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SAN DIEGO STATE UNIVERSITYUNIVERSITY OF CALIFORNIA, SAN DIEGOMental Health and Quality of Life of Undocumented Latino Immigrants in the California-Mexico Border: Risks and Protective FactorsA dissertation proposal submitted in partial satisfaction of the Requirements for the degree Doctor of PhilosophyinClinical PsychologybyLuz M. GarciniCommittee in charge:San Diego State UniversityProfessor Elizabeth A. Klonoff, Chair Professor John P. Elder Professor Vanessa L. MalcarneUniversity of California, San DiegoProfessor Neil DoranProfessor Mark G. MyersProfessor Monica D. Ulibarri2013 TC "Signature Page" \l 1 The Dissertation Proposal of Luz M. Garcini is approved, and it is acceptablein quality and form:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Chair San Diego State UniversityUniversity of California, San Diego2013 TC "Table of Contents" \l 1 TABLE OF CONTENTSSignature Page …........................................................................................................... iiiTable of Contents …....................................................................................................... ivList of Abbreviations ….................................................................................................. viiAcknowledgements ….................................................................................................... ixAbstract …...................................................................................................................... 11Introduction …................................................................................................................ 14The Foreign-Born Latino Population ................................................................. 15 Undocumented Latino Immigrants ..................................................................... 17Background ..................................................................................................................... 20Mental Health of Undocumented Immigrants .................................................... 20 Immigration-Related Risk Factors ..................................................................... 22 Protective Factors ............................................................................................... 26Culture and Context Sensitive Mental Health Assessment with Latinos ....................... 28Cultural Concepts of Distress ............................................................................ 28 Nervios and Ataque de Nervios among Latino Immigrants.................... 30Contextual Concepts of Distress among Immigrants ......................................... 33Ulysses Syndrome ................................................................................... 34Theoretical Framework and Significance ....................................................................... 36New Contribution ............................................................................................... 36General Aims ...................................................................................................... 37Phase One: Formative Study .......................................................................................... 38Specific Aims ..................................................................................................... 38Method ............................................................................................................... 38Participants ............................................................................................ 38Inclusion/Exclusion Criteria ................................................................. 39Protection of Research Participants ...................................................... 39Design ................................................................................................... 40Measures ............................................................................................... 41Translation ............................................................................................ 41Analyses ............................................................................................... 42Phase Two: Clinical Study ........................................................................................... 44Specific Aims ................................................................................................... 44Method ............................................................................................................. 46Participants .......................................................................................... 46Targeted Sampling .............................................................................. 47Respondent Driven Sampling ............................................................. 47Inclusion/Exclusion Criteria ............................................................... 49Power Analyses ................................................................................... 50Protection of Research Participants .................................................... 52Design ................................................................................................. 53Measures ............................................................................................. 53Translation .......................................................................................... 67Analyses ............................................................................................. 68Hypotheses ......................................................................................... 68Table 1. Demographic and socio-economic characteristics by immigration legal status categories .............................................................................................................. 73Table 2. Lifetime prevalence of mental health disorders among Latinos ...................... 74Table 3. Assessment of Cultural and Contextual Concepts of Distress ........................ 75Figure 1. Dahlgreen & Whitehead (1991) Socioecological Model ............................... 78Appendix A: Screening Questions for Participation in Focus Groups .......................... 79Appendix B: Mental Health Services Contact List ....................................................... 80Appendix C: Demographic Questionnaire: Focus Groups ........................................... 81Appendix D: Focus Groups Guided Discussion Questions ......................................... 83Appendix E: Translation Forms ................................................................................... 84Appendix F: Screener for Participation Eligibility in Quantitative Study ................... 91Appendix G; Questionnaire and Measures for Quantitative Study .............................. 92References .................................................................................................................... 114 TC "List of Abbreviations" \l 1 List of AbbreviationsACSAmerican Community Survey PAAmerican Psychological AssociationBSI-18 Brief Symptom Inventory-BriefBSI-46Bradford Somatic InventoryCIDI Composite International Diagnostic Interview CDCPAR Cancer Disparities Community Partners and Research CFICultural Formulation Interview DREAMersDevelopment, Relief, and Education for Alien Minors ActDSMDiagnostic and Statistical Manual of Mental Disorders EMICExplanatory Model Interview CatalogueGAD Generalized Anxiety DisorderHTQHarvard Trauma QuestionnaireICDInternational Classification of Diseases INSImmigration and Naturalization ServicesIRBInstitutional Review Board for the Protection of Human SubjectsM.I.N.I. Mini International Neuropsychiatric Interview MDD Major Depressive Disorder MLSMultidimensional Loss Scale NIMH National Institute of Mental Health NLAAS National Latino and Asian American StudyPI Principal investigatorPMLDPost-Migration Living Difficulties QuestionnairePTSD Post-traumatic Stress Disorder QOLQuality of lifeRDSRespondent Driven SamplingSCI-2Sense of Community Index Version 2SCID Structured Clinical Interview for DSM diagnosisSDPRC San Diego Prevention Research CenterSDSUSan Diego State UniversitySPSSStatistical Package for the Social Sciences SoftwareUCSDUniversity of California, San DiegoUIsUndocumented immigrants US United StatesWHO World Health OrganizationWHOQOL-BREF World Health Organization Quality of Life Questionnaire-Brief TC Acknowledgements \l 1 Acknowledgements Con infinito agradecimiento a mis mentores y profesores Elizabeth Klonoff, Vanessa Malcarne, Guadalupe Ayala, John Elder, Monica Ulibarri, Neil Doran, Mark Myers, Ana Navarro and Kate Murray, por sus valiosas ense?anzas, guia, y apoyo durante los pasados cinco a?os en el programa. Este trabajo no seria posible sin todos ustedes. Gracias tambien a mi mentor Jeff Baker por haber creido en mi y por ser un modelo ejemplar de dedicacion en este bello campo.Mi agradecimiento tambien va para mis companeros y amigos, Luis Medina y Sheeva Mostoufi, por ayudarme, aconsejarme y guiarme en el proceso de esta propuesta. Gracias por tomarme de la mano y caminar conmigo. Tambien me gustaria reconocer el apoyo financiero de Humberto B. Galvan durante mi desarrollo academico, asi como a Ford Fellowship Foundation y a UCSD San Diego Fellowship program por haber invertido en mi. Este trabajo es parte del resultado. A mis hijos, Thania y Baruch Galvan, no tengo palabras suficientes que puedan expresar lo mucho que agradezco su presencia en mi vida. Ustedes son mi motor y mi empuje. Mi trabajo y mi vida entera estan dedicados a ustedes. A mis hermanos, Carlos y Ana, gracias por existir, y a mis padres Luz y Carlos, gracias por darme el ser. Sin ello, este trabajo no existiria! Gracias tambien a mis cachorros, Benito y Clarita, por su constante compania durante largas horas de trabajo. Nunca han dejado que me sienta sola. Especial agradecimiento es para los millones de immigrantes indocumentados que luchan dia a dia en este pais por salir adelante. Gracias por producir y servirnos la comida que comemos, por mantener y cuidar las casas en las que vivimos, por atender y velar por nuestros hijos y familias como si fueran propias, pero sobre todo, gracias por ser un vivo ejemplo de que “Si se puede!” Gloria, te recurdo y tu muerte no fue en vano. Te llevo a ti y a tu familia en mi pensamiento y este trabajo es el resultado. Gracias por darme un proposito. Tambien, gracias a Margaret Kahn, Susan Wooley, Marina Plon, Issac Plon, Richard Alter, Karina Miranda, Lorena Nuno, Abel Gomez, Carlos Mendez y Rosa Zepeda, porque cada uno de ustedes me ayuda a levantar cuando me cuesta trabajo caminar. Gracias por estar presentes en mi vida. Sobre todas las cosas, gracias a Dios por ser mi roca, mi fortaleza y mi guia en todo momento. “Porque yo sé muy bien los planes que tengo para ustedes —afirma el Se?or—, planes de bienestar y no de calamidad, a fin de darles un futuro y una esperanza” (Jeremias, 29:11) TC Abstract \l 1 ABSTRACT OF THE DISSERTATIONMental Health and Quality of Life of Undocumented Latino Immigrants in the California-Mexico Border: Risks and Protective FactorsbyLuz M. GarciniDoctor of Philosophy in Clinical PsychologySan Diego State University, 2013University of California, San Diego, 2013Professor Elizabeth A. Klonoff, ChairBackground: Undocumented Latino immigrants (UIs) and their families make up a considerable proportion of the US population at-risk for mental health distress. Yet, research to inform the mental health and quality of life (QOL) of UIs is scant and existing studies often lack scientific rigor. Objective: This study aims to use the socio-ecologic framework and context-sensitive methodology to study risk and protective factors associated with mental health outcomes among UIs living in San Diego and surrounding areas. Design: This study has two phases. In phase one, focus groups with 30 Latino immigrants knowledgeable about the undocumented population in San Diego will be conducted to gather qualitative data to: (1) assess the perceived relevance of mental health as a concern among UIs; and (2) obtain feedback on the proposed methodology for the clinical mental health assessments to be undertaken in phase two. Phase two is a cross-sectional study aimed to: (1) assess the prevalence of mental health disorders among UI Latinos and compare it to rates for other US populations; (2) evaluate the QOL of UIs and identify its association with mental health; (3) identify demographic, socioeconomic and immigration-related risk factors associated with mental health disorders among UIs; and (4) identify moderators of the association between immigration-related loss/trauma and mental health among UI Latinos. The cross-sectional study will use semi-structured clinical interviews to assess the mental health and QOL of approximately 200 UIs Latino adults. Recruitment will utilize Respondent Driven Sampling (RDS) with the collaboration of networks-based referrals from the SDSU/UCSD Disparities Community Partners and Research (CDCPAR) Resource. Measures: Mental health disorders will be assessed primarily using the Spanish version of the M.I.N.I. International Neuropsychiatric Interview, as well as adapted versions of the Diagnostic and Statistical Manual for Mental Disorders 5th Edition (DSM-V) Cultural Formulation Interview (CFI) for the assessment of Cultural and Contextual Concepts of Distress. Analysis: Qualitative data will be analyzed using systematic methods outlined by Miles and Huberman (1994), whereas multivariate sequential regression analyses will be used to assess quantitative associations of interest. Significance levels will be set at p ≤ .05. Conclusion: Results will increase understanding of the mental health needs of UI Latinos, which is important to decrease inappropriate use of healthcare services, and ensure a healthier workforce and community, as well as to inform the development of interventions and policies. I. INTRODUCTION A current important issues in the global policy agenda is that of international migration, that is, the movement of people across international boundaries, given its enormous impact on the economy, society, culture and health indicators of countries of origin, transit and destination. According to the World Health Organization (WHO) (2010), international migration is at its all-time-high with more than 230 million people or approximately 3% of the world’s population being international migrants. This estimate represents an approximate 34% increase in the international migrant population over the past two decades, with the greatest flow of migration taking place from less developed to more industrialized countries, as migrants cross borders in search of better economic and social opportunities (WHO, 2010). For more than two decades, the United States (US) has been identified as the most popular destination for international migrants, with an average annual immigration growth of 2.8% (WHO, 2010). Recent estimates show that approximately 13% of the US population is foreign-born, with immigrants from Latin America comprising the majority of the US foreign-born population (53%) (US Census Bureau, 2012). If population trends remain unchanged, it is estimated that nearly one in five Americans will be foreign-born by 2050, with a large proportion being Latinos (Pew Research Center, 2013). The increase in global mobility, advances in communication infrastructure, demand-pull factors in the US (e.g., family unification, economic opportunity) and supply-push factors in sending countries (e.g., poverty, violence), make it likely that Latinos will continue to migrate to the US at a fast rate. Thus, it is in the best interest of this country to increase knowledge about the complex needs and health status of Latino immigrants by putting it at the forefront of national policy, public health initiatives, economic planning, and research agendas. The foreign-born Latino population in the United StatesForeign-born Latinos in the US vary widely in terms of country of origin, geographic distribution, demographics, socio-economic position, health status, and immigration-related characteristics. For example, of the approximately 21 million foreign-born Latinos in the US, 11.7 million or more than half (55%) are of Mexican-origin (US Census Bureau, 2012). This means that of the total US foreign-born population, more than 29% were born in Mexico (US Census Bureau, 2012). Also, despite recent increases in foreign-born Latino populations across various US states, California continues to be the state with the largest number of foreign-born Latinos, including housing the majority of UIs (Brown & Lopez, 2013). Several counties in Southern California, including those near the California-Mexico border, have been identified as having a rapid growth in their foreign-born Latino population, particularly of Mexican origin (Brown & Lopez, 2013). If these population trends continue, the Latino immigrant population in this region will grow at a faster rate than the population as a whole, in both the US and Mexico (Immigration Policy Center, 2012). When compared to the US-born population, foreign-born Latinos differ considerably in demographic and socioeconomic characteristics. According to the American Community Survey (ACS) (2012), the majority of foreign-born Latinos (55%) is between the ages of 18-44 years, whereas only 35% of the US-born population is within such age range. Disparities in educational attainment are also evident with a greater proportion of foreign-born Latinos reporting lower levels of education when compared to the US-born general population. The aforementioned disparities in age and education highlight the important contribution of foreign-born Latinos to a productive workforce in secondary job markets, which is essential to foster economic growth in the US. Unfortunately, disparities in poverty rates are also evident between foreign-born Latinos and the US-born population, with a greater number of foreign-born Latinos living in poverty (18 versus 10% respectively). Important to note is that the