the interactional process that occurs between the stigmatized and the non stigmatized. level conditions, cultural norms, and inst itutional policies that constrain the opportunities, resources and well

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3 7 Ellie identifies how structural factors like SES and the unequal allocation of power and resources contribute to health disparities among undocumented young adults. Ellie noted that there is a lack of knowledge amongst the undocumented community about where to go to access good care and even how to go about scheduling an appointment. Participants who avoided the formal health care system often named cost of services and difficulty of access, specifically the ability to locate culturally sensitive providers and services in general, as reasons why they did not access care. Participants who did access care through safety net options described these facilitie s as being overwhelmed and busy and suggested that practitioners participated in inequitable treatment practices. Layla recounted a time when she visited a student run free c linic to address issues she was having with her stomach: I went right at the time that they opene hours until 10 p.m. They saw me and I was like, "I have this pain. Oh my god. I have this pain." It doesn't go away ... and I still have it to this day. They [the practitioners] were just like "Oh" and eve ntually someone just came in to talk with and they were like, "Um so you told us you're a student. Maybe you're just stressed." I was just like, "No. Something is wrong. " Eventually ...they did the stool test and I took my stool in a bag to the lab on th e big campus. They never followed up with me so I kept e mailing them and no one would reply. I eventually went back [to the clinic] again when I had more time and said everything came back normal so maybe it was just something you had ate that week or something. I said it's still here. Tired of being dismissed by the health care system as an undocumented young adult, Layla chose not to go back to the clinic, and at the time of the interview she was still trying to locate a doctor that she could afford and would acknowledge her symptoms. Claudia also experienced unfair treatment at a safety net dental clinic. She went to the clinic because she had been experiencing pain with her wisdom teeth and she wanted to get an estimate on wisdom teeth remov al. Claudia explains that the treatment she experienced at the low cost dental clinic was different then her experience at the private Orthodontist office :

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38 Yeah, the services could have been better. I think a lot of it, they have a lot of Latino community come in, and so they kind of treat them a bit different, and they give them all these prices, because they know that they don't have insurance for oral care, so it's just ... I don't know, I think it's a different vibe compared to when I was going to my o rthodontist, I felt a lot different. I was treated like a normal patient, but at this Latino dentist [office] , I don't know, it's different. Although Layla and Claudia both sought necessary health care services, Layla for treatment, and Claudia for preve ntative care, the frustrating delays and the dismissal of their symptoms by health care providers discouraged them from reaching out for additional health care services and following up on their care. Bureaucratic o bstacles including Identification cards ( ) , specifically driver licenses, and medical office forms, also led some participants to experience health systems barriers to care. The Colorado Road and Community Safety Act (CO RCSA SB13 251) uthorizes the issuance of a Colorado driver license, instruction permit , or identification card to those individuals who either cannot demonstrate lawful presence in the U.S. or can only demonstrate temporary lawful presence in the U.S. CO RCSA SB13 251 , 2013; Colorado Department of Revenue, 2019) . While SB13 251 is a positive development for many undocumented individuals l iving in Colorado , the law has already had unintentional consequences as it relates to program backlog. As of 2019, the re are three Department of Motor Vehicle Offices in Colorad o (Westgate, Grand Junction, and Colorado Springs) that are ava ilable to process first time applicant appointments and renewal appointments, and an additional location in Aurora that can process renewal appointments only ( C olorado Department of Revenue, 2019). Hatzenbuehler demonstrates that structural level stigma can be both intentional (i.e., laws that prohibit undocumented immigrants from receiving public benefits) and unintentional (Hatzenbuehler, 2018). Although not intentional , SB 13 251 can contri bute to health systems barriers to care for undo cumented immigrant young adults. As demonstrated in Figure 2 below (Colorado

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39 Department of Revenue, 2019) , SB 13 the wording NOT VALID FOR FEDERAL IDENT IFICATION, VOTING, OR PUBLIC BENEFIT PURPOSES Figure 2. Image of a Colorado Driver's L icense for those individuals who either cannot demonstrate lawful presence in the U.S. or can only demonstrate temporary lawful presence in the U.S. Reprinted from Colorado Department of Revenue, Division of Motor Vehicles, Card Images , 2019 . [PDF]. Retrieved from https://www.colorado.gov/pacific/sites/default/files/251CardImages.p df . Several participants described feeling uneasy and embarrassed about having to provide their or social security card 4 at medical appointments: I definitely feel nervous when the social starts with different [number] 8, either like they [health care staff] are wonder ing why it starts with an 8 or why my ID, when they see my ID or they're checking it . I feel like t hey're like, "Hey, can I check your ID to check you 4 Once an approval of Deferred Action for Childhood Arrivals and an application to work in the United States is approved, DACA recipients may be eligible for a Social Security number.