aforementioned estimates are based on national data not likely to be inclusive of UIs; thus, it is possible that the previously mentioned socio-economic disparities may be even larger than reported for certain foreign-born Latino subgroups, specifically UIs. Health disparities have also been documented between foreign-born Latinos and their US-born counterparts, with greater advantage found among the foreign-born (Cunningham, Ruben, & Narayan, 2008). Some potential explanations to the health advantage observed among foreign-born Latinos have been attributed to: (a) better lifestyles before and immediately following migration to the US; (b) extensive social support, and (c) health selection through immigration screening (Cunningham, et al., 2008). Although it is possible that these explanations may be valid for some foreign-born subgroups, it is also likely that these assumptions may not hold truth for most disadvantaged immigrants (e.g., UIs). Unfortunately, foreign-born Latinos are often studied as a homogeneous group, without much attention given to within group differences, including variations among those differing in immigration legal status. UIs, who often immigrate to the US as a result of harsh living conditions in their country of origin, must face distressing and marginalized lifestyles while residing in the US (Garcini, Murray, Zhoe, Klonoff, Myers, & Elder, under review). Faced with restricted opportunities for legalization and family reunification, the distress experienced by UIs often becomes chronic and more severe. Extensive research shows that the health advantage of foreign-born Latinos, often dissipates over time, with longer time of residence in the US associated with significant deterioration in health status (Cunningham, et al., 2008). Research to inform on the health status of disadvantaged foreign-born Latinos, including UIs, is needed to elucidate on existing health disparities so that effective prevention and treatment alternatives may be developed (Vega, Rodriguez, & Gruskin, 2009). Undocumented Latino immigrants in the United StatesA current national political debate is the issue of defining a path towards legalization to address the millions of UIs in the US. It is estimated that only about 29% of foreign-born Latinos are naturalized citizens, with the rest being non-citizens (71%), including legal residents and UIs (American Immigration Council, 2012). UIs and individuals living in “mixed-status” families, that is, families in which at least one member is undocumented, make up a considerable proportion of the US population. It is estimated that in 2011 there were approximately 11 million UI Latinos in the US; approximately 4% of the total US population (Pew Research Center, 2013). UIs comprise about 30% of the US foreign-born population, with the majority being of Mexican-origin (Pew Research Center, 2013). Also, there are approximately 4.5 million US-born children whose parents are unauthorized (Passel & Cohn, 2009; 2010; 2012), and at least 9 million Latinos living in “mixed-status” families (Taylor, Lopez, Passel, & Motel, 2011). Moreover, estimates show that UIs comprise 5.4% of the US workforce, accounting for up to 10% of the labor force in states such as California (Passel & Cohn, 2009). Also, it is estimated that one in four farmworkers is an UI, and that UIs comprise a large proportion of jobs in the construction, food, transportation and maintenance industries. Unfortunately, most UIs and their families experience socioeconomic disadvantage. When compared to the general foreign-born Latino population, UIs have lower educational attainment and higher poverty rates. These socioeconomic disparities become even greater when UIs are compared to the general US-born population. Table 1 summarizes some of the aforementioned disparities by immigration legal status. Although some UIs eventually return to their country of origin, a good proportion decides to stay and establish permanent residence in the US. Most UIs that make the US their permanent residence include those able to reunite with their families in the US, as well as those with US-born children. Estimates show that approximately 43% of UIs have resided in the US for more than 10 years (Passel & Cohn, 2008). The negative effects on health of socioeconomic disadvantage, marginalization, and demanding work conditions over time are widely documented (Commission on Social Determinants of Health, 2008), as is the economic impact of poor health on the healthcare system. Yet, there is growing proportion of foreign-born Latinos, particularly UIs and their US-born children, for whom such negative health effects may become reality over time. Identifying protective factors to ameliorate the negative health effects of poverty, marginalization and harsh living environments in this population is necessary to develop prevention interventions, reduce healthcare cost, and inform policy.II. BACKGROUND Immigrant health has been a seriously neglected area of research, although this is gradually changing with a recent increase in studies focusing in quality and use of healthcare among at-risk immigrants, including UIs. Unfortunately, research to understand the effects of immigration legal status, particularly undocumented status, on physical and mental health is limited. Given that UIs make up a considerable proportion of the US population and its workforce, facilitating understanding of their wellbeing and mental health challenges is important to decrease inappropriate use of healthcare services, and ensure a healthier workforce and community, as well as to inform the development of interventions and policies. Mental health of undocumented immigrants in the United StatesAccording to Healthy People 2020, mental health is 1 of 12 leading health indicators given it is essential to a person’s wellbeing, quality of life, physical functioning, interpersonal relationships, and productivity (US Department of Health and Human Services). The association between mental health and quality of life is widely documented, with better mental health associated to increased wellbeing. In a study of UI Latinos from the 2009 San Diego Prevention Research Center (SDPRC) Community survey, depression was found to be the only factor significantly associated with poor quality of wellbeing scores (β =-13.34, 95% CI = -22.32, -4.36, p = 0.01), after controlling for demographic, socioeconomic and migration-related factors, including length of time in the US and language acculturation (Garcini, Renzaho, Molina, & Ayala, in preparation). The immigration path to the US often presents with multiple stressors and complex challenges at different stages of the migration process, which increase risk for emotional disturbance and may compromise mental health (Chung, Bernak, Ortiz, & Sandoval-Perez, 2008; Sluzki, 1979; Ornelas & Perreira, 2011). UIs are a population at increased risk for mental health distress given the additional complex stressors that these population face above and beyond those of documented immigrants (Sullivan & Rehm, 2005). Research to explore determinants of health among UIs has increased considerably within the past decade; however, a recent systematic review of 23 studies showed that there is very little research to inform the wellbeing and mental health of UIs, and that existing studies often lack scientific rigor and are limited in providing prevalence data for mental health disorders and associated risk factors (Garcini, et al., under review). The use of self-report, imprecise measurement, and the limited analysis of mental health outcomes by immigration legal status also make it challenging to identify the prevalence of mental health disorders among UIs. Among the few studies reporting on prevalence of mental health disorders in this population, only one provided actual Diagnostic and Statistical Manual for Mental Disorders 4th Edition (DSM-IV) diagnosis. This study explored the prevalence and predictors of PTSD among 212 UIs at their point of entry to the US (Rasmussen, Rosenfeld, Reeves, & Keller, 2007). Results from this study showed that 11% of UIs (95% CI = 0.07, 0.16) met criteria for PTSD, with at least 82% of participants reporting having experienced previous trauma. When compared to national estimates using data from the National Latino and Asian American Study (NLAAS) for US-born and foreign-born Latinos, the prevalence of PTSD among UIs was considerably higher (5.9%, 95% CI = 0.04, 0.07 and 4.0%, 95% CI = 0.03, 0.05, respectively) (Alegria, Canido, Shrout, Woo, Duan, Vila, et al., 2008). The aforementioned disparities in the prevalence of PTSD across Latino subgroups suggests that the mental health advantage often reported among foreign-born Latinos, may not accurately reflect that of UIs, particularly in regards to trauma and stress related disorders. Moreover, although not specifically reported based on DSM-IV diagnosis, research shows that depression is also prevalent among UIs. A preliminary study using data from the 2009 SDPRC Community survey on 397 Latino immigrants (15% undocumented) showed that 12% of UIs reported moderate to severe levels of depression, with depression identified as a significant predictor of wellbeing after controlling for relevant covariates (Garcini, et al., in preparation). Likewise, in a study of 90 Mexican-origin immigrant women (67% undocumented), results showed undocumented women not qualifying for amnesty to have significantly higher levels of depression when compared to UIs qualifying for amnesty and legal residents (Rodriguez & DeWolfe, 1990). Various qualitative studies have also render support for depression as a relevant concern among UIs, along with anxiety, somatization, and substance use/abuse disorders (Garcini, et al., under review). Additional studies to provide background data on the prevalence of the aforementioned mental health disorders among UIs that is based on DSM-V or ICD-10 diagnosis are needed to inform decision-making and the provision of health services. Immigration-related risk factors Psychological distress has been identified as common to the undocumented experience with stressors varying across different stages of the immigration process (Garcini, et al., under review). Salient stressors identified as common among UIs pre-migration include having a sense of failure related to the inability to succeed in the country of origin, as well as history of political/war trauma (Horton, 2009; Paris, 2008; Walter, Bourgois, & Loinaz, 2004). Dangerous border crossing, including exposure to environmental hazards, violence and extortion from immigration authorities and organized crime, witnessing death of others while crossing, and abandonment by border crossing guides or “coyotes,” have also been identified as salient stressors experienced in-transit (DeLuca, McEwen, & Keim, 2010; Infante, Idrovo, Sanchez-Dominguez, Vinhas, & Gonzalesz-Vazquez, 2012; McGuire & Georges, 2003; Paris, 2008). Additionally, multiple post-migration stressors are faced by UIs upon their arrival to the US, which often become chronic stressors over time. A salient contextual stressor often experienced among UIs is marginalization and isolation. This includes experiencing a restricted existence due to a limited social sphere of activity, isolation from the larger community, separation from family and friends, inability to travel internationally to visit family or during emergencies, and experiencing a sense of voicelessness, invisibility, and “loss of all rights” (Abrego, 2006; Aroian, 1993; Ellis & Chen, 2013; Hass, Dutton, & Orloff, 2000; Hondagnew-Sotelo & Avila, 1997; Horton, 2009; Infante, et al., 2012; Joseph, 2011; McGuire & Georges, 2003; Paris, 2008; Walter, et al., 2004). Fear of deportation and limited resources, including trouble getting employment, financial difficulties, limited access to healthcare, poor housing and unsafe neighborhoods, have also been identified as relevant concerns in this population (Abrego, 2006; Aroian, 1993; Ellis & Chen, 2013; Hass, et al., 2000; Infante, et al., 2012; Joseph, 2011; McGuire & Georges, 2003; Paris, 2008; Walter, et al., 2004). One study identified food insecurity/hunger as a stressor among UIs (28%), and a significant predictor of poor mental (p = .04) and physical health (p < .0001) (Hadley, et al., 2008). Exploitability and victimization, including working strenuous jobs and demanding work schedules, low wages, working without benefits and enduring silent physical, psychological, and sexual abuse associated to domestic violence for fear of deportation, have also been identified as stressors commonly experience by UIs post-migration (Aroian, 1993; Hass, et al., 2000; Hondagnew-Sotelo & Avila, 1997; McGuire & Georges, 2003; Sabina, Cuevas, & Sebally, 2013). Acculturation, that is difficulties transcending cultural differences in terms of beliefs, values, and behaviors, as well as difficulties communicating due to limited English proficiency, have also has been identified as salient difficulties for UIs post-migration. UIs with limited English proficiency have been identified as most at-risk for experiencing acculturative stress, as well as those with deficits in stress-coping resources and strong attachments to their families in the country of origin (Miranda & Matheny, 2000; Sanchez, Dillon, Ruffin, & De La Rosa, 2012). Regarding the association between length of time in the US and mental health outcomes, studies have found that longer time lived in the US was associated with increased mental health distress among UI adults (Hadley, et al., 2008; Santos, Bohon, & Sanchez-Sosa, 1998). In addition to the aforementioned contextual stressors, UIs experience various intrapersonal and interpersonal stressors post-migration. Intrapersonal stressors commonly experienced by UIs include: (a) identity shift related to changes in gender and family roles/expectations, which differ from the immigrant’s culture (e.g., from mother/wife in country of origin to laborer/provider in the US) (Hondagnew-Sotelo & Avila, 1997; Horton, 2009; Paris, 2008; Walter, et al., 2004); (b) variation in self-perception associated with changes in racial classification (e.g., from being perceived as “White” in country of origin (Brazil) to “Latino” in the US) (Joseph, 2011); (c) internalization of the undocumented stereotype, which may be associated to decreased self-esteem, a sense of being burdensome, guilt/shame, and a loss of motivation (Abrego, 2006; Ellis & Chen, 2013); (d) distressing emotions associated with a sense of moral failing for leaving family behind, as well as resentment or guilt among UIs living in mixed-status families in which some members have documentation and greater access to resources/opportunities not available to undocumented family members (Horton, 2009; Walter, et al., 2004); and (e) deception associated with downward social mobility and limited opportunities, primarily among UIs with higher educational attainment in their country of origin who settle for jobs in the US secondary markets, as well as for DREAMers who despite excellence in their early academic achievements may not have opportunities to further their studies (Abrego, 2006; Aroian, 1993; Ellis & Chen, 2013; Joseph, 2011). Interpersonal stressors are also common to the undocumented experience. For example, strained family relationships and conflicts resulting from displacement of negative emotions onto others, specifically jealousy and anger toward those with a documented status or towards other UIs who may represent competition for jobs/resources, have been reported as prevalent (Aroian, 1993; Ellis & Chen, 2013; Hondagnew-Sotelo & Avila, 1997; Horton, 2009; McGuire & Georges, 2003; Paris, 2008; Walter, et al., 2004). Discrimination and stigmatization on the basis of race, language proficiency, and anti-immigrant sentiments are also common (Chavez, 1994; Ellis & Chen, 2013; Infante, et al., 2012; Joseph, 2011). UIs are clearly an at-risk population for emotional and mental health distress given the many stressors that they faced, which are often experienced over time and endured under harsh living conditions. UIs represent a marginalized group, for whom access to health services, including mental health services, is restricted and limited; thus, increasing risk for the progression towards more severe psychopathology over time. Identifying protective factors that may reduce the negative effect of migration-related stress on the mental health of UIs is important to inform prevention efforts, public health action and policy development. Protective factors Research to identify protective factors likely to ameliorate the effect of migrant-related stressors on the mental health of UIs is extremely limited, and most studies that exist are qualitative (Garcini, et al., under review). Some protective factors previously identified in the qualitative literature include: (1) building and maintaining adequate social support and sense of community, which includes maintaining close family ties with those left in the country of origin; (2) resourcefulness and creativity to find viable solutions to social challenges, which includes becoming proficient in English and development of job skills; (3) religiosity and/or spirituality; (4) having an optimistic view of the future, which includes reframing the undocumented experience in a more positive way; and (5) experiencing increased empathy for marginalized others (Aroian, 1993; Chavez, 1994; Ellis & Chen, 2013; McGuire & Georges, 2003; Paris, 2008). Among the few quantitative studies that exist, most have focused exclusively on social support as a protective factor, with one study reporting higher levels of social support to be associated with lower symptoms of depression and anxiety (Potochnick & Perreira, 2010). Additional research is needed to better understand the effect of the aforementioned protective factors as moderators to the association between migration-related stress and mental health outcomes in this population. III. CULTURE AND CONTEXT-SENSITIVE MENTAL HEALTH ASSESSMENT WITH LATINO UNDOCUMENTED IMMIGRANTSAccording to the American Psychological