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40 in?" It has no federal use or no federal benefits, and I've had people question that and then they start thinking, "Who are you? Where are you coming from?" They're like, "Oh, I've never seen that. What kind of card is this?" labels of her undocumente d status and that before she was insured her willingne ss to seek out health care was a ffected because she was afraid and embarr health car e staff. Like Adeline, Layla identifies also experiencing scrutiny by rece ption staff in health care settings: I 've been afraid to give somebody my ID because it has a black line across it, and so, yeah, I get question check in at the ometimes the receptionist can be so loud and they ask me about these things in front of the whole office. tes as a form of stigma . It contributes to st atus loss by means of labeling undocumented people as less human and reliable , possibly discouraging undocumented immigrant young adults from seeking health care . Furthermore, participants pointed to bureaucratic medical paperwork as another health systems barrier to care. Most new patient intake forms require people to complete patient data , including current address , phone number, occupation, social security numbe r, and payment information. Such forms are necessary in health care to help with the initial evaluation of the patient profile , analyzing treatment results, and for plan ning treatment protocols (Thomas, 2009). Nonetheless, for the undocumented community, t hese documents can be another form of unintentio nal stigma. As an undocumented person, K.S.G. recalled feeling nervous when she was asked to complete paperwork at the medical office: W hen I went to see a health care provider and I was asked to provide my social security numbe r. I got uncomfortable, because when I was filling my insurance was asked to give m y social security number, I was just like ... I would say, my tone changed because I was like, "I don't have one." It's just really unc t ime it is one reason why I am not seeing a doctor right now.

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41 Being that this was the first time K.S.G. had to complete such paperwork for herself, her experience with having to provide such detailed information made her feel apprehensive and scared. This particular situation occurred when e program, the overall experience led K.S.G. to avoid seeking out formal medical care for almost three and half years in her young adult life. Unlike K.S.G. , Claudia and her family effectively try to avoid delaying medical care; however, for her and her f amily this means making tough decisions about w hat information to disclose on medical intake forms and how to report the information. Specifically, Claudia spoke about the importance of seeking out health care services in a timely manner , but because of her cost of services , she indicated that he r mother has work around solutions to such forms: As an undocumented person she is very afraid when she fills out these forms. She uses her middle name on th e forms most of the time and then it switches to her first name other times . She switches things because she has all these hospital bills and all these medical bills that she owes. She's really, really afraid that her name is out there, and no social secur ity number at all that's designated with her name. Although Claudia indicated that she has never put the wrong birthday or a made up social security number on a medical form because of fear and the possibility of not being considered for an amnesty progr am, she said she does wor ry about whether they [bill collectors] will come unpaid medical bills . Claudia specified that she is very scared that her mom will get in trouble and p ossibly deported because of her decisions to alter such paperwork . As a result, Claudia said she only goes to th e doctor when she can afford to pay for it in full.

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42 Out of the 12 participants that I interviewed, all were clear about the role structural lev el stigma plays in their health seeking behaviors. Yet, the participants also made it clear that there are additional reasons beyond laws and policies that dissuade them from accessing and utilizing formal health care. The Role of Undocumented Status and Other Social Positions in Shaping Health Care Access and Utilization Life course scholarship focuses on individual development as being a life long process. At every stage of the life course , 5 events mark shifts an d trajectories of new roles. Colorado, like many other states, has determined that individuals are to be treated as adults at the age of 18, with some exclusions , such a s drinking and purchasing alcohol, renting cars, and paying for hotel room s (Colorado Judicial Branch, n.d.). Additi onally, Colorado s tate law specifies that of competence ody and the body of his (Conway, 2017). Essentially, this law refers to medical consent to care . In Colorado, u nless a minor aged 15 or older is emancipated and living apart from their parents and managing their own financial affairs, or is legally married , or has children of their own, most of the time 6 , parental consent is required for medical treatment until the age of 18 ( C onway, 2017 ). Addressing medical consent is important for this particular study because up until the age of 18, immigration status , low SES , and cultural beliefs about health and illness , and were at the will of decisions about health care access and utilization. I contend that the participants in 5 The stages of the life course are most commonly categorized as childhood, adolescence, adulthood, and old age (Greene, Wheatley, & Aldava, 1992) . 6 In Colorado, many laws allow a minor to consent to medical treatment that address medical situations in which a minor may be less likely to seek treatment if parental consent were required (i.e., reproductive health, pregnancy, sexually transmitted infections, drug use, and mental he alth services) (Conway, 2017).

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43 this study started to feel their own immigration status, cultural beliefs about health and illne ss , and low SES as individual barriers to health care access and utilization once they turned 18, and tried, or needed to, seek out their own health care. Additionally, since undocumented immigrant children and adolescents are afforded many of the same ben efits as their U.S . born and legal counterparts, such as access to K 12 education and school based health clinics and medical vouchers , they are unprepared to transition in to the adult health care system at the age of 18 . Systems such as school based health clinics, school nurse s, sports programs, and health care vouchers , substitute as forms of safety net care for undocumented im migrant children and adolescents . Conversely, once young undocumented people graduate out of these systems they are left to navigate the adult health care system on their own without the supplementary opportunities of health care access and coverage afforded to their U.S. born and legal counterparts . Social and cultural factors can influence health beliefs and health seeking be haviors (Kreuter & McClure, 2 004; Thomas, Fine, & Ibrahim, 2004 ) . In particularly f or Hispanics/Latinos, cultural influences such as male dominance, female modesty, and the prac tice of keeping problems within the family can lead to health risks (Galanti , 2003; Caballero, 2011 ). For traditional Hispanics/Latinos , lo yalty to the extended family is more important than the nee ds of the individual, a concept known a s familismo (Galanti, 2003 ; Caballero, 2011 ). For this study, cultural beliefs about health and illness and immigration status co ntributed to the overall health and health seeking behaviors of the participants as children and adolesce nts . As Layla explains, being undocumented, n ot having money, and trying to handle things within the family, can lead to future health consequences: The scariest part and I still have pain from it, physical pain from it today, is when I broke my collarbone in high school playing volleyball. We didn't have health insurance and my