Association Multicultural Guidelines, investigators should aim to “apply culturally-appropriate skills [and measures] in their research and clinical practice” (APA, 2002, p. 43). This includes incorporating the use of culture and context-sensitive methodologies, as well as assessment measures that are relevant and adapted for use with the target population. The use of culture and context-sensitive assessments is essential to acquire an understanding of the ways in which relevant experiences relate to presenting psychological distress, as well as to avoid misdiagnosis. Thus, additional attention must be given to the study and assessment of Cultural Concepts of Distress, previously referred to as Culture-Bound Syndromes (American Psychiatric Association, 2013), and their patterns of association to more traditional DSM-V diagnosis. Likewise, the study of contextual concepts of distress, such as that experienced among marginalized immigrants, including UIs, is necessary for the development and provision of context-sensitive interventions (Achotegui, 2005). Cultural Concepts of Distress According to the DSM-V, Cultural Concepts of Distress refer to “ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions” (American Psychiatric Association, 2013, p. 758). The DSM-V identifies three different types of cultural concepts needed to better understand distress among diverse populations (American Psychiatric Association, 2013). These include: Cultural syndromes, which represent “clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, and contexts and that are recognized locally as coherent patterns of experience” (American Psychiatric Associatino, 2013, p. 758). Cultural idioms of distress, which are “ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns (e.g., everyday talk about “Nervios”) (American Psychiatric Association, 2013, p. 758). Cultural explanations or perceived causes, which are “labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress” (American Psychiatric Association, 2013, p. 758). Research on Cultural Concepts of Distress is helpful to integrate cultural and clinical knowledge in a way that it may be feasible to provide “diagnostic universality” and “cultural specificity” (Guarnaccia & Martizen-Pincay, 2005). Nevertheless, although some associations have been suggested between certain psychiatric diagnosis and some Cultural Concepts of Distress (e.g., Ataque de Nervios and its association to Panic Attacks), no clear one-to-one relationships have been established. Additional studies are needed to better understand potential associations and/or differences between Cultural Concepts of Distress and traditional mental health disorders based on DSM-V diagnosis. As previously mentioned, this information is necessary for the development of more appropriate and effective interventions among diverse populations. Nervios and Ataque de Nervios among Latino Immigrants. Among Latino immigrants, two specific Cultural Concepts of Distress that have recently received attention include “Nervios” and “Ataque de Nervios.” According to DSM-V, Nervios refers to “a general state of vulnerability to stressful life experiences and to difficult life circumstances . . . [which is characterized by] a wide range of symptoms of emotional distress, somatic disturbance, and inability to function” (American Psychiatric Association, 2013, p. 835). Some DSM-V conditions that appear to be related to Nervios include Major Depressive Disorder (MDD), dysthymia, Generalized Anxiety Disorder (GAD), Social Anxiety Disorder, and Somatic Symptom Disorder (American Psychiatric Association, 2013). According to DSM-V, Ataque de Nervios may be considered as “normative expressions of acute distress” that are characterized by “symptoms of intense emotional upset, including acute anxiety, anger, or grief; screaming and shouting uncontrollably; attacks of crying; trembling; heat in the chest rising to the head; becoming verbally and physically aggressive [among other symptoms]” (American Psychiatric Association, 2013, p. 833). A generalized feature of Ataque de Nervios is a sense of being out of control, and the Ataques are often related to a stressful life event, mostly involving the family (e.g., death, family conflict, accidents). Some DSM-V disorders that have been related to Ataque de Nervios include Panic Attack, Panic Disorder, Conversion Disorder, unspecified or specified forms of Dissociative Disorders, and Intermittent Explosive Disorder (American Psychiatric Association, 2013). Research has shown that Latinos are likely to define mental illness as Nervios and Ataque de Nervios, which are usually contextualized as transitory diffuse idioms of distress, which may not require traditional clinical treatment (Gonzales & Gonzales-Ramos, 2005). Similarly, research shows that Latinos are more likely to somatize psychological distress when compared to non-Latino Whites (Gonzales & Gonzales-Ramos, 2005), and that in many cases symptoms differ from those traditionally reported by the general population (e.g., feeling pins and needles in your hands or feet, feeling heat inside the body, sensations of fluttering in the stomach). Thus, somatic disturbance is an important characteristic of Nervios and Ataque de Nervios that merits further study. Among Latino immigrants, Nervios and Ataque de Nervios have been identified as prevalent conditions. In a recent study of 422 Latino migrant farmworkers the prevalence of Nervios was 22%, with lower income, drug use, higher acculturation and poor housing conditions more likely to be associated with a Nervios diagnosis (O’Connor, Stoecklin-Marois, & Schenker, 2013). In addition, Nervios has also been found to be significantly associated with poor or fair self-reported health, symptoms of depression, and high-perceived stress (O’Connor, et al., 2013). In regards to Ataque de Nervios, a study using data of 2554 Latinos from the NLAAS found the prevalence of Ataque de Nervios among Latinos to range between 7-15% varying by Latino subgroups, with Puerto Ricans reporting the highest prevalence (14.9%) and Mexican immigrants the lowest (6.0%) (Guarnnacia, Lewis-Fernandez, Martinez-Pincay, Shrout, Guo, Torres, et al., 2010). In that study, Ataque de Nervios was found to be more prevalent among women, those with disrupted marital status, and those with higher acculturation to the US. Ataque de Nervios was also prevalent among those meeting criteria for anxiety and substance use disorders. Given the association of Nervios/Ataque de Nervios and distress, the high prevalence of Nervios among Latino immigrants, and the multiple and complex distressing events often faced by UIs, studies are needed to identify the prevalence of Nervios and Ataque de Nervios among UIs, as well identify patterns of comorbidity with more traditional DSM-V diagnosis. Most information on the clinical description of Nervios and Ataque de Nervios has been gathered from qualitative data, with fewer studies using quantitative data to define the disorder and identify severity. The use of combined methodologies to the study of Cultural Concepts of Distress among at-risk Latino immigrants, including UIs, is essential to better contextualize the experience of Nervios and Ataque de Nervios from multiple cultural and contextual perspectives. While quantitative methods may provide a measure for the pervasiveness and severity of Nervios and Ataque de Nervios, as well as to identify patterns of association to specific risk and protective factors, qualitative information would facilitate an understanding as to why and/or how such associations exist and the range of their effects (Creswell, Klassen, Plano, Clark & Smith, 2011). Additionally, the use of qualitative information to supplement quantitative data is particularly valuable to use with this population given possible variations in the meaning and presentation of clinical symptoms. UI Latinos vary widely in their ethnic composition (e.g., indigenous versus mestizo); thus, it is possible that variations in symptoms meaning and expression may exist. Consistent with the use of culture and context sensitive methodology (Creswell, Klassen, Plano, Clark & Smith, 2011), this study will assess the prevalence of Nervios and Ataque de Nervios by using a combination of qualitative open-ended questions, as well as previously validated clinical measures of perceived distress and somatic symptoms. In doing so, this study aims to provide not only prevalence data, but also descriptive information on the clinical manifestation, severity, and specifiers (e.g., lifetime prevalence, trait, current) of Nervios and Ataque de Nervios based on DSM-V description. Table 3 summarizes the measures and criteria to be used in this study to identify the prevalence and clinical manifestation of Nervios and Ataque de Nervios. The measures included in Table 3 are described in detail in the measures section of “Phase Two: Quantitative Study” of the present proposal. Contextual Concepts of Distress among ImmigrantsFor certain immigrant subgroups, such as UIs, the immigration experience presents with multiple and chronic stressors, which over time, exceed the immigrant’s capacity for adaptation and increase risk for mental health disorders (Achiotegui, 2005). Among UIs, the distress associated with the undocumented experience is not only chronic, but also complex and in excess to that attributed to typical acculturative stress (Achiotegui, 2002). Unfortunately, there is yet to be a classification within DSD-V diagnosis, which may best describe and categorize the distress experienced by UIs from a cultural and contextual perspective. Providing a diagnosis for Adjustment Disorder to this immigrant population is inaccurate and lacking of contextual sensitivity given that Adjustment Disorder is contextualized as a transitional state to life events in which symptoms disappear with removal of the stressor, whereas the distress experienced by UIs is chronic and unlikely to lead to adaptation, unless the immigrant returns to his/her country of origin. Thus, developing a culture and context sensitive approach to the study of distress among unique immigrant populations (i.e., UIs), is needed to: (1) avoid misdiagnosis; (2) reduce stigma associated to mental health problems rooted in contextual influences and for which the immigrant may have little control over (e.g., fear of deportation, restricted access to resources); (3) validate the distress and somatic symptoms experienced by the immigrant as to reduce marginalization; and (4) develop effective treatments and prevention alternatives by considering the effect of relevant contextual influences. Ulysses Syndrome. For over a decade, and given the large inflow of UIs into Europe, researchers overseas have worked diligently to contextualize the distress experienced by different at-risk immigrant subgroups. Among such efforts has been the study of the Immigrant Syndrome with Chronic and Multiple Stress or Ulysses Syndrome, named as such in reference to the Greek hero Ulysses, who endured countless adversities and dangers away from his homeland (Achiotegui, 2002). The Ulysses Syndrome is defined as a behavioral and emotional “response [experienced by immigrants] when faced with a situation of [chronic and severe] stress, [which] is superior to the adaptation capacities of the [immigrant]” (Achiotegui, 2002). From this perspective, the Ulysses Syndrome is a cluster of emotional and somatic symptoms, as well as a prodromal for more severe forms of mental health distress if experienced over time and without access to treatment, support systems or coping strategies. Specifically, the clinical expression of Ulysses Syndrome involves: (1) symptoms of depression, particularly sadness, crying spells and difficulty concentrating, but not necessarily apathy, low self-esteem or thoughts or death/dying as often characterized in depressive disorders; (2) symptoms of anxiety, for example tension, worry, irritability, and nervousness; (3) somatic symptoms (e.g., headaches, fatigue, body aches); (4) migration-related grief in one or more of seven identified areas including: (a) family and friends left in country of origin; (b) language difficulties; (c) loss/change of cultural values; (d) missing of cultural practices (i.e., food, landscapes); (e) loss of/change in social status; (f) marginalization/discrimination; and (g) threat to physical and mental health. Similar to the research on Nervios and Ataque de Nervios, most information regarding the conceptualization of Ulysses Syndrome comes from qualitative data and assessments. Consistent with the use of culture and context sensitive methodology, and as previously illustrated for the assessment of Nervios and Ataque de Nervios, this study will assess the prevalence of Ulysses Syndrome by using a combination of qualitative open-ended questions, as well as previously validated clinical measures of perceived distress, somatic symptoms and migration-related stressors. As previously mentioned, in using combined assessment measures, this study aims to provide not only prevalence data for Ulysses Syndrome, but also a preliminary categorization for the clinical conceptualization of Ulysses Syndrome using a cultural and contextual formulation of distress consistent with the CFI of the DSM-V (American Psychiatric Association, 2013). Table 3 summarizes the measures and criteria to be used in this study to identify the prevalence and clinical manifestation of Ulysses Syndrome. IV. THEORETICAL FRAMEWORK AND SIGNIFICANCEFrom a socio-ecological perspective, “the human experience results from reciprocal interactions between individuals and their environments, varying as a function of the individual, his or her context and culture, and over time” (APA, 2012, p. 4) (Bronfenbrenner & Morris, 2006; Dahlgren & Whitehead, 1991; Serdarevic & Chronister, 2005). Figure 1 depicts Dahlgren and Whitehead’s (1991) socio-ecological model of health, which will be used as theoretical framework in this study. Thus, this study focuses on the influences of context and culture, in particular risk and protective factors, which may undermine or protect the mental health of UI Latinos. New ContributionDespite the identification of relevant stressors, there is limited information on the prevalence for specific mental health disorders among UIs, and existing studies often lack scientific rigor (Garcini, et al., under review). Additionally, an assessment of methodology and findings of existing studies showed that there are salient selection and information biases in this area of research, and that culture and context-sensitive studies are needed to inform the mental health of UIs. Equally important to identifying salient mental health disorders among UIs is the identification of Cultural and Contextual Concepts of Distress, as well as protective factors that may reduce risk and facilitate coping and adjustment to the migration process. Only few studies, mostly qualitative, have reported on factors useful to ameliorate or cope with distress among UIs (Aroian, 1993; Chavez, 1994; Ellis & Chen, 2013; McGuire & Georges, 2003; Paris, 2008). Unfortunately, the aforementioned studies were often limited in providing clarification of construct definitions for the identified protective factors, quantitative assessment of such factors and/or a description of the quantitative association of protective factors to specific mental health outcomes. General AimsGiven limited research and existing limitations on studies to inform the mental health of UIs, this dissertation will use the socio-ecologic framework, a context-sensitive approach and a mix-methods design to study the prevalence of mental health disorders and Cultural and Contextual Concepts of Distress among UI Latinos in San Diego and nearby areas, as well as to identify risk and protective factors associated with mental health disorders in this population. Thus, this study includes two phases: a formative phase and a clinical study. V. PHASE ONE: FORMATIVE STUDYSpecific Aims The objectives of this formative phase of the proposed dissertation are explained by two specific aims of this research.Aim 1. Use focus groups to assess the perceived relevance of specific mental health concerns among UIs as reported from Latino immigrants and key experts with extensive knowledge about the undocumented community in San Diego and nearby areas. Aim 2. Obtain feedback and specific recommendations from community members and key experts on the proposed methodology to be used in a clinical study to assess the mental health needs of UIs in San Diego and nearby areas. This information will be used to make culture and context-sensitive modifications to the research protocol to be used in the clinical mental health assessment to be conducted in phase two of this proposed dissertation. METHODParticipants. Participants will be recruited using networks-based referrals from the SDSU/UCSD Cancer Disparities Community Partners and Research (CDCPAR) Resource, as well as from the principal investigator’s social network. The CDCPAR provides liaisons to academic and community partners to facilitate outreach, research, and the provision of health-related services for underserved communities and hard-to-reach populations, including at-risk Latino immigrants. The CDCPAR represent the Latino communities themselves, and is familiar with health issues relevant to undocumented Latinos. Approximately 30 Latino immigrant adults (over age 18) knowledgeable about the undocumented population in San Diego will participate in the focus groups. Participants will receive $20 for their participation. Inclusion/Exclusion Criteria. Participants must be Latino adults over 18 years of age, be born outside of the US, and report to be knowledgeable about the undocumented community in San Diego. To determine eligibility for participation, a brief screener in Spanish will be presented to potential subjects prior to participation in the focus groups (see Appendix A). To assess eligibility based on knowledge about the undocumented community, two dichotomous (Yes/No) proxy questions have been included in the