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44 parents are undocumented I remember that night I was crying and begging them can't. We don't have health insurance. We don't have money." I'm like, "Oh my god, oh my god, oh my god." They took me to this lady's house. She's a chiropractor. She was like, "Here, let me touch it." She was like, "Oh I can't really feel ... . " Then she tried to put it back into place. It was the most insane pain ever. That's when she told m y parents, "Okay, this is going to be the cheapest way to get this taken care of . You have to go to this place and get x rays. Take the x rays and then go to the hospital. That way you don't get charged for the x rays at the hospital." They took me to this place. The x rays were $60.00 and I took the x rays and they definitely showed that my collarbone was broken the bill came to $10,000.00 for a sling and some Vicodin. They are still paying on it and the bill collectors call all the time. Breaking her collarbone and having to beg her parents to take her to the hospital was a traumatic experience for Layla. In fact, Layla highlighted that this particular experience caus ed a rift in her relationship with her parents for about two years. Layla recalled as a child being told that because of her parents immigration status , and that if as no need to seek out health care services. She indicated that when she broke her collarbone that her parents waited to take her to the hospital first and foremost because of expense, then because of their immigration status, but also because they believe d h er injury would heal on its own was Like Layla, immigration status, health beliefs, and financial situation played a role in his health seeking behaviors as a child and adolescent. Alex described that if there was ever anything wrong health wise as a child, his family cho se to take him to a Curandero 7 because are not expensive. as a child except for when he broke his a He indicated that he ess something is really wrong because it costs too much 7 a traditional native healer or shaman

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45 deterrent from seeki with talking to adults and then being worried about translating right Some participants highlighted the value of the health seeking behaviors that they were taught by their family . Yasmin, a former pre med student, specified that when she gets sick, she consults with her family firs t because family resources and referrals are more trustworthy and affordable : So I got bacterial pneumonia like almost two years ago, and obviously I didn't have healthcare insur ance back then but my mom c ontacted my aunts in Mexico and my aunts were like, I'm really good friends with my doctor here , I'm gonna ask them. They asked them, and then they contacted my mom and they're like she needs to take this type of medication, antibiotics It's funny 'cause I didn't even need a doctor but like, I was already diagnosed [by] the third person. So my mom went to our secret Hispanic pharmacy on Colfax for medication that's been imported from Mexico. I got my antibiotics for way cheaper , and like in three days I was fine. Yasmin indicated that her aunts doctors in Mexico and also k nowing about th e 8 9 have been forms of saver s for her because cheaper medication and you don and the people at the pharmacy understand her more A lthough Yasmin highlighted family con nections and knowing where to buy assets that shape her health seeking behaviors, such practices may be a result of low health literac y and can lead to poor health outcomes and increased rates of hospitalization and less recurrent use of preventative services (Berkman, Sheridan, Donahue, Halpern, & Crotty , 2011). 8 9 In Denver and in Aurora there have been news reports of local grocery stores that serve the Hispanic/Latino community selling antibiotics that should be dispensed by a licensed pharmacist. Some of these pills can be purchased for as little as 90 cents each (Denver CBS4, 2016).

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46 In addition to cultural and parental influence, seeking behaviors as children and adolescen ts were influenced by the availability of school based safety net systems. Many of the participants described ease of access to preventative care services as children because of their wel come participation in the K 12 education system. Monroe, a college graduate, explains that the last time she went to the dentist was when she was in middle school: Oh my gosh, years because the last time I ever went was when I got my root canal and I was actually getting help through, was it my middle school or high school, I don't know. I think it was my middle school or high school, they would give me a voucher for me to be a ble to go and get that help and ever since I got out of school, I don't get that help anymore. So it's been a bunch of years that I've been to the Sometimes my root canal bothers me a litt le bit when I chew on that side but I get help. Monroe said she understood the severity of putting off dental work, but because she was not aware of wher time , Monroe also acknowledged that the last time she received standard immunizations like the flu shot was in middle school: I actually got those through the school most of the time. Elementary and middle schoo l they really cared about getting our shots, which that's the only reason why I had access to do that. It was like a mandatory thing to be able to go into school and to stay in school so you had to go get these immunizations. Many of the female partici pants also described that they were able to learn about and receive contraception through voucher programs or school based clinics. Bernadette spoke about who and where she would go as an adolescent for reproductive health information: Well, for the longest time, I didn't have [health] insurance, so I didn't know where to go have any resources. So mainly when I was in high school, I turned to Denver Health Clinic for birth control, and just kind of working with those people from Denver Health. They had a clinic school based at my school, so that was the only place that I knew where to go to get my birth control. Likewise, Ana recalled being able to get birth control from her school based health clinic to treat her polycystic ovarian syndrome :

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47 A recurring problem that I had in high school was that I wasn't getting my period regularly and so my mom was really worried and I was really worried. So, I went to the school based clinic and they diagnosed me with something called, polycystic ovarian syndrome, which I still have, but it's better now. I think that the main concern at the time was t so that I could get my period regularly. The biggest concern was that I needed to have access to it and the school based doctor was able to help and I continued to get birth control there until I graduated. Having access to preventative care services such as health screenings, immunizations, and reproductive health services via school based health centers and voucher programs is critical in reducing educational gaps and advancing health equity among the young adult undocumented immigrant population . Yet , such services are only a stopgap for this population until they turn 18 years of age. B ecause of their immigration status and formal exclusion from recent health care reform , undocumented immigrant young adults have a much harder time than their U.S. born and legal counterparts with the transition from the pediatric health care system to the adult health ca re system. Most of the participants in this study stopped important health screenings, wellness visits, immunizations, and contraception as a result of not knowing where to go and how to locate providers and services once they graduated from high school. It is at this point , respectively at the age of 18 , when undocumented young adults are forced to transition into the adult health care system , where there is little to no support for them , that the respondent own undocumented status, socioeconomic status , and cultural beliefs about health and well being started to play a role in their health seeking behaviors. Although 10 out of the 12 participants were DACAmented (having DACA status) , their cultural beliefs about health and illness , legal exclus ion from the health care system, and fears contributed to their ability to navigate the health care system and their ability to engage in appropriate self care and disease management. Ellie, a full time student with school based health

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48 insuranc e , talked about a serious medical conditi on that she had been putting off because of cost and her immigration status: The doctors found some problems the last time I went for a physical for birth control. expensive I mean, just being undocumented, it just limits opportunities for anything so much that sometimes it's just not even worth looking or trying to get help with som ething like this , because it's not going to work out based on past experiences. Similarly, Sophia, insured by her employer at the time of the interview, spoke about not using her health care coverage because her health concerns were not that serious and b ecause she where to go to get care. Furthermore, Sophia had concerns about cost of services and her immigration status : I have health insurance through my employer. Do I use it? No. health issues, and if I did, know where to go and I don't ask friends for referrals just because they're obviously not in my situation without documentation. The places they will refer me to will cost me an arm and a leg if I go . Because of my immigration status wherever I go be treated differently. Maybe they won't like recommend certain things that would be beneficial for me, just 'cause they know my status and they assume certain things. Likewise , Itzel identified that the do I get my health checked, or pay for rent? Do I go check my health or do I help buy food for my family ? Similar to Itzel, all except one participant described having to pick and choose between accessing health care services and paying for day to day needs such as food, transportation, rent, and even college tuition . Notably, dramatic health disparities related to low socioeco nomic status exist among poor Americans and legal immigrants in the U.S. ; however, public benefit programs exist to help eligible low income individuals cover basic expenses like food, housing, health care , and even tuition and fee costs . Regrettably, under federal law, undo cumented immigrants are not eligible

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49 to receive public benefits such as Supplemental Nutrition Assistance Program (SNAP), 10 regular Medicaid, Suppleme ntal Security Income (SSI), Temporary Assist ance for Needy Families (TANF) , and fede ral financial aid for college tuition (Broder, Moussavian, & Blazer , 2015 ; USA.GOV, 2019 ) socioeconomic status and cultural beliefs about health and illness reinforced their legal exclusion from the health care system, and further contributed to barriers to health care access and utilization. Less Deserving Health Citizens as a R esult of Their Form of Health Care C overage The participants who were able to succeed at naviga ting the structural barriers to care, and their multiple individual barriers to care , including cultural beliefs about health and well being , immigration status , and socioeconomic status, experience d new barriers to care at the health systems level once they obtain ed health care coverage . Heal th e conomists argue that health insurance is not created equal and that many insured as a result of limited access to relatively few providers and the terms under which i nsurance is available ( Schansbe rg, 2014). Furthermore, a nthropologists argue that health care coverage does not necessarily equal better of thei , p. 105 ). Though insured, as undocumented immigrant young adults from low socioeconomic and low health literacy backgroun ds, the 10 participants who had health insurance coverage at the time of their interview, cam e face to face with the limits of th eir health insurance coverage. Adeline compares how she was treated when 10 SNAP was formerly kn own as the Food Stamp Program .