screener: (a) do you think you have a good understanding of the experiences of undocumented Latino immigrants living in San Diego and surrounding areas?; and (b) in general, do you have weekly interactions with undocumented Latino immigrants in San Diego or surrounding areas?. Affirmative responding to both of the aforementioned questions is required to meet eligibility criteria. There will be no gender restrictions on enrollment. Given that the focus groups will be conducted in Spanish, no English language proficiency is required for inclusion. Participants must also be able to provide written informed consent. TC "Protection of Research Participants" \l 3 Protection of Research Participants. All participants will sign informed written consent approved by the Institutional Review Boards (IRB) at both SDSU and UCSD (SDSU IRB Study Number: Conditionally Approved). There is minimal risk associated with this study, which may include social stigma associated with undocumented legal status and mental health problems. The group facilitator will normalize and validate concerns regarding public discussion of reported issues. Also, although unlikely, it is possible that participants may experience some emotional discomfort upon discussing mental health issues in their community. For participants expressing emotional discomfort associated to the discussion, they will be provide with referral information for accessible, low cost, and Spanish mental health services in San Diego, where participants may receive needed services regardless of their immigration legal status (See Appendix B). Additionally, to protect confidentiality, focus group discussions will emphasize the undocumented experience and mental health concerns as a whole as opposed to personal, individual experiences. During the consent process participants will be informed that this study has no association with the Immigration and Naturalization Service (INS) and none of the information provided will be reviewed by the INS. Also, participants will be informed during the consenting process that the proposed study has no foreseeable direct benefits to them. All study materials and data will be kept confidential and participants’ names and other identifying information will be removed from the data that is to be analyzed. Data will be kept in a locked cabinet and digital data will be password-protected. Only study personnel will have access to research records. Design. Approximately 4 to 5 focus groups will be conducted. Individuals who agree to participate and who meet the inclusion criteria will be asked to fill out a brief demographic questionnaire and to participate in a focus group discussion that will last approximately 2 hours in duration. The demographic questionnaire will take approximately 5 minutes to complete, and it will be administered in Spanish prior to beginning the focus group. For participants unable to read and/or write, the questionnaire will be read to the participant in private by a bilingual research assistant. The focus groups will be audio-recorded to facilitate the analyses of data. TC Measures \l 2 Measures. The instruments used in this study can be categorized into a demographic questionnaire and the focus group discussion questions. Demographic questionnaire. All participants will be given a brief demographic questionnaire (see Appendix C) to be completed at the beginning of the focus group. Information to be collected in this questionnaire includes sex, age, marital status, educational attainment, employment, country of birth, length of residence in the US, self-reported overall health and mental health, personal and family mental health history, and social networking with the undocumented community.Focus group discussion questions. Focus groups will be conducted using a semi-structured guide (See Appendix D). This guide includes questions aimed at fostering discussion pertaining to: (a) perceptions about mental health; (b) perceived relevance to the study of mental health among UIs and identification of specific mental health issues relevant to this population; and (c) perceived barriers and resources that may limit or facilitate participation in health and mental health research studies among UIs. Translation. The demographic questionnaire and the focus group discussion questions will be translated using established methodology (Beaton, Bombardier, Guillemin, & Ferraz, 2002). The following process will be used in the translation of the aforementioned measures: Translation. This will involve at least 2 independent forward translations (English to Spanish) done the principal investigator and bilingual research assistant, which can then compare their versions to identify discrepancies indicative of ambiguous wording within the questionnaire. Quality control. In this phase, a third bilingual individual, specifically a community health representative, reviews both Spanish translations and makes revisions or recommendations as necessary. Back Translation. In this phase, another person blind to the original survey, back translates the new Spanish questionnaires into English, and compares it to the original English questionnaire to check the validity of the translation.Expert Committee Review. An expert committee, comprised of the principal investigator, the research assistant involved in the translation process, the community member who synthesized both Spanish versions, and staff members of the SDSU/UCSD CDCPAR resource will meet with the purpose of consolidating the different versions of the Spanish and English questionnaires to produce the final forms and ensure equivalence between the English and the new Spanish version. Pretesting. The translate questionnaire and the focus group questions will be given to 5 Latino community members using standard cognitive interviewing techniques to assess for ambiguity in the questions. Recommended forms developed by Beaton, et al (2002) will be used for the written documentation of the translations process at all of the different stages (see Appendix E). Analyses. Statistical analysis will be a two-part process. The first part will involve the analysis of quantitative data from the demographic questionnaires. Descriptive statistics (e.g., frequencies, measures of central tendency) will be used to develop an overall demographic profile for participants in this study, as well as profiles for participants in the different focus groups. Demographic profiles for participants in each group will be used to assess for the generalizability or inconsistency of comments across the groups. All quantitative analysis will be conducted using SPSS, version 20 (SPSS, Inc., 2013). The second part will involve the analysis of qualitative data gathered from the focus groups. The qualitative data will be analyzed through systematic methods outlined by Miles and Huberman (1994). The focus group audio-recordings will be transcribed and then analyzed by the principal investigator and bilingual research assistants in Spanish with collaboration of supervising faculty and staff members from the SDSU/UCSD CDCPAR Resource. The data will be read and re-read to develop, revise, and summarize themes within the data through a collaborative and iterative process. This qualitative approach is particularly beneficial given this study is exploratory to obtain formative data that will be used to inform phase two of this dissertation. Qualitative analysis will be conducted using NVivo, version 10 (Nvivo, Ltd, 2013).VI. PHASE TWO: CLINICAL STUDYSpecific Aims The objectives of the quantitative phase of the proposed dissertation are explained by five specific aims of this research.Aim 1. Assess the prevalence of mental health disorders and perceived psychological distress in this sample of UIs and compare it to rates for other Latino and non-Latino populations in the US. More specifically, this includes: Identify the prevalence of perceived psychological distress as measured by the Brief Symptom Inventory-18 in this sample population. Identify the prevalence of DSM-V depressive disorders (i.e., MDD), anxiety disorders (i.e., Agoraphobia, Panic Disorder, GAD, and Social Anxiety Disorder), trauma and stress-related disorders (i.e., Adjustment disorder and PTSD), Somatic Symptom Disorder, and substance related disorders (ie., Substance Dependence and Addiction). Identify the prevalence of Cultural Concepts of Distress, specifically Nervios and Ataque de Nervios in this population.Identify the prevalence of Contextual Concepts of Distress, specifically Ulysses syndrome, in this population. Identify comorbidity and disparities in the prevalence of the aforementioned mental health disorders between this sample of UIs and other Latino and non-Latino populations in the US. Aim 2. Assess the QOL of this sample population using the World Health Organization Quality of Life-Brief (WHOQOL-BREF), and identify its association to prevalent mental health disorders, after controlling for relevant covariates (i.e., age, gender, and socioeconomic status). More specifically, this includes:Assess the overall level of QOL in this sample population. Identify the association between QOL and prevalent mental health disorders after controlling for age, gender, and socioeconomic status.Identify the association between QOL and perceived psychological distress after controlling for age, gender, and socioeconomic status.Aim 3. Identify the association between immigration-related risk factors and diagnosis of a mental health disorder and psychological distress, after controlling for relevant demographic and socioeconomic factors. Most specifically, this includes: Identify the prevalence of immigration-related loss or trauma, including pre-migration loss/trauma, in-transit trauma, and post-migration living difficulties in this sample population. Identify the association between migration-related factors, including age of arrival in the US, length of residence in the US, migration-related loss/trauma and post-migration living difficulties, with diagnosis of a mental health disorder, after controlling for relevant covariates. Identify the association between migration-related factors, including age of arrival in the US, length of residence in the US, migration-related loss/trauma and post-migration living difficulties, with perceived psychological distress, after controlling for relevant covariates. Aim 4. Identify moderators to the association between immigration-related loss/trauma/difficulties and diagnosis for a mental health disorder in this sample of UIs, as well as moderators to the association between immigration-related loss/trauma/difficulties and perceived psychological distress after controlling for relevant covariates. More specifically, this includes: Identify the effect of family intactness as moderator to the association between immigration-related loss/trauma/difficulties and diagnosis of a mental health disorder/perceived psychological distress, after controlling for relevant covariates. Identify the effect of social support as moderator to the association between immigration-related loss/trauma/difficulties factors and diagnosis of a mental health disorder/perceived psychological distress, after controlling for relevant covariates. Identify the effect of sense of community as moderator between the association of immigration-related loss/trauma/difficulties and diagnosis of a mental health disorder/perceived psychological distress, after controlling for relevant covariates. Identify the effect of spirituality and religiosity as moderators between the association of immigration-related loss/trauma/difficulties and diagnosis of a mental health disorder/perceived psychological distress, after controlling for relevant covariates. Identify the effect of English language proficiency as moderator between the association of immigration-related loss/trauma/difficulties and diagnosis of a mental health disorder/perceived psychological distress, after controlling for relevant covariates. Aim 5. Outline health and immigration policy implications for the improvement of mental health outcomes in this population. METHODSParticipants. Given the hidden nature of the target population, network-based referral is currently the most effective and safe method to reach UIs as long as these individuals maintain social networks among UIs like themselves (Cornelius, 1982; Nalven, 1982, Zhang, Hong, Takeuchi, & Mossakowski, 2012). Snowball sampling is the most commonly used recruitment method based on network-based referrals. However, given that snowball sampling is accomplished through convenient and haphazard recruitment strategies (e.g., participants originate mostly from the researcher’s social contacts), there are inherent selection biases in this recruitment process. Two methodologies developed to reduce some of the inherent biases in snowball sampling are Targeted Sampling (Watters & Biernacki, 1989) and Respondent Driven Sampling (RDS) (Heckathorn, 1997). Participants for this study will be recruited using combined strategies modeled from Targeted Sampling and RDS methodology. Targeted Sampling. This method uses experienced field researchers to map out areas where a target population may be found and recruit a pre-determined number of subjects at each of the identified sites on the map. In this study, information gathered from: (a) expert health researchers at the SDSU/UCSD Disparities Community Partners and Research (CDCPAR) Resource; (b) qualitative data gathered from the focus groups completed in phase one of this dissertation; and (c) key informants with expertise serving the undocumented community, will be used to map out areas where UIs in San Diego and nearby areas may be found. Then, at each of the identified sites, a small number of initial subjects (seeds) will be recruited for participation in this study. In turn, each of the initial seeds will be ask to recruit other UIs for participation using RDS methodology. Respondent Driven Sampling. RDS is a methodology based on a mathematical model of the social networks that connect participants in a study. In other words, RDS uses network-based methods along with the statistical validity of standard probability sampling methods to assess hard-to-reach populations. RDS relies on a structured chain referral system that uses successive waves of participant recruitment to achieve diversity and equilibrium so that initial samples no longer mirror later samples. Key assumptions of the RDS system are: (1) degree (i.e., participants accurately report their degree in the network); (2) random recruitment (i.e., respondents recruit at-random from their personal networks; (3) reciprocity (i.e., network connection are reciprocal); and (4) convergence (i.e., the sample composition becomes independent of the initial “seeds” in a short number of steps). As a result, RDS modifies traditional snowball sampling in three ways. First, to increase the breadth of the social network captured by the sample, subsequent recruitment is limited by a coupon-based quota system, in which an interviewee is only allowed a fixed number of referrals. Second, by using referral coupons, subjects do not have to personally identify referrals to the researcher and the resulting anonymity encourages participation. Third, since some individual may tend to have more social connections that others, they are more likely to be recruited into a survey. To make the results of an RDS-based survey representative of the target population (and not just respondents with large social networks), a systematic weighting scheme is build into the RDS model. The weighting scheme is based on the respondent’s social network size; that is, based on their probability of being captured by this survey technique-as well as other features of the network which can affect the referral process. As a result, although RDS will start with a convenience sample of UIs, a structured process will be used in recruitment so that it may be possible to obtain unbiased estimates of the overall undocumented population in San Diego. Specific RDS steps that will be used in this study are: (1) a small number of subjects or “seeds” will be recruited for participation in the study; (2) these seeds will be provided with referral coupons to recruit other subjects for participation; (3) next wave of recruits will be provided another set of referral coupons to recruit additional subjects for participation in this study; and (4) sampling will continue until the targeted community is saturated, or until the desired sample size and “equilibrium” is reached. Equilibrium will be verified empirically through the use of RDS software (RDSAT, Version 7.1, Volz, Wejnert, Cameron, Spiller, Barash, Degani, et al., 2012), and it indicates that the final subjects recruited no longer have identical characteristics to the initial “seeds.” Consistent with RDS methods, each participant will be limited to a predetermined number of referral coupons (three coupons per study subject); thus, limiting biasing the sample towards those with large social networks.Although data requirements for RDS analysis are minimal, there is specific information needed from each participant in order to conduct the RDS analysis. This information includes: (1) size of the respondents personal network within the target population (degree); that is, estimated number of UIs that are personally known by the participant; (2) participant’s serial number, that is, this is the serial number of the coupon that the participant was recruited with; and (3) respondent’s recruiting serial numbers; that is, serial numbers from the coupons that the respondent is given to recruit other participants for the study. In this study, initial participants or “seeds” for recruitment will be identified in collaboration with networks-based referrals from the SDSU/UCSD Disparities Community Partners and Research (CDCPAR) Resource, as well as referrals from the principal investigator’s social network. As previously mentioned in phase one of this dissertation, the SDSU/UCSD CDCPAR provides liaisons to academic and community partners to facilitate outreach and research to