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50 she had student health insurance verses how she was treated as a consumer of the Colorado Bridge Program: I went to the health center on campus a couple of times, but it was always a little uncomfortable, just because it was more like, "Oh, you really don't have health insurance. You have school insurance. You're just here for that [school] ." I think that the one time I went the health center was mo re for my acne at the time and I got an acne prescription, does. It was more like, "Well, this is going to help your skin," and I was just like, "Okay." I used it once , I think. O n the other hand, now that I have Kaiser through the Bridge Program, I feel like since I started going [there], I was more exposed to what my real health was and how I was supposed to sustain it and better it. Undoubtedly, Adeline felt more deserving as a patient when she accessed health care services unexpected cancellation unfair Pe ople who are insured by the program are like me, young and undocumented, so why should they [Kaiser] Adeline reconciled with her limited access to health care services after the announcement of the end of the Colorado Bridge Program , and focused instead on how s he was going to schedule more appointments while she still had health care coverage. a source of health care coverage was not felt by all of the participants. In fact, 8 of the 10 insured respondents felt like the type of insurance coverage they had limited their access to seeing doctors they wanted, like specialists , and they also felt like the type of coverage contributed to how they were treated when seeking health services and to who treated them during their health encounters . Layla recalled being diagnosed with depression and anxiety by her primary care physician: Well, the first time I went to the doctor, was because I had already had the Bridge it. I wouldn't go to the doc tor at all, because I didn't know what to do, or how to get a doctor or whatever the whole process was. Just the process of . I t wasn't until I started having I was just really sad and crying all the time, that I was just like, okay, maybe I should call. I made an appointment, and they were like, oh, you need to be seen

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51 by her [the doctor] for three weeks and I was told by her I could see a Psychiatrist I think. I want to do that but I cause it takes time, like four weeks before or something, before they can get me in . Layla was certainly grateful and excited that she was able to see, her with her mental health issues. She was overwhelmed by how long she would have to wait to see a specialist and was scared that sh Program ended. Like Layla, others described being appreciative that they had health care coverage and a regular provider , but they also expressed difficulty in understand ing their h ealth conditions and treatment ir provider cared about them. Claudia emphasized this point by talking about the treatment she r eceived when she went to Kaiser for an issue with her stomach : I try to go t o the doctor like every three to four months, just because I'm taking medication for my stomach issues. And this is weird to me because I am not all about the medication just because I am very skeptical , but that is what my doctor said I needed . He also pr escribed me antidepressants. because I am not sure how my IBS [Irritable Bowel Syndrome] is connected with depression, but he [the doctor] said stress can cause IBS . And so I think the medication has been making me feel okay, but I think it's just covering everything else. I think they pills, but the doctor is the expert, right?... He said I need them [the pills]. Like Layla , Claudia was grateful that she had access to see a doctor regularly, but she was clearly frustrated by how she was treated by her provider. More specifically, she described her and that he never really explained why he put her on anti depressan ts. She talked about only depressants) when she needs t why she was taking them and additionally, they cos t too much.

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52 Furthermore , o ther insured respondents conveyed feeling discriminated against simply because of who was treating them. When I interviewed Sofia, she was insured by the Colorado Bridge Program. She was upset about all the steps she had to go thr ough to make an appointment, only to be seen by a physician assistant (PA) : Now that I have Bridge, I decided I needed to see a doctor because I was paying for it. I Sometimes these things just get so tedious I wouldn't know what I was selecting a nd for what, but I'd still wanted to do it [see a doctor]. So then I finally got an appointment e difference, but I thought I was going to see a doctor. She was Middle Eastern, so I think that was okay, but I feel sad about the situation. In spite of the efforts made by Sofia to figure out how to schedule an appointment and with whom, she was disappointed with the clinical encounter because she felt like she should have been treated by a physician or told she was going to see a PA instead of a doctor. She indicated that she scheduled the appointment with a doctor, and not a PA. Others felt toward the type of provider they saw as an insured person. Bernadette illustrates this point by describing the number of times she has had to go to Urgent Care and the Emergency Department or at Kaiser: I've been with a provider I've been to the urgent care, I've been to the ER, and it's been covered by my insurance, I Like Bernadette, many of the participants highlighted feel ing offended when they arrived at their appointments only to discover that they were going to be seen by a nurse or a physician assistant and not a doctor. The truth is, and it can be difficult t o see a doctor in a timely manner. Nevertheless, whatever the motivation was for why some of the participants saw other providers besides a doctor at their health visits, the

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53 consequence f or this group was that they did not feel like they were worthy healt h citizens. T hose that were part of the Bridge Program per ceived that they were being treated differently than other Kaiser patients because of the type of health coverage th at they had; one participant described the Bridge Program for undocumented immigrants. Thus on the one hand, the participants recognized the importance of having health care coverage resulting in their ability to access and afford health care. On the other hand , the participants also recognized that they did not experience a sense of health equality during their health encounters as a result of their perceived quality of care and because of who treated them when they sought out health care services via an in network facility.

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54 CHAPTER VI DISCUSSION AND CONCLUSIONS Previous research on undocumented immigrants and health care access and utilization and health coverage focuses largely on health disparities and barriers to care and the exclusion from health care reform ( Zuckerman, Waidmann , & Lawton 2011; Raymond Flesch et al., 2014; Hacker, Anies, Folb, & Zallman, 2015 ; Martinez et al., 2015 ). Furthermore, existing studies about access and use of health care services among undocumented immigrants in the U.S. have rarely addressed the he a lth care needs of undocumented immigrant young adults and the challenges they face in not only accessing health care, but also their overall health care experiences (for exceptions, see Vega, Rodriguez, & Gruskin, 2009; Artiga & Ubri , 2017; Sudhinaraset, T o, Ling, Melo, & Chavarin, 2017 ; Philbin, Flake, Hatzenbuehler, & Hirsch, 2018). Yet, the findings presented in this study draw on the experiences of primarily i nsured undocumented immigrant young adults. Using the case of undocumented immigrant young adul ts who have private health insurance, I argue that barriers to care and exclusion from health care reform are not simply the result of being an undocumented person and that immigration status as a sole explanation to these issues does not properly reflect the health seeking behaviors of undocumented immigrant young adults. highlights the multiple influences on health services' use and, consequently, on health status. The feedback loops show that outcomes, in turn, affect subsequent predisposing factors and perceived need for health care services as well as health behavior. Another possible predisposing component which may be conceptually distinct from th ose listed in the current model is structural stigma. I emphasize how structural stigma, specifically health care related laws and

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55 related polices, parental social positions, including undocumented status , culture, and socioeconomic status, p ar ticipant social positions, including undocumented status, culture, and socioeconomic status , and perceived quality of care, intersect over time to shape health seeking behaviors of undocumented immigrant young adults. I argue that these elements overlap wi th each other and heighten health system and individual barriers to c are and health care utilization amongst this population . An overarching premise of this research is that when considered alongside one another, structural stigma, pa rental social locations, social locations of the undocumented young adult, and perceived quality of care, predict the health seeking behaviors of undocumented immigrant young adults . Furthermore, when looked at simultaneously these inhibiting predictors of health seeking behaviors among undocumented immigrant young adults enable a broad band of social determinants of health and multiple negative health outcomes for this population. Use of health services by undocumented immigrant young adults is key to th eir overall health and well being . As my research suggests , structural level stigma in the form of health care related polices , plays an imp ortant role in producing health disparities among st the undocumented immigrant young adult population. In particular, federal and state level policies that limit or restrict access to care, notably contribute to t he most damaging aspects of barriers undocumented young . Such policies co ntribute to when and where undocumented immigrants access care. As such, many undocumented immigrant young adults choose to access formal health care as a last resort (Garcés, Scarinci, & Harrison, 2006; Raymond Flesch et al., 2014). Additionally, when und ocumented immigrants do access care, it tends to be through safety net options such as the emergency department and safety net clinics (Raymond Flesch et al., 2014; Sommers, 2013).

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56 t improving overall public safety, contributes to the stigmatization of undocumented immigrant young adults. The information required to be on a s license of an undocumented immigrant serves as a label of immigration status which can lead to an indi vidual being treated differently prior to and during a health encounter. S uch policies can dissuade undocumented immigrant young adults from seeking formal M y findings also show that the health seeking behaviors of undocumented immigrant young adults are further shaped by their health beliefs and the ir experience within the health care system. First, parental social positions, including undocumented status, culture, and socioeconomic s tatus , influence the health seeking behaviors of undocumented immigrant young adults at an early age . signing up for health benefits could leave them and their children susceptible to deportation, it is more likely that they will forgo care not only for themselves, but for their children as well. Thus, t he urge to access care is often outweighed by parental immigration status. Undocumented children and adolescents are at the will of decisions about health care access and utilization. Furthermore, c ost of care contributes to why parents who are undocumented cho ose to delay or not to take their children to see a doctor. Such behaviors contribute to negative attitudes aro und the necessity of care . Specifically, undocumented immigrant children are taught that formal health care sh ould be used as a last resort. Unfortunately, d elaying care can lead to worse health and more costly care, which means that future care could be m ore difficult to access due to cost . At the age of 18, undocumented immigrant young adults experience their own barriers to care as a result of their own social positions. I mmigration status, low socioeconomic status, and cultural beliefs abo ut health and illness reinforce their legal exclusion from the health care

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57 system, and further contribute to system and individual barriers to health care access and utilization. Undocumented immigrant young adults have to navigate an increasingly more complex healt h care environment without the support systems afforded to their U.S . born and legal counterparts . As a result, many undocumented immigrant young adults lack the ability to navigate the health care system, including knowing how to complete complex health c are paperwork and locating providers and services. Additionally, because of their low socioeconomic status , undocumented immigrant young adults are less likely to be able to afford preventative care services and engage in appropriate self care and disease management. Such behaviors can have long term effects on health. Finally, even after undocumented immigrant young adults obtain health care coverage, their health seeking behaviors are further influenced as a result of new barriers to care at the health s ystems level . Although being included in the health care system can provide a sense o f security and comfort, it can also lead to further health inequalities. The types of health care coverage available to undocumented immigrant young adults can contribute to negative health care experiences. There has been recent scholarly inquiry into the Medicaid expansion and experiences of health inequality for the undocumented immigrant young adult population are th e consequences of how one is treated and by whom during the health care encounter . For insured undocumented immigrant young adults, the ir q uasi inclusion in the health care system, and perceived negative health care experiences, ultimately shapes their sen se of self as less deserving health citizen s . Furthermore, as highlighted, the fact that health care coverage can be taken away at any time undermines the