underserved populations, including UIs. Inclusion/Exclusion Criteria. Participants must be Latino adults over 18 years of age with current undocumented immigration legal status. To determine eligibility for participation, a brief screener in Spanish will be presented to potential subjects prior to participation in the study (see Appendix F). To assess eligibility based on immigration legal status, a rule-out system will be used which, asks a series of yes-no questions outlining current legal statuses except undocumented status, so that respondents who answer no to all questions would be coded as UIs. The use of a rule-out system has been previously used in other studies of undocumented Latino immigrants, and it is recommended as the preferred method to assess immigration legal status (Marcelli, Holmes, & Estrella, 2009). In using a rule-out system, respondents are not forced to blatantly admit to being undocumented, but rather undocumented status is determined by denying all possible legal ways to be currently residing in the US. There will be no gender restrictions on enrollment. Given that the interviews will be conducted in Spanish, no English language proficiency is required for inclusion. Participants must also be able to provide verbal informed consent. Power analysis. Mood disorders (i.e., depression and dysthymia), anxiety disorders and somatic symptom disorders have been identified as the most prevalent disorders among foreign-born Latinos. Although prevalence estimates vary across studies, results from the National Latino and Asian American Study estimated that approximately 14.8% of foreign-born Latinos meet criteria for a mood disorder and 15.2% for anxiety disorders (Guarnaccia, Martinez-Pincay, Alegria, Shrout, Lewis-Fernandez, & Canino, 2004). Similarly estimates for the NLAAS showed Mexican-origin foreign-born immigrants to have an estimated prevalence of 12.9% for depressive disorders and 14.2% for anxiety disorders. Unfortunately, estimates for the prevalence of diagnosed mental health disorders among UIs are unknown. Thus, to assess for the prevalence of a mental health disorder in this sample population, the estimate for the most prevalent mental health disorder (Anxiety) among Mexican-origin foreign-born immigrants was selected as reference. The Mexican-origin foreign-born population was chosen given that the majority of UIs in California are of Mexican-origin; thus, the chose estimate may most closely resemble true prevalence in this sample population. To estimate the need sample size for this study, an a priori power analysis was conducted using OpenEpi, Version 3.01 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"bmavj1tkh","properties":{"formattedCitation":"(Faul, 2008)","plainCitation":"(Faul, 2008)"},"citationItems":[{"id":333,"uris":[""],"uri":[""],"itemData":{"id":333,"type":"book","title":"G*Power [computer software]","publisher":"Universit?t Kiel","publisher-place":"Kiel, Germany","version":"3.1.0","event-place":"Kiel, Germany","author":[{"family":"Faul","given":"Franz"}],"issued":{"year":2008}}}],"schema":""} (Dean, Sullivan, & Soe, 2013). In order to detect prevalence at a historical proportion of .14 within a 95% confidence interval at 7% precision and with a design effect of 1, a sample size of 95 subjects would be needed. This means that based on the historical proportion of mental health disorders among Mexican-origin foreign-born immigrants, approximately 14% of the aforementioned sample would meet diagnosis for a mental health disorder with a 95% confidence that the prevalence estimate will be within 7% of the true prevalence value. For studies using RDS, it has been recommended the use of sample size at least twice as large as would be needed under simple random sampling (Salganik, 2008). Thus, a total of 190 subjects will be recruited for this study. Additionally, to assess for the adequacy of the aforementioned sample size to perform the proposed multivariate analysis in this study, two additional power analyses were conducted. First, an a priori power analysis was performed using G*Power, Version 3.1 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"bmavj1tkh","properties":{"formattedCitation":"(Faul, 2008)","plainCitation":"(Faul, 2008)"},"citationItems":[{"id":333,"uris":[""],"uri":[""],"itemData":{"id":333,"type":"book","title":"G*Power [computer software]","publisher":"Universit?t Kiel","publisher-place":"Kiel, Germany","version":"3.1.0","event-place":"Kiel, Germany","author":[{"family":"Faul","given":"Franz"}],"issued":{"year":2008}}}],"schema":""} (Faul, 2008) to determine if the sample size would be adequate to conduct sequential linear regression analysis with ten predictors included in the model. Results showed that in order to detect a medium effect size for regression analyses (f = 0.15) including 10 predictors that is statistically significant at the p < 0.05 level and using a desired power of 0.95, a total sample size of 172 individuals would be necessary. The proposed sample size of 190 subjects exceeds the aforementioned sample size; thus, this suggests that the proposed sample size will be appropriate for conducting the proposed linear regression analyses. Second, an a priori power analysis was performed using G*Power, Version 3.1 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"bmavj1tkh","properties":{"formattedCitation":"(Faul, 2008)","plainCitation":"(Faul, 2008)"},"citationItems":[{"id":333,"uris":[""],"uri":[""],"itemData":{"id":333,"type":"book","title":"G*Power [computer software]","publisher":"Universit?t Kiel","publisher-place":"Kiel, Germany","version":"3.1.0","event-place":"Kiel, Germany","author":[{"family":"Faul","given":"Franz"}],"issued":{"year":2008}}}],"schema":""} (Faul, 2008) to determine if the sample size would be adequate to conduct logistic regression analysis with ten predictors included in the model. Results showed that in order to detect a change in the dependent variable with an odds ratio of 1.9 that is statistically significant at the p < 0.05 level using a desired power of 0.95, a total sample size of 171 subjects would be necessary. The proposed sample size of 190 subjects exceeds the aforementioned sample size; thus, this suggests that the proposed sample size will be appropriate for conducting the proposed logistic regression analyses. TC "Protection of Research Participants" \l 3 Protection of Research Participants. All participants will provide verbal informed consent as is customary in research studies with undocumented immigrants (Garcini, et al., under review). Some of the questions in the interview deal with emotional status and migration experiences; thus, participating subjects may feel some emotional discomfort when reporting sensitive information (e.g., migration related loss or trauma) or may experience some difficulty in remembering details of certain events. To reduce potential discomfort, subjects will be fully informed that they choose how much they want to share their stories, and that they can refuse to answer any questions at any time during the interview. Subjects can terminate the interview at anytime without any penalty. In addition, interviews will be conducted in a private location, identified by the participant as convenient and safe, where the conversation cannot be overheard by a third party. Also, the PI has considerable experience working with undocumented immigrants, and most importantly all interviews will be conducted by psychology trainees with expertise in the clinical assessment and treatment of mental health disorders who will work under the supervision of a licensed clinical psychologist. Additionally, for participants expressing emotional discomfort during or after the interview, they will be provide with referral information for accessible, low cost, and Spanish mental health services in San Diego, including the SDSU Psychology Clinic, where participants may receive needed services regardless of their immigration legal status (See Appendix B). To ensure participants of confidentiality, they will be informed during the consent process that this study has no association with the Immigration and Naturalization Service (INS) and that none of the information provided will be reviewed by the INS. Participants will be informed that the proposed study has no foreseeable direct benefits to them, and that all study materials and data will be kept confidential, with any identifying information removed from the data that is to be analyzed. Data will be kept in a locked cabinet and digital data will be password-protected. Only study personnel will have access to research records. Design. A cross-sectional survey design will be used. Individuals who agree to participate and who meet inclusion criteria will be asked to complete an in-person semi-structured clinical interview lasting approximately 1 to 1.5 hours in duration depending on the extent of the psychopathology reported. The clinical interviews will be conducted in Spanish by Latino psychology trainees, including the principal investigator, working under the supervision of a licensed clinical psychologist. Participants will be given a choice to complete the clinical interviews at the SDSU Psychology Clinic or at location identified by the participant as convenient and safe. Measures. The instruments used in this study can be categorized into a demographic questionnaire, immigration history, respondent driven sampling questions, health-related quality of life assessment, clinical mental health assessment, migration-related loss, trauma and difficulties, and protective factors. In addition, at the end of each interview, the interviewers will complete a questionnaire to record clinical and behavioral observations. Demographic questionnaire. All participants will be asked a series of demographic questions (see Appendix G). Information to be collected in this questionnaire includes sex, age, educational attainment, employment, and household income. Demographic questions were modeled from the 2009 San Diego Prevention Research Center (SDPRC) Community Survey, which assessed various aspects of health and health behaviors among Latinos in the US, including UIs. These questions are available in Spanish and have been previously used with UIs in San Diego. Immigration history. Participants will be asked some questions about their immigration history (see Appendix H). Immigration history information to be collected includes country and state of birth, country and state where migrant spent most of his/her life, age of arrival in the US, and length of time in the US. These questions were modeled from the 2009 SDPRC Community Survey, as well as from the San Diego Labor Trafficking Survey Questionnaire (Zhang, 2012). These questions have been previously translated into Spanish and have been used to assess immigration history among undocumented Latinos. Respondent driven sampling questions. Four questions will be used exclusively for the purpose of mapping recruitment location and to calculate RDS estimates (see Appendix I). These questions include area of residence (town name only), size of the respondent’s personal network who are UIs, relationships to the referral source (person who provided the coupon to the participant), and length of time that the participant has known the referral source. These questions were modeled from the San Diego Labor Trafficking Survey Questionnaire (Zhang, 2012), which are available in Spanish and have been previously used in studies with UIs. Health-related quality of life assessment. This will be done using two measures. First, a shortened and adapted version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) Chronic Conditions Module Version 3.0 will be used to assess the past (prior to immigration) or present history of commonly occurring chronic health conditions known to influence QOL including arthritis, chronic pain, heart disease, hypertension, asthma, diabetes, stomach problems and cancer (Haro, Arbabzadeh-Bouchez, Brugha, Girolamo, Guyer, Lepine, et al, 2006). This shortened version of the CIDI Chronic Conditions takes approximately a minute to complete. Second the World Health Organization Quality of Life Scale-Brief (WHOQOL-BREF) will be used to assess subjective overall quality of life across various domains (Skevington, Lotfy, & O'Connel, 2004). Previous research shows that subjective assessment of QOL is most appropriate with at-risk immigrant populations, given objective measures are often limited in considering the potential effects of factors such as trauma or post-migration living difficulties on quality of life (WHOQOL Group, 1998). For this study and consistent with the WHO definition, QOL is defined as “an individual’s perception on their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (Skevington, Lotfy, & O'Connel, 2004, p. 8) The WHOQOL-BREF is an abbreviated 26-item version of the WHOQOL-100, which is a well-established measure to assess quality of life worldwide. The WHOOLF-BREF takes approximately five minutes to complete. The WHOQOL-BREF was found to have comparable discriminant validity to the WHOQOL-100 in differentiating between ill and well individuals. The WHOQOL-BREF includes 26 items to assess QOL across four domains:Physical: This domain assesses distress and interference with life functioning in the areas of pain and discomfort, energy and fatigue, sleep, mobility and activities of daily living, dependence on medication and/or treatments, and work capacity. Psychological: This domain assesses a person’s experiencing of positive and negative feelings, a person’s perspective of his/her thinking, self-esteem, perceptions of body image/appearance, and spirituality. Social relationships: This domain assesses the extent to which individuals experience social and emotional support from others, including family, friends and intimate relationships. Environment: This domain assesses a person’s sense of safety and security from physical harm, quality of the home environment, financial stressors, access to health and social services, opportunity and desire for new knowledge, opportunities for leisure and recreation, and accessible transportation. Domain scores for the WHOQOL-BREF are calculated by taking the mean of all items included in each domain and multiplying by a factor of four. These scores are then transformed to a 0-100 scale, with higher scores denoting higher quality of life. Cronbach alpha values for each of the four domains scores range from .66 (for domain 3) to .84 (for domain 1) demonstrating good internal consistency. It has been recommended that Cronbach alpha values for domain 3 (social relationships) be read with caution as they were based on three scores, rather than the minimum recommended of four items for assessing internal reliability. The WHOQOL-BREF was developed cross-culturally, and it has been validated in field studies in 50 different languages, including Spanish for use in US populations, which facilitates cross-cultural comparisons worldwide. The WHOQOL-BREF is the most widely used QOL measure in the world, and has been previously used to assess QOL among at-risk immigrants (e.g., Benner, Townsend, Kaloi, Htwe, Naranichakul, Hunnangkul, et al., 2010; Kashdan, Morina, & Priebe, 2009; Laban, Komproe, Gernnat, & de Jong, 2008). Clinical mental health assessment. Mental health outcomes to be assessed in this study include: (1) Perceived psychological distress, (2) traditional mental health disorders previously considered within Axis I diagnosis and previously identified as prevalent among Latino immigrant populations; (3) Cultural Concepts of Distress relevant to Latino immigrants; and (4) Contextual Concepts of Distress to migrant populations. Traditional mental disorders to be assessed in this study include: Major Depressive Disorder (MDD), Dysthymia, Agoraphobia, Panic Disorder, Generalized Anxiety Disorder (GAD), Social Anxiety Disorder (Social Phobia), Post-Traumatic Stress Disorder (PTSD), Adjustment Disorder, Somatic Symptom Disorder, Alcohol Dependence/Abuse and Substance Dependence/Abuse, as well as suicidality. Cultural Concepts of Distress to be assessed in this study include Nervios and Ataque de Nervios. Contextual Concepts of Distress to be assessed in this study include Ulysses Syndrome. To assess for perceived psychological distress, the Brief Symptom Invetory-18 (BSI-18) will be used. This 18-item questionnaire is a self- report measure of emotional or psychological distress in the past week (Derogatis, 2000). The 18-items are rated on a 5-point Likert scale with 0 = not at all to 4 = extremely. The BSI-18 renders a total score, which consists of the sum of the 18 items, and a score for each subscale of 6 items (Anxiety, Depression, and Somatization). For this study, the Spanish translation published by Derogatis (2000) will be used. This version has shown adequate construct validity and reliability in previous studies with Latino populations (Galdón, Dura, Andreu, Ferrando, Murgui, Perez, et al., 2008). In the present study BSI-18 scores will be used in two ways. First, the total score on BSI-18 will be used as a measure of overall psychosocial distress, which has been showed to have satisfactory internal consistency (Cronbach’s α = .91). Second, cutoff scores as recommended by Derogatis (2000) will be used to determine “caseness” of psychological distress in order identify criteria for the assessment of Cultural and Contextual Concepts of Distress (to be described later in this section). The BSI-18 has been normed for use with clinical and non-clinical populations. Subjects with a T-score of 63 or higher in the general distress scale or at least in two of the BSI-18 dimensions will be considered as experiencing clinical levels of distress (Derogatis, 2000). To assess for the prevalence of traditional mental health disorders previously specified, two measures will be used. M.I.N.I. International Neuropsychiatric Interview (V. 6.0) (Sheehan, Lecrubier, Harnett-Sheehan, Janavs, Weiller, Bonara, et al., 1997; Sheehan, Lecrubier, Harnett-Sheehan, Amorim, Janavs, Weiller, et. al., 1998). Specific modules of the