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58 extent to which undocumented immigrant young adults can experience equality in the health care system . In order to better understand that the health and well being of undocumented immigrant young adults cannot be disconnected from the political and social environment , the general public, health care professionals, and policymakers will need to develop an understanding of the complexity of federal el igibility provisions and states choices in extending or further restricting health care coverage for undocumented immigrants . Furthermore, our c urrent political environment around immigration has created a sens e of constant hypervigilance and fear amongst the undocumented immigrant populati on in our country. Persistent structural and social stigma take a toll on the mental and physical health of undocumented immigrants and their loved ones, in turn increasing t heir risk of poor health and diminished access and utilization of health care. Core values of public health include promoting health care equity, quality and accessibility, valuing every life, and preventing harm (CDC Foundation, 2019). Regardless of poli tical and social positions on immigration, the real ity that undocumented immigrant young adults have significant unmet health needs, and the sheer number of undocumented immigrants between the ages of 18 39 living in the U.S. , indicates that it is imperati ve to understand and address barriers to health care utilization for this group because the impact goes beyond the individual and local community. U nequal access to care and unequal care during the health encounter harms undocumented immigran t patients, th eir families, the health care providers who treat them, and the entire country. Limited access to health services, and lower health care utilization among undocumented immigrants because of health beliefs, low SES, and fear of

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59 being stopped by police and p otential deportation, infiltrates society as a whole and it becomes a matter of public health.

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60 CHAPTER VII LIMITATIONS AND FURTHER RESEARCH There are important gaps and knowledge about the health seeking behaviors of undocumented immigrant young adults. In this section I will highlight limitations of my own research and areas to guide future research on this topic. Study Limitations Although my research methodology attempted to conduct a broad review of health seeking behaviors of undocumented immigrant young adults in the Denver metropolitan area , limita tions remain. While undocumented immigrants from Mexico and Central America contribute to the largest numbers of the undo cumented population in the U.S. , due to new migration patter ns, the number of undocumented immigrants from the Caribbean, South America, Asia, Eastern Europe, and Africa has increased (Migration Policy Institute; 2019) . Trends in health seeking behaviors for undocumented immigrant young adults from these regions is not reflected in this study (s ee for example Gonzales & Burciaga, 2018 ) . The authors point out that certain ethnic communities feel a sense of stigma and shame as a result of their undocumented status, making it much harder to recruit and interview people from certain regions of national origin (Gonzales & Burciaga, 2018) . Furthermore, a possible methodological limitation exists with the sample size. Although sampling saturation was met for this study , for publication purposes, it would be ideal to have a larger sample size and perhaps a comparative sample. For example, adding a comparison sample of undocumented young adult males and females, or U.S. born and legal counterparts could add to the context of the research problem. It should be noted that becau se of fear of arrest, deportation, or exclusion from qualification for amnesty if it becomes available, undocumented

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61 immigrants in general avoid talking about their immigration status, making it harder to understand their specific health care access and ut ilization experiences. Also, despite the fact that males represent more than half (53%) of the undocumented immigrant population in the U.S. (M igration Policy Institute; 2019 ), many feel vulnerable about sharing their story. For this study , it should be noted that men in general are less likely to speak about their health and participat e in risk mitigating behaviors (s ee for example Courtenay , 2000 ) . Because only one of the study participants identified as male, I cannot speak confidently abo ut the undocumented immigrant young adult male narrative regarding health seeking behaviors. Furthermore, because the study is based on self reported data it is limited by the fact that it can not be independently verified. The data may contain several pot ential sources of bias including: (1) selective memory bias ; (2) telescoping bias ( recalling events that occurred at one time as i f they occurred at another time ; (3) attribution bias ( attributing positive events and outcomes to one's own agency, but attri buting negative events and outcomes to external forces); and, (4) exaggeration. Such limitation s can serve as an important opportunity to identify new gaps in the literature and to describe the need for further research. Recommendations for Further Research It is suggested that future research on health seeking behaviors of undocumented young adults include a more diverse narrative around gender, region of birth, and geographic location. Gender is a crucial factor that impacts health and well being. Gender perspectives are important in contemporary immigration research on health care access and utilization because gender socialization among undocumented Hispanic/Latino immigrants may play a role in the willingness to seek out and utilize health care (Nuñez et al . , 2016 ) . For undocumented immigrant Hispanic/Latino males , the concept of machismo defines beliefs and expectations around the role

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62 of men in society. Nuñez et al ., describe machismo positive and negative aspects of masculinity, including bravery, honor , dominance, aggression, sexism, sexual prowess, and reserved emotions Nuñez et al., p. 3, 2016 ). For undocumented immigrant Hispanic/Latino females the concept of marianismo , defines the values and expectations regarding female gender ro les. Marianismo stresses the role of women as family and home centered; it influences passivity, selflessness , and modesty ( Nuñez et al., 2016 ). T he association between the construct of machismo and marianismo and health seeking behaviors of undocumented Hispanic/Latino males and females remains unclea r. Nuñez et al. identify that most of the existing literature on male gender roles in general has been attained from college students and non Hispanic White male and female populations , and has not always ref lected c ultural aspects of gender roles (Nuñez et al., 2016). Thus future research should draw on the differences and similarities of health seeking behaviors among male and female undocumented immigrant young adults. Most research on undocumented immigra nts and health in the U.S. has focused primarily on Hispanic/Latino immigrants , especially those from Mexico. We know that i mmigrants in general tend to have better health and mortality profiles than the ir native born counterparts , especially fr om the same racial/ethnic group (Markides & Rote, 2015). However, more data are required to systematically examine whether the relationship between health seeking behaviors and structural stigma, undocumented status, culture, and SES, operates similarly or differently among undocumented immigrants from different nationalities. D ue to new migration patterns in the U.S. , it is important to conduct future research on the health and health seeking behaviors of undocumented immigrants from the Caribbean, South Am erica, A sia, Eastern Europe, and Africa. Disaggregating results by nativity will allow researchers to determine whether certain undocumented groups are disproportionately affected by structural stigma and their social

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63 locations, including undocumented stat us, culture, and SES. Assessing nativity and health seeking behaviors among undocumented immigrants in the U.S. is particularly important because undocumented immigrants from certain underserved sub groups (i.e., those who speak fair/poor English, low educ ation levels, those who are experiencing acculturative stress) are more likely to experience negative health outcomes. P lace and neighborhood context and health are inherently linked . In order to encompass the full breadth of health seeking behaviors of undocumented immigrant young adults, it is important to replicate this research in rural communities and furthermore, in states that have restrictive laws directed at undocumented immigr ants . According to t he 2010 Decennial Census, almost 60 million people, about 19 percent of the population, lived in rural areas of the U.S. (U nited States Census Bureau, n.d.). Health disparities research has emphasized that people who live in rural comm unities are at risk for poorer health compared to urban and suburban residents (Warshaw, 2017; Centers for Disease Control and Prevention, 2017). Furthermore, people who live in r ural communities often encounter barriers to health care that limit their ab i lity to obtain the care they need (Rural Health Information Hub, 2019). Future research should examine whether the health seeking behaviors of undocumented immigrant young adults are similar or different in rural vs. urban locales. As mentioned in the literature review, much of what we know about the health care needs and barriers to care for undocumented immigrants, is based on research conducted in immigrant friendly states (states that have laws that make it easier for undocumente d immigrants to access jobs, higher education, he alth care, and driver licenses). There is a growing body of research on s tate level differences in migration control and their effects on US migration p atterns (Leerkes, Leach, & Bachmeier, 2012 ; Ellis, Wrig ht, & Townley, 2016). Such research suggests that state -

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64 level and local level hostile immigration policies arose mostly after 2007 and are disproportionately found in places where the rates of foreign born population gro wth are high, but also where they ar e mostly Hispanic/Latino ( Leerkes, Leach, & Bachmeier, 2012; Ellis, Wright, & Townley, 2016 ). A dapting earlier research on Latino migration by Leerkes, Leach, classifies states into two groups: "hostile states," which have enacted laws that ar e restrictive in some way (i.e., Ariz., Ark., Colo., Conn., Fla., Ga., Md., Miss., Mo., N.C., Nev., Okla., Ore., S.C., Tenn., T exas, Utah, and Va.) and all others, which the authors refer to as "non hostile states " ( Ellis, Wright, & Townley, 2016 ). S tate level and local level statutes around immigration enforcement have inten ded and unintended health consequences for undocumented immigrants. Future work should therefore examine whether there is a difference in health seeking behaviors amongst undocumented immigrant Additionally, more work is needed on the health seeking behaviors of undocumented immigrant young adults who live in a sanctuary city ( a c ity where city level laws tend to protect undocumented immigrants from deportation or prosecution, despite federal immigration law ) located in an exclusionary or state . Finally, more work is needed in the areas of policy and public health programmin g . Future investigation should examine how educational programming around health and health care access might improve the health of undocumented immigrants and lessen health disparities. For example, culturally sensitive health literacy intervent ions could be developed for undocumented children, adolescents, young adults and their families. Additionally, a comprehensive website dedicated to information about health, health care access, and health care resources, could be developed for local commun ities and states. To make informed choices,

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65 people need accessible and accurate information. Thus, the accessibility of information about health and health care resources is important in ensuring undocumented immigrants can make choices about their health and can do so in an informed way. Furthermore, in order to improve health care services and access to care for undocumented immigrants, more research is needed around how health care services are coordinated and when, where, and by whom patients are referr ed. Patient navigation is an internationally utilized, culturally grounded, and multi layered strategy that is used to enhance pati collaboration with the health care team and system in order to help decrease existing health care disparities (Natale Pereira, Enard, Nevarez, & Jones, 2011). Patient navigators were first used at a public hospital in Harlem, health care a dvocates for poor black women who were diagnosed with breast cancer ( Freeman, 2012). Patient navigation has evolved into an effective approach to help improve health outcomes amongst vulnerable populations (economically disadvantaged, racial and ethnic minorities, the uninsured and underinsured, low income children, the elderly, the homeless, and those with HIV, other chronic health conditions, and or severe mental illness), by reducing barriers to timely diagnosis and treatment of cancer, chronic diseases, and infectious diseases ( Natale Pereir a, Enard, Nevarez, & Jones, 2011; Freeman, 2012). For undocumente d immigrants , a patient navi gator could help with care coordination, they could provide general health literacy information (educatio nal pamphlets, resources, etc.), and they could provide information about appropriate health ca re screenings by age and gen der. At a minimum, a patient navigator could develop and provide health information about risks associated to behavior (smoking, unsafe sex , etc.) in multiple languages .

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