M.I.N.I. will be used to assess for MDD, agoraphobia, panic disorder, GAD, social anxiety disorder, PTSD, Alcohol Dependence/Abuse, Substance Dependence/Abuse and suicidality. The M.I.N.I. is a short, structured diagnostic interview used widely in clinical and research settings worldwide to assess for DSM-V and ICD-10 psychiatric disorders. This measure has been validated against the much longer Structured Clinical Interview for DSM diagnosis (SCID) and the Composite International Diagnostic Interview for IDC-10 diagnosis (CIDI) (Lecrubier, Sheehan, Weiller, Amorim, Bonara, Sheehan, et al., 1997; Sheehan, et al., 1997). The M.I.N.I. has been identified as a more time-efficient alternative to the SCID-P and CIDI given that the interview can be completed in approximately 15 minutes. The Spanish translations and adaptations of the M.I.N.I. have been conducted in Spain and in the United States. The sensitivity and specificity of the most common disorders using the Spanish version of the M.I.N.I. were MDD (94.1 and 62.2, respectively), GAD (92.3 and 64.6) and social phobia (100 and 84.2) (Bobes, 1998). The positive and negative predictive values for these disorders were 41.0 and 97.4 for MDD, 34.2 and 97.6 for GAD, and 14.2 and 100 for social phobia. Thus, the Spanish version of the M.I.N.I. is considered to have adequate psychometric properties and it is recommended for use with Latino populations (Mestre, Rossi, & Torrens, 2013). Structured Clinical Interview-SCID (DSM-VResearch Version). The SCID DSM-V Research Version is a structured clinical interview used for the diagnosis of DSM disorders among adults not suffering from severe cognitive impairment, agitation or severe psychotic symptoms (First, Spitzer, Gibbon, & Williams, 2002). In this study, only two modules of the SCID will be used: (1) Adjustment Disorder module, and (2) Somatic Symptom Disorder module. The SCID has been long recognized as "gold standard" in determining the accuracy of clinical diagnoses for mental health disorders (e.g., Shear, Greeno, Kang, et al., 2000; Steiner, Tebes, Sledge, et al., 1995). Ratings on the SCID are based on both patient’s answers and the expertise of the interview/rater, who may add additional questions to clarify ambiguity in diagnosis and assess the severity of the symptoms. To score the SCID, interviewers codify the responses of the modules as 1=absent/false, 2=subthreshold, or 3=present/true, indicating a need to continue to another module when applicable. There is a fourth rating option ? to be used when information is insufficient. The SCID had demonstrated superior validity over standard clinical interviews at intake (Kranzler, Kadden, Babor, Tennen, & Rounsaville, 1996), and reliability coefficients have ranged from fair to excellent varying across disorders. Also, studies have shown to SCID to achieve up to 90% accuracy in diagnosis (Lobbestael, Leurgans & Arntz, 2011; Ventura, Liberman, Green, Shaner, & Mintz, 1998). Reliability coefficients for the diagnosis of any somatoform disorder using the SCID-I has been shown to be .84 (Segal, Kabacoff, Hersen, Van Hasselt, & Ryan, 1995), whereas no report for reliability was found for the diagnosis of adjustment disorder. The SCID has been translated and validated in Spanish (First, Spitzer, Gibbon, & Williams, 1999); thus, it is recommended for use with Latino populations (Mestre, Rossi, & Torrens, 2013). To assess for Cultural Concepts of Distress, specifically Nervios and Ataque de Nervios, five measures will be used. Explanatory Model Interview Catalogue (EMIC) for the assessment of nervios and ataque de nervios. The EMIC is a collection of adapted explanatory semi-structured interviews developed for use in cultural psychiatry to better understand Cultural Concepts of Distress from an epidemiological and anthropological perspective (Weiss, 1997). An adapted version of the EMIC is available to assess for the experiencing of Nervios and/or Ataque de Nervios among Latino-origin individuals (Guarnaccia, Lewis-Fernandez, & Marano, 2003). As recommended by Guarnaccia et al. (2003), this study will use four modified questions derived from the EMIC approach to assess for lifetime and current prevalence of “Nervios” and “Ataque de Nervios” among this sample of undocumented Latino immigrants. Responses to the aforementioned questions are given in dichotomous format (Yes/No), as well as in a continuous form to denote the number of Ataque de Nervios that an individual has had in their lifetime and/or recently (within the past 12 months). These questions are available in Spanish. Ataque de Nervios Module from the National Latino and Asian American Study (NLAAS) Questionnaire (Alegría, Vila, Woo, Canino, Takeuchi, Vera, et al., 2004). The NLAAS is a nationwide study funded by the National Institute of Mental Health (NIMH) to estimate the lifetime and current prevalence of mental health disorders and mental health service use among Latino and Asian-origin populations in the US. The NLAAS Ataque de Nervios Module includes a list of 15 different symptoms that a person may experience during an Ataque de Nervios episode (e.g., get dizzy, fall to the floor with a “seizure,” shout a lot, become hysterical). Respondents are considered to meet syndrome criteria if they report having experienced a previous Ataque de Nervios (as assessed by the EMIC Ataque de Nervios question) and if they responded positively (Yes) to having experienced four or more symptoms during the attack. The cut-off of four or more symptoms was derived statistically using tests of distribution of the responses, as well as previous analysis of reported symptoms in clinical studies (Guarnaccia, Lewis-Fernandez, & Martinez-Pincay, 2010). This measure is available in Spanish and has been validated for use with various Latino populations in the US. The Brief Symptom Inventory (BSI-18), which will be used to assess for clinical level of psychological distress. As recommended by Derogatis (2000), a T-score of 63 or higher in the general distress scale or at least in two of the BSI-18 dimensions will be considered to meet criteria for clinical level of psychological distress. Bradford Somatic Inventory (BSI), which will be used to assess for somatic disturbance related to Nervios and Ataque de Nervios. The BSI is a 46-item multi-ethnic questionnaire used to assess a wide range of somatic symptoms in transcultural research (Mumford, Bavington, Bhatnagar, Hussain, Mirza, & Naraghi, 1991). The BSI evaluates whether physical symptoms, including those commonly reported among subjects suffering from Nervios (e.g., headaches, stomach disturbances, dizziness, tingling, trembling), have been present in the last month, with possible answers including: 0 = absent, 1 = present less than 15 days in the past month, and 2 = present on more than 15 days in the past month. Test-retest reliability of the BSI administered after a week has been found to be good, with an overall α reliability ranging from 0.86 to 0.92 (Chakraborty, Avasthi, Kumar, & Grover, 2010; Mumford, et al, 1991). The basic construct of the BSI is that the somatic symptoms enlisted are: (1) somewhat “unusual” compared to symptoms that are usually reported in somatic diseases with clear pathophysiology (e.g., fluttering or feeling of something moving in the stomach), or (2) general and/or vague (e.g., headaches), and that the coexistence of a number of symptoms scoring of at least 14 can be used as an index representing the association of symptoms of various types that are not likely based on a common pathophysiology. Consistent with previous research, a cutoff score of 14 discriminates between psychiatric cases (somatic symptoms related to psychological conditions) and non-cases (symptoms due to a medical condition) with 0.75 specificity and 0.87 sensitivity (Aragona, Catino, Pucci, Carrer, Colosimo, La-Fuente, et al., 2010). The BSI has been formerly used to assess somatization among different immigrant populations, including undocumented immigrants (86% of sample was undocumented, of which 46% was of Latino origin) (Aragona, et al., 2010; Aragona, Monteduro, Colosimo, Maisano, & Geraci, 2008). The BSI has been previously translated into Spanish following translation-back translation methodology (Aragona, et al., 2010) Interference with functional ability due to Nervios and Ataque de Nervios will be assessed using a question from the NLAAS (Alegria, Vila, Woo, Canino, Takeuchi, Vega, et al., 2004; Center for Multicultural Mental Health Research, 2013). This question asks participants to rate on a a scale from 0 = none to 10 = most interference, how much have “Nervios” and “Ataque De Nervios” interfere with household chores, quality of work, and social life/relationships. Individuals rate the level of interference for each of the three identified domains. To assess for Contextual Concepts of Distress, specifically Ulysses Syndrome, five measures will be used: Questions adapted from the DSM-V Cultural Formulation Interview (CFI) (American Psychiatric Association, 2013), which will be used to assess for: (a) contextual definition of the undocumented experience as a distressing event, and (b) contextual effect of the undocumented experience on identity. For this purpose, four open-ended questions will be used as presented in Appendix G. The Brief Symptom Inventory (BSI-18), which will be used to assess for clinical level of psychological distress. As recommended by Derogatis (2000), a T-score of 63 or higher in the general distress scale or at least in two of the BSI-18 dimensions will be considered to meet criteria for clinical level of psychological distress. Bradford Somatic Inventory-46 (BSI), which will be used to assess for somatic disturbance as previously described. As previously mentioned and consistent with previous research in immigrant populations, including Latinos in Europe, a cutoff score of 14 discriminates between psychiatric and non-psychiatric cases (Aragona, et al., 2008; 2010). Multidimensional Loss Scale (MLS), which will be used to assess for the presence of migration related losses/mourning and distress associated to the loss. The MLS is a 24-item measure used to index experiences of loss and associated distress across multiple domains (cultural, social, material and interpersonal) relevant to immigrant populations (Vromans, Schweitzer, & Brough, 2012). The MLS has been shown to have good internal consistency for the experience of loss events (α = .85) and associated distress (α = .92); thus, reflecting a unitary construct of multidimensional loss related to the immigration process (Vromans, et al., 2012). Results from factor analysis have provided support for a five-factor model structure of this measure: (1) loss of symbolic self (e.g., loss of wealth, traditions, values, language use, life beliefs) (α = .90), (2) loss of interdependency (e.g., change in how you are being treated, role or social position) (α = .75), (3) loss of home (e.g. leaving your country, home, land, possessions) (α = .86), (4) interpersonal loss (e.g., separation from family, death of family/friends) (α = .71), and (5) loss of interpersonal integrity (e.g., loss of freedom and autonomy, sense of wellbeing) (α = .64). Responses to each loss item are done in two ways: (a) dichotomous answer (Yes/no) depending on whether the loss has been experienced or not, and (b) rating of perceived stress associated to each specific loss including not at all or little distressing, quite a bit distressing, and extremely distressing. Interference with functional ability due to loss, which will be used with the MLS rating of perceived stress associated to each specific loss as previously described. Migration-related loss and trauma. This will be done using three measures, which include: Multidimensional Loss Scale (MLS), which will be used to assess for the presence of migration related losses/mourning and distress associated to the loss as previously described. A total score will be calculated by adding up all of the loss items reported as quite distressing or extremely distressing, so that higher scores would denote greater amount of loss experienced as distressing. Harvard Trauma Questionnaire (HTQ), which will be used to assess for pre-migration and/or in-transit trauma (Mollica, Mcdonald, Massagli, & Silove, 2004). The HTQ was designed to assess trauma experiences among at-risk immigrant populations (e.g., refugees). The HTQ is composed of two parts. Part one comprises 17 items used to measure participant’s experience and/or witnessing of 17 common forms of human rights violations that may lead to trauma (e.g., lack of food/water, lost or kidnapped, sexual abuse), while part two assesses trauma-related symptoms. For the purpose in this study, only part one of the HTQ will be used given that PTSD symptoms will be assessed using the M.I.N.I. as previously described. Thus, a total trauma score will be computed by adding up all trauma events experienced and/or witnessed so that higher scores will denote greater exposure to traumatic/distressing events related to the migration process. Post-migration Living Difficulties Questionnaire (PMLD) will be used to assess post-migration living difficulties. The PMLD is a 23-item questionnaire used to assess recent adverse life experiences typical of migration (Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997; Steel, Silove, Bird, McGorry, & Mohan, 1999). The PMLD yields a total score, as well as five subscale scores which measure: 1) financial, 2) health, 3) family and relational, 4) discrimination; and 5) immigration stressors. Responses to each living difficulty were given using a five-point scale from 0 = no problem at all to 3 = very serious problem.” A high cumulative score indicates a high amount of post-migration stress.Protective factors. These will be assessed using 4 measures, which include: Family intactness, which will be assessed using two questions aimed at identifying the marital and parental status of the respondent, as well as whether his/her spouse or children immigrated with the respondent to the US or if they continue to live in the country of origin. Responses to these questions will be used to create a categorical variable to denote 0 = family intact versus 1 = family not intact. An intact family will be defined as that in which a respondent’s spouse (if any) and his/her children (if any) reside in the US with the participant. Sense of Community Index Version 2 (SCI-2), which is a 24-item measure used to assess perceived sense of community (Chavis, Lee, & Acosta, 2008). The SCI-2 was modeled after the Sense of Community Index (SCI), a widely used measure of sense of community, in order to overcome some of its limitation. The SCI-2 has been shown to have good reliability (α = .94). The SCI-2 includes four subscales related to perceptions of sense of community: (1) reinforcement of needs (e.g., when I have a problem, I can talk about it with members of this community); (2) membership (e.g., being a member of this community is part of my identity); (3) influence (e.g., I have influence over what this community is like); and (4) shared emotional connection (e.g., I can trust people in this community). These subscales have also been shown as having good reliability with coefficient α scores of .79 to .86. Responses to each item are given using a four-point scale: 0 = not at all, 1 = somewhat, 2 = mostly, and 3 = completely. The SCI-2 renders a total score by summing up all items in the scale, as well as scores for each subscale. In this study, a total sense of community score will be used, with higher scores denoting stronger sense of community. Religiosity, which will be measured using three questions assessing perceptions of religiosity, influence of religion, and church attendance (Hovey, 2000). The first question is “how religious are you?” and responses are given in a four-point scale from 1 = not at all religious to 4 = very religious.” The second question is “how much influence does religion have upon your life?” and responses are also given in a four-point scale from 1 = not at all influential to 4 = very influential.” The third question is “how often do you attend church?” and responses are given in six-point scale from 1 = never to 6 = once a week or more.” These questions have been previously used to assess religiosity with Mexican immigrants in the US, and have been found to be significantly associated with anxiety, depression and suicidal ideation in this population (Hovey, 2000; Hovey & Magana, 2002). For this study, a latent variable with the three aforementioned questions will be created to assess an overall measure of religiosity. English language proficiency, which will be assessed using three items from the National Latino and Asian American Study (NLAAS) Questionnaire (Alegría, Vila, Woo, Canino, Takeuchi, Vera, et al., 2004). The questions assess proficiency in speaking, writing and reading English using a four-point rating scale from 1 = poor to 4 = excellent. A total English proficiency score will be calculated by adding up scores to the three questions. Translation. Measures not available in Spanish for use with Mexican-origin populations will be translated using established methodology (Beaton, et al., 2002). The steps involved in the translation process will be the same as those previously described in phase one of this dissertation. Recommended forms developed by Beaton et al (2002) will also be used for the written documentation of the translations process (see Appendix E). For this phase of the study, the following questions/measures will be translated using the aforementioned process: Adapted questions from the DSM-V Cultural Formulation Interview to assess for the Contextual Concept of Distress associated with Ulysses Syndrome (4 questions). World Health Organization Composite International Diagnostic Interview-Short form of the Chronic Health Conditions Module.Multidimensional Loss Scale (MLS). Harvard Trauma Questionnaire (HTQ)-Only the experienced events section. Family intactness questions (4 questions). Sense of Community Index. Analyses. Data will be analyzed using SPSS V. 20. Descriptive statistics will be used to assess prevalence and describe participant characteristics. Multivariate sequential logistic regression analyses will be used to assess for the association between risk factors and diagnosis of a mental health disorder after controlling for relevant covariates. Multivariate sequential linear regression analyses will be used to assess for the association between risk factors and perceived psychological distress after controlling for relevant covariates. Additionally, various multivariate regression models will be used to assess for the moderating effect of various protective factors (i.e., family intactness, social support, sense of community, spirituality/religiosity and English language proficiency) to the association between migration-related loss/trauma and/or difficulties and diagnosis of a mental health disorder/perceived psychological distress, after controlling for relevant covariates. All significance levels will be set at p ≤ .05. HYPOTHESESAim 1. Assess the prevalence of mental health disorders and perceived psychological distress in this sample of UIs and compare it to rates for other Latino and non-Latino populations in the US. Given the limited information on the prevalence for mental health disorders among UIs, prevalence rates for Mexican-origin foreign-born immigrants will be used as reference to hypothesize prevalence rates for UIs. The decision for using prevalence rates for the Mexican-origin foreign-born population instead of those for the foreign-born Latino population was based in that the majority of UIs in San Diego are of Mexican-origin; thus, there rates may be closer to estimate prevalence in the target population. Table 2 summarizes prevalence rates for the majority of mental health disorders assessed in this study for US-born Non-Latino Whites, US-born Latinos, foreign-born Latinos, and Mexican-origin foreign-born. Hypothesis 1. The prevalence of overall psychological distress as measured by the BSI-18 will be ≥ 14%, which is somewhat similar to that reported in the literature for foreign-born Latino immigrants in the US. Hypothesis 2. The prevalence for depressive disorders, anxiety disorders, somatic symptom disorder, stress related disorders (i.e., adjustment disorder and PTSD) and substance use disorders will be ≥ 14%, which is somewhat similar to that reported in the literature for foreign-born Latino immigrants in the US. Hypothesis 3. The prevalence for Cultural Concepts of Distress, specifically Nervios and Ataque de Nervios, will be ≥ 20% for Nervios and ≥ 6% for Ataque de Nervios, which is somewhat similar to that reported in the literature for foreign-born Latino (O’Connor, et al., 2013) and Mexican-origin immigrants in California (Guarnnacia, et al., 2010). Hypothesis 4. The prevalence for Contextual Concepts of Distress, specifically Ulysses syndrome, will be ≥ 20% given it is likely that this estimate may be similar to that reported for Nervios. Aim 2. Assess the QOL of this sample population using the WHOQOL-BREF, and identify its association to prevalent mental health disorders and perceived psychological distress, after controlling for relevant covariates (i.e., age, gender, and socioeconomic status). Hypothesis 1. After controlling for age, gender and socioeconomic status, a diagnosis ofa mental health disorder will be associated with decreased QOL. Hypothesis 2. After controlling for age, gender and socioeconomic status, greater levels of perceived psychological distress will be associated with decreased QOL. Aim 3. Identify the association between immigration-related risk factors and diagnosis of a mental health disorder/perceived psychological distress, after controlling for relevant demographic and socioeconomic factors. Hypothesis 1. After controlling for age, gender, and socioeconomic status, youngerage upon arrival to the US and longer time of residence in the US will be associatedwith increased likelihood of diagnosis with a mental health disorder. Hypothesis 2. After controlling for age, gender, and socioeconomic status, youngerage upon arrival to the US and longer time of residence in the US will be associatedwith greater levels of perceived psychological distress. Hypothesis 3. After controlling for age, gender, and socioeconomic status, greaterexposure to migration-related loss/trauma and post-migration living difficulties over along time, will be associated with increased likelihood of diagnosis with a mental healthdisorder.Hypothesis 4. After controlling for age, gender, and socioeconomic status, greaterexposure to migration-related loss/trauma and post-migration living difficulties over along time, will be associated with greater levels of perceived psychological distress. Aim 4. Identify moderators to the association between immigration-related loss/trauma and post-migration living difficulties, and diagnosis for a mental health disorder/perceived psychological distress, after controlling for relevant demographic, socio-economic factors, and other migration-related factors. Hypothesis 1. Family intactness will moderate the association between immigration-related loss/trauma/difficulties and diagnosis of a mental health disorder/perceived psychological distress, after controlling for age, gender, socio-economic status and length of time residing in the US. In other words, migration-related trauma and/or difficulties may be less likely associated to the presence of a mental health disorder/perceived psychological distress among immigrants with nuclear family living in the US when compared to those whose families are still left behind in the country of origin. Hypothesis 2. Sense of community will moderate the association between migration-related loss/trauma and/or difficulties and diagnosis of a mental health disorder/perceived psychological distress, after controlling for age, gender, socio-economic status and length of residence in the US. In other words, migration-related trauma/loss and/or difficulties may be less likely associated to the presence of a mental health disorder/perceived psychological distress among immigrants reported a higher sense of community when compared to those with limited sense of community. Hypothesis 3. Religiosity and/or spirituality will moderate the association between immigration-related loss/trauma and/or difficulties and diagnosis of a mental health disorder/perceived psychological distress, after controlling for age, gender, socio-economic status and length of residence in the US. In other words, migration-related trauma/loss and/or difficulties may be less likely associated to the presence of a mental health disorder/perceived psychological distress among immigrants reporting higher religiosity/spirituality when compared to those with lower religiosity/spirituality. Hypothesis 4. English language proficiency will moderate the association between immigration-related loss/trauma and/or difficulties and diagnosis of a mental health disorder/perceived psychological distress, after controlling for age, gender, socio-economic status and length of time in the US. In other words, migration-related trauma/loss and/or difficulties may be less likely associated to the presence of a mental health disorder/perceived psychological distress among immigrants reported to be proficient in the English language when compared to those with less English language proficiency. TABLE 1Demographic and socio-economic characteristics by immigration legal status categories*US-BornLegal ResidentsUndocumentedAge % Men ages 20-39 % Population ages ≥ 65 % Children 14.012.027.018.016.0 6.032.0 1.213.0Household Characteristics % Couple with family Mean family size 21.035.047.0Education % < High school (ages 25-64)8.022.047.0Language % Speaks English proficiently 100 23.0 (1st gen)88.0 (> 1st gen)NRFinancial Status Median household income (< 10 yrs in US) Median household income (≥ 10 yrs in US) % Homeownership (< 10 yrs in US) % Homeownership (≥ 10 yrs in US) % Adults living in poverty % Children living in poverty 50.00050,00070,070.010.018.050,00041,30054,10040.068.0NPNPNP35,00038,00027.045.020.030.036,000Employment % In the labor force (Men) % In the labor force (Women)837385669458Insurance % Uninsured142559*Information based on 2008 estimates from the Pew Research Center (2008) NP=Not provideda Results based on data from the 2008 ACS (1 year estimate). b Results for UIs based on 2007-2008 data provided by the Pew Research Center (2008). TABLE 2Lifetime prevalence of mental health disorders among Latinos (Alegria, et al., 2008)aNon-Latino WhitebUS Latino Population (N=2,554)Mental DisorderUS-born Non-Latino White (N=4,088) US-born Latinos(n=924)Foreign-born Latinos n=(1,630)Mexican-OriginForeign-born (n=498) % 95% CI % 95% CI % 95% CI % 95% CIAny Depressive Disorder 27.6 25.1 - 30.5 19.8 17.3 - 22.514.4 12.6 - 17.012.9 9.9 - 16.0 Dysthymia 6.2 4.7 - 7.8 3.4 2.2 - 4.5 3.1 2.1 - 4.1 2.8 1.3 - 4.5 MDD 26.9 24.2 - 29.8 18.6 16.1 - 21.113.4 11.6 - 15.411.8 9.1 - 14.5Any Anxiety Disorder 30.8 28.0 - 33.7 18.9 16.2 - 21.515.2 13.2 - 17.314.2 11.3 - 17.1 Agoraphobia 4.0 2.8 - 5.4 3.7 2.5 - 5.1 3.7 2.7 - 4.8 3.4 1.9 - 5.0 GAD 10.0 8.3 - 11.8 4.4 3.1 - 5.6 4.7 3.6 - 5.8 4.8 3.2 - 6.5 Panic Disorder 6.0 4.7 - 7.4 4.5 3.1 - 6.0 3.4 2.2 - 4.6 3.4 1.6 - 5.1 PTSD 9.5 7.9 - 11.3 5.9 4.4 - 7.5 4.0 3.0 - 5.1 3.5 2.1 - 5.0 Social Anxiety Disorder 16.9 14.9 - 19.0 8.5 6.5 - 10.2 6.0 4.6 - 7.2 4.7 2.9 - 6.6Any Substance Disorder 26.4 23.6 - 29.0 20.4 18.0 - 22.9 7.0 5.4 - 8.5 7.0 4.7 - 9.5 Alcohol Abuse 12.1 9.6 - 14.4 9.3 7.4 -11.2 3.5 2.3 - 4.8 3.5 1.9 - 5.4 Alcohol Dependence 10.1 8.2 - 12.0 6.9 5.2 - 8.5 2.8 1.9 - 3.8 2.8 1.4 - 4.2 Drug Abuse 7.7 6.0 - 9.5 6.1 4.5 - 7.8 2.8 1.4 - 3.1 2.0 0.8 - 3.4 Drug Dependence 6.4 4.7 - 8.0 5.1 3.6 - 6.8 1.7 0.9 - 2.6 1.7 0.5 - 3.0Any Disorder52.5 49.5 - 55.3 37.1 33.9 - 40.024.9 22.5 - 27.223.9 20.6 - 27.2MDD=Major Depressive Disorder; GAD=Generalized Anxiety Disorder; PTSD=Post Traumatic Stress Disorder. aData drawn from the 2003 National Comorbidity Survey Replication (NCS-R) bData drawn from the 2003 National Latino and Asian American Study (NLAAS)TABLE 3Assessment of Cultural and Contextual Concepts of Distress Cultural Concept of DistressConstructCriteria Measure UsedData/Response/Cut offNervios1. Cultural Syndromea. Current acknowledgment of Nerviosb. Somatic symptoms (including those specified in DSM-V)c. Emotional distress symptomsd. Functional limitation EMIC: 1. Have you ever suffered from “Nervios” in your life? 2. Do you suffer from “nervios” now or in the past 12 months?BSI-46BSI-18Adapted from NLLAS: On a scale from 0-10…How much your Nervios interfered with: 1.Household chores 2. Quality of your work 3. Social life/relationshipsResponse: Yes/NoYes/NoTotal score ≥ 14T ≥ 63 in general distress scale ORT ≥ 63 in any of the individual subscales Frequency per domain from 0=no interference to 10= most interference2. Cultural Idiom of Distressa. Life time Prevalenceb. Nervios as a traitc. Cultural expression of distressEMIC: Have you been “nervous” since childhood”?EMIC: Are you a “nervous” person? EMIC: How do you describe your experiencing of “Nervios”? Yes/NoYes/NoQualitative description3. Cultural Explanationa. Causal explanation of perceived distressEMIC: What is the most probable cause of your “Nervios”?Qualitative descriptionAtaque de Nervios1. Cultural Syndromea. Current acknowledgment of Ataque de Nerviosb. Somatic symptoms (including those specified in DSM-V)c. Emotional distress symptoms(including those specified in DSM-V)d. Frequency of Attaques de Nerviose. Functional limitation EMIC:1. Have you ever had an “Ataque de Nervios” where you felt totally out of control? 2. Have you had an “Ataque de Nervios” where you felt totally out of control within the past 12 months?NLAAS Ataque de Nervios Module (Symptoms section)NLAAS Ataque de Nervios Module (Symptoms section)EMIC: How many Ataque de Nervios have you had in the past 12 months? Adapted from NLAAS: On a scale from 0-10…How much the episode or Ataque de Nervios interfered with: 1.Household chores 2. Quality of your work 3. Social life/relationshipsResponse:Yes/NoYes/No4 pt Likert Scale: Scores ≥ 4 suggest somatization4 pt Likert Scale: Scores ≥ 4 suggest emotional distressFrequencyFrequency per domain from 0=no interference to 10= most interference2. Cultural Explanationa. Causal explanation of Ataque de NerviosNLAAS Ataque de Nervios Module (Causal section)Responses:List format Yes/NoContextual Concept of Distress: Ulysses SyndromeUlysses Syndrome 1. Contextual Syndromea. Emotional distress symptoms b. Somatic symptoms c. Functional limitation due to distress associated to loss BSI-18BSI-46MLSa. Distress associated to migration-related lossT ≥ 63 in general distress scale ORT ≥ 63 in any of the individual Total score ≥ 14Total score ≥ 14b. Total score for losses experienced as extremely distressing2.Contextual Idiom of Distressa. Contextual expression of distressb. Contextual effect on identityAdapted from DSM-V CFI:1. How would you describe your experience as an undocumented immigrant to others? 2. What troubles you most about being an undocumented immigrant?Adapted from DSM-V CFI:1. How do you feel about being undocumented? Qualitative descriptionQualitative descriptionQualitative description3. Contextual Explanationa. Causal explanation of Ulysses Syndromeb. Contextual effect of migration-related lossAdapted from DSM-V CFI: How much distress do you experience from being undocumented? MLS To assess for: a. Experiencing of migration related losses Frequency per domain from 0=no interference to 10= most interferencea. Frequency of losses by migration-related domainEMIC= Explanatory Model Interview Catalogue BSI-46= Bradford Somatic InventoryBSI-18= Brief Symptom Inventory (Anxiety, Depression, Somatization)NLAAS=National Latino and Asian American StudyMLS=Multidimensional Loss ScaleFigure 1. Dahlgren & Whitehead (1991) Socio-ecological model of health. APPENDIX AScreening Questions for Participation in Focus Groups1. Do you identify yourself as Latino(a)? ___ Yes ___ No2. Are you over 18 years of age? ___ Yes ___ No3. Where you born outside the US? ___ Yes ___ No 4. Do you think you have a good understanding of the experiences of undocumented Latino immigrants living in San Diego and surrounding areas? ___ Yes ___ No5. In general, do you have weekly interactions with undocumented Latino immigrants in San Diego or surrounding areas? ___ Yes ___ No 6. Approximately, what percentage of people in your social network of friends and family in San Diego or surrounding areas are undocumented? ____ (enter %)Appendix B Mental Health Services Contact ListThe service agencies included in this list provide confidential and low cost mental health services in Spanish that are based on sliding scale fees for patients without insurance and regardless of immigration legal status. Linda Vista Health Care Center- Logan Heights Family Health San Diego Family Care Centers of San Diego (858) 279-0925 (619) 515-23006973 Linda Vista Road 1809 National AveSan Diego, CA, 92111 San Diego, CA, 92113M, W, F 8 am -5 pm M 8 am- 7 pmT 8 am - 8:30 pm T-Th 8 am -6 pmS 9 am -1 pm F 8 am-5:30 pm S 8 am -5 pmLogan Heights Family Nestor Community Health CenterCounseling Center IBCC(619) 515-2355 (619) 429-37332204 National Ave. 1016 Outer Rd. San Diego, CA, 92113 San Diego, CA, 92154M 8 am – 5 pm M, W 8 am – 8 pmT & W 8 am – 8 pm T, Th, F 8 am – 5 pmTh & F 8 am – 5 pm Operation Samahan Operation Samahan Mira Mesa Outreach Clinic Rancho Penasquitos(858) 578-4220 (858) 312-670010737 Camino Ruiz, S. 235 9955 Carmel Mountain Rd F2San Diego, CA, 92126 San Diego, CA, 92129M-S 8:30 am-5 pm M-F 9 am – 1 pmSDSU Psychology Clinic San Ysidro Health Center(619) 594-5134 Euclid Family Counseling Center 6363 Alvarado Ct, Suite 103 (619) 205-1947San Diego, CA, 92120 292 Euclid Ave. M & F 9 am -4:30 pm San Diego, CA, 92114T & Th 9 am – 7 pm M-F 1 pm -5 pmW 9 am -5 pmThis list was obtained mostly from the HOPE California Healthcare Resource Guide for Undocumented Immigrants. Appendix CDemographic Questionnaire: Focus GroupsParticipant ID # _____________Todays date (mm/dd/year): ____ /_____ / ________ Focus Group # _____________Please read each question and check or circle the answer that corresponds with your answer.All of the responses are confidential.1. Please circle your sex Men Woman2. Please indicate your age ______ Years 3. Please circle, what is your marital status? Single Married or living as married Divorced Widow Prefer not to answer4. Please circle, what is the highest degree or level of school you completed? No school Elementary School Middle School Some high school (no diploma) High school with diploma (or GED) Some college or higher Prefer not to answer5. Please circle, are you currently employed? If Employed , what type of work do you: Yes No Type of work: _______________________6. What country were you born in? Country: ________________________7. How many years have you lived in the U.S.? ______ Years8. Please circle, how would you rate your overall health? Excellent Very Good Good Fair Poor9. Please circle, how would you rate your overall mental health? Excellent Very Good Good Fair Poor10. Please circle, have you ever been diagnosed with a mental health condition? Yes NoIf YES, what mental health condition(s) have you been diagnosed with? _____________________________________11. Has anyone in your family (including siblings, parents and grandparents) ever been diagnosed with a mental heath condition? Yes NoIf YES, what mental health condition(s) have they been diagnosed with? ______________________________________12. Approximately, what percentage of people in your social network of friends and family in San Diego or surrounding areas are undocumented? _____(enter % of people)13) Approximately, how may days a week do you interact with undocumented Latino immigrants ? _____ (# of days per week) Appendix DFocus Group Guided Discussion Questions What comes to mind when you hear someone talking about mental health? How relevant do you think is the study of mental health among the undocumented community in San Diego and surrounding areas? Why do you think it is important to study mental health among UIs?What do you think may be some relevant mental health issues for undocumented immigrants (UIs) in San Diego and surrounding areas? What may be some relevant mental health issues for UIs upon their arrival to the US? What may be some relevant mental health issues for UIs later on as they settle in the US? Which of the aforementioned issues may be more relevant to women? Men? Children? Families?How likely do you think are UIs to participate in health studies? Who would be more likely to participate? (e.g., men, women, recent UIs, UIs with longer time in the US, those working in the field?)How likely do you think are UIs to participate in mental health studies? Who would be more likely to participate?How is this different from participating in health studies? What do you think may be some concerns, limitation or fears that could make UIs not want to participate in mental health studies? (e.g., lack of trust, lack of time, family conflict, fear of deportation, literacy)What would you do to encourage participation in mental health studies among UIs? What would you do to increase their motivation to participate? (e.g., use of incentive, type of incentive)What would you do to increase their motivation to refer other UIs in their network of friends and family to participate in your study? What would you do to increase their trust in researchers?What would you do to reduce their concerns about disclosing their immigration legal status to researchers? How would you invite UIs to participate in your study? Where would you recruit UIs for your study? (e.g., locations, settings)Where would you conduct the study? (e.g. field, university, community center, church)What would be the best way to interview these participants? (e.g., phone, in-person, online)How long should the interviews last? Who should conduct the interviews? Do you have any other suggestions or recommendations as to how you would improve studies on the mental health of UIs and their families? Appendix E Translation formsForm A: Report on the cross-cultural adaptation of an outcome or covariate measureSource Questionnaire: Questionnaire being adapted: _________________________ Version: __________________Target group information: Country where it will be used: _________________________Culture: _________________________Language: _________________________Resources used and reports included: NamesReport CompletedForward translators: 1. 2. Synthesis of translations: Expert CommitteeBack-translators: 1. 2. Expert committee: Methods: Clinician: Language Expert: All translators: T1 T2 BT1 BT2Pre-testingCoordinatorForm B: Forward Translation into Target LanguageTranslator (Circle one): T1 T2Name of Translator: ___________________________Profile of Translator (Circle one): Aware of concept Native to concept Name of Questionnaire: ________________________________________Original Version Item: Forward Translated Version (T1 or T2)Instructions: Items: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Translation of response categories: Form C: Form summarizing the synthesis of the two forward translations (Version T-12)* Submit notes on discrepancies and their resolution on separate formName of Questionnaire: ________________________________________Original Version Item: Final Translated Version (T-12)Instructions: Items: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Translation of response categories: Synthesis process report of discrepancies (dealt with in State II to create T-12)Issue: (specify item # and describe issue:Resolution:Form D: Back-Translation into English*** Back translation is done without looking at this form, or the original questionnaire. Results are then summarized on this form. It is important that the back translator is blind to the original instrument. Back-Translator (Circle one): BT1 BT2Name of Back Translator: ___________________________Country of origin (where was English spoken as first language: _____________________ Name of Questionnaire: _______________________________________________________Original Version Item: Back Translated Version (BT-1 or BT-2)Instructions: Items: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Translation of response categories: Form E; Expert Committee ReportMembership: Role: Name: Methodologist: Clinician: Translator # 1Translator # 2Back Translator # 1Back Translator # 2Language Specialist Report of discrepancies and their resoluation: Issue: (Specify item # and describe the issue)Resolution: Form F; Pilot testing report (Participants in this study will also be used to pilot the translated measures) Sample description: Sample size: Description: Age (mean, SD):Gender: # males = __________ # females = ____________Study descriptionReliability: (Internal consistency, test-retest reliability)Please describe the methods used: Please describe the results: Validity: Methods used (list constructs, how they were measured):Summarize results for each construct: Responsiveness: Described methods used: Describe results: Other Psychometric testing (e.g., Factor Analysis)Describe: Describe results: Appendix FScreener for Participation Eligibility in Quantitative Study Are you over 18 years of age? _______________ Yes _____________NoDo you self-identify as Latino(a) or Hispanic? ______________ Yes ____________NoWhere you born outside the U.S.? ______________ Yes ____________NoAre you a naturalized citizen of the U.S.? ______________ Yes ____________NoDo you have a legal permanent residency (pink, green or brown) card that permits you to reside in the U.S? ______________ Yes ____________NoDo you have a visa that permits you to reside in the U.S. temporarily (e.g., as student, visitor, business visitor? ______________ Yes ____________NoAppendix GQuestionnaires for Quantitative Study Participant Voucher # (RDS Serial Number) ______________________Date of Interview (mm/dd/year): ____ /_____ / ________Interviewer’s initials: ___________________________Interview location: _______________________________INSTRUCTION TO INTERVIEWER: (Follow IRB procedures to explain this study and confidentiality protection procedures. Obtain definitive verbal consent prior to interview). READ: I will ask you many questions that are sensitive and private. I want to remind you that the interview is completely anonymous and that any information you share with me cannot be tracked back to you. You can refuse to answer any question that you do not want to answer. If you do not want to answer a question, just tell me and we will move to the next question. I. DemographicsI.1. Gender. Please circle participants’ gender Men WomanI.2. How old are you? _______________ years (777) DK (999) REFI.3. What is the highest level of school you completed? No schoolElementary school (6th grade)Middle School (9th grade)Some high school (no diploma)High school with diploma (or GED) (12th grade)Technical education Some college (no degree). Ask: College degree or higher(777) DK(999) REFI.4 Are you currently employed? (1) Yes. Ask Type of work: __________________________(2) No(777) DK (999) REFI.5 Would you mind if I ask which one of the following ranges was your total gross household income for last year? Less than $ 5, 000 (6) $ 40, 000 to $ 49,000 $ 5,000 to $ 9,999 (7) $ 50,000 or more $ 10,000 to $ 19,999 (777) DK $ 20,000 to $ 29,999 (999) REF II. Immigration history II.1. Where were you born? Country: ________________________ State: ____________________ (777) DK (999) REFII.2. Where did you spend most of your life? Country: ________________________ State: _____________________ (777) DK (999) REFII.3. At what age did you first come to the U.S. to live? ___________ Age first came to U.S. (in years) (777) DK (999) REFII.4. From the time you first moved to U.S. until today, how many years have you lived in the U.S.? _____________ years (777) DK 999. REFIII. Respondent Driven Sampling QuestionsIII.1 What is the name of the area you live (e.g., town name) (for mapping recruitment location purposes only)? ________________________________________________________________________III.2 How many friends, relatives or anyone you know by name do you have in or near San Diego who are undocumented? ________________________________(enter # of people) III.3 What is your relationship with the person that gave you the coupon? RelativeFriendAcquaintance StrangerOther. Specify: _________________III.4 How long have you known this person? ____________months OR ______________yearsIV. Quality of Life IV.1 CITI Chronic Conditions What chronic health conditions, if any, did you have prior to immigrating to the US? Yes No (777) DK(999) REF(1) Arthritis or Rheumatism(2) Chronic pain. Specify: (3) Heart disease(4) High blood pressure(5) Asthma or respiratory disease(6) Diabetes or high blood sugar(7) Stomach problems(8) Cancer. Specify: (9) Mental disorder. Specify: Other. Specify: What chronic health conditions do you currently have? Yes No (777) DK(999) REF(1) Arthritis or Rheumatism(2) Chronic pain. Specify: (3) Heart disease(4) High blood pressure(5) Asthma or respiratory disease(6) Diabetes or high blood sugar(7) Stomach problems(8) CancerOther. Specify: IV.2 World Health Organization Quality of Life –BREF (WHOQOL-BREF) Are you currently ill? Yes No (777) DK (999) REF If something is wrong with your health, what do you think it is? ______________________________________________________________________________This assessment asks how you feel about your quality of life, health and other areas of your life. Please answer all the questions if you can. If you are unsure about which response to give to a question, please choose the one that appears most appropriate. This can often be your first response. Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the LAST TWO WEEKS. Very poorPoorNeither poor, nor goodGoodVery good1.How would you rate your quality of life?12345Very dissatisfiedDissatisfiedNeither satisfied, nor dissatisfiedSatisfiedVery Satisfied2.How satisfied are you with your health? 12345The following questions ask how much you have experienced certain things in the last two weeks. Not at allA littleA moderate amount Very muchAn extreme amount3.To what extent do you feel that (physical) pain prevents you from doing what you need to do? 123454. How much do you need any medical treatment to function in your daily life? 123455.How much do you enjoy life? 123456. To what extent do you feel your life to be meaningful? 12345Not at allA littleA moderate amountVery muchExtremely7.How well are you able to concentrate? 123458.How safe do you feel in your daily life? 123459.How healthy is your physical environment? 12345The following questions ask about how completely you experience or were able to do certain things in the last two weeks. Not at allA littleModeratelyMostlyCompletely10. Do you have enough energy for everyday life? 1234511.Are you able to accept your bodily appearance? 1234512. Have you enough money to meet your needs? 1234513. How available to you is the information that you need in your day-to-day life? 1234514.To what extent do you have the opportunity for leisure activities? 12345Very poorPoorNeither poor, nor goodGoodVery good15. How well are you able to get around?12345The following questions ask you to say how good or satisfied you have felt about various aspects of your life over the last two weeks. Very dissatisfiedDissatisfiedNeither satisfied, nor dissatisfiedSatisfiedVery Satisfied16. How satisfied are you with your sleep? 1234517. How satisfied are you with your ability to perform your daily living activities? 1234518.How satisfied are you with your capacity for work? 1234519. How satisfied are you with yourself? 1234520. How satisfied are you with your personal relationships? 1234521. How satisfied are you with your sex life? 1234522. How satisfied are you with the support you get form your friends? 1234523. How satisfied are you with the conditions of your living place? 1234524. How satisfied are you with your access to health services? 1234525. How satisfied are you with your transport? 12345The following question refers to how often you have felt or experienced certain things in the last two weeks. NeverSeldomQuite oftenVery oftenAlways26. How often do you have negative feelings such as blue mood, despair, anxiety, depression? 12345V. Mental Health V.1 Brief Symptom Inventory-18 (BSI-18) Below is a list of problems that people sometimes have. Please indicate how each problem has distressed or bothered you during the past 7 days including today. (0) = Not at all (1) = A little bit (2) = Moderately (3) = Quite a bit (4) = ExtremelyNot at all(0)A little bit(1)Moderately(2)Quite a bit(3)Extremely(4)DK777REF9991. Faintness or dizziness2. Feeling no interest in things3. Nervousness or shakiness inside4. Pains in your chest5. Feeling lonely6. Feeling tense or keyed up7. Nausea or upset stomach8. Feeling blue9. Suddenly scared for no reason10. Trouble getting your breath11. Feeling of worthlessness12. Spells of terror or panic13. Numbness or tingling in parts of your body14. Feeling hopeless about the future15. Feeling so restless you couldn’t sit still 16. Feeling Weak in parts of your body17. Thoughts of ending your life18. Feeling fearfulV.2 M.I.N.I. Neuropsychological Clinical Interview. The following disorders will be assessed using specific modules of the MINI based on DSM-V and/or ICD-10 diagnosis, as well as risk of suicidality: CategoryDSM-V /ICD-10SpecifiersDSM-V CodeICD-10 CodeDepressive DisordersMajor Depressive Disorder (MDD)Current (2 weeks) PastRecurrent296.2x296.2x296.3xF32.xF32.xF32.xAnxiety DisordersAgoraphobiaGeneralized Anxiety Disorder (GAD) Panic DisorderSocial Phobia (Social Anxiety Disorder) CurrentCurrent (Past 6 months)Current (Past month)LifetimeCurrent (Past month)GeneralizedNon-generalized300.22300.02300.0300.0300.23300.23300.23F40.00F41.1F41.0F41.0F40.10F40.10F40.10Trauma & Stress-related DisordersPost-traumatic Stress Disorder (PTSD)Current (Past month)309.81F43.10Substance-related & Addictive DisordersAlcohol DependenceAlcohol AbuseSubstance Dependence (Non-Alcohol)Substance Abuse (Non-Alcohol)Past 12 monthsPast 12 monthsPast 12 monthsPast 12 months30x.xx30x.xxVaries by drugVaries by drugF10.xF10.xF1x.xF1x.xSuicidality SuicidalityCurrent (Past month)Low, Moderate, HighNot applicableNot applicableV.3 SCID-RV DSM-VThe following disorders will be assessed using specific modules of the SCID-RV for DSM-V diagnosis: CategoryDSM-V /ICD-10SpecifiersDSM-V CodeICD-10 CodeDuration of AdministrationDepressive DisordersPersistent Depressive Disorder (Dysthymia)Current (Only)Early/Late OnsetPersistentIntermittent 300.4F34.1Approx 3 minSomatic Symptom & Related DisordersSomatic Symptom Disorder Current (only)With/Without PainPersistent/Not persistentMild/Moderate/Severe300.82F45.1Approx 5 minTrauma & Stress-related disorders*Adjustment DisorderCurrent (Only)With DepressionWith AnxietyMixed (Depression/Anxiety)Disturbance of conductDisturbance of emotion309.0F43.2xApprox. 3 min.*Adjustment disorder must be evaluated as the last mental health disorder in this clinical assessment, and should ONLY be assessed if individual reports symptoms of psychological distress at a clinical level based on BSI-18 scores and if he/she does not meet criteria for any other DSM-V diagnosis. V.3 Cultural Concepts of DistressV.3.1 EMIC Nervios and Ataque de Nervios assessment (Section B)1.Have you been “nervous” since childhood”? Yes No (777) DK (999) REF2.Are you a “nervous” person? Yes No (777) DK (999) REF3.Have you ever suffered from “nervios” in your life? Yes No (777) DK (999) REFIf Yes, ask Do you still suffer from “nervios” now or in the past 12 months?Yes No (777) DK (999) REF If Yes, ask How do you describe your experiencing of “nervios”? What do you feel?______________________________________________________________________________________________________________________________________________________ What do you think is the most probable cause of your “nervios”? ______________________________________________________________________________________________________________________________________________________V.3.2. Bradford Somatic Invetory (BSI)Please tell us if you have had any of the following symptoms during the past month . . . 0No1YES< than 15 days in the past month2YES> than 15 days in the past month777. REF999. DK1,Have you had severe headaches? 2. Have you had fluttering or a feeling of something moving in your stomach? 3. Have you had pain or tension in your neck or shoulders? 4. Has your skin been during or itching all over? 5. Have you had a feeling of constriction of your head, as if it wwas being gripped tightly from outside? 6. Have you felt pain the chest or heart? 7. Has your mouth or throath felt dry?8. Has there been darkness or mist in front of your eyes? 9. Have you felt burning sensation in your stomach? 10. Have you felt a lack of energy (weakness) much of the time? 11. Has your head felt hot or burning? 12. Have you been sweating a lot? 13. Have you felt as if there was pressure or tightness on your chest or heart? 14. Have you been suffering ache or discomfort in the abdomen? 15. Has there been a choking sensation in your throat? 16. Have your hands or feet have pins and needles or gone numb? 17. Have you felt aches or pains all over the body? 18. Have you had a feeling of heat inside your body? 19. Have you been aware of palpitantions (heart pounding)? 20. Have you felt pain or burning in your eyes? 21. Have you suffered from indigestion? 22. Have you been trembling or shaking? 23. Have you been passing urine more frequently? 24. Have you been having low back trouble? 25. Has your stomach felt swollen or bloated? 26. Has your head felt heavy? 27. Have you been feeling tired, even when you are not working? 28. Have you been getting pain in your legs? 29. Have you been feeling sick in the stomach (nausea)?30. Have you had a feeling of pressure inside your head as if your head was going to burst? 31. Have you had difficulty in breathing, even when resting? 32. Have you felt tingling? 33. Have you been troubled by constipation? 34. Have you wanted to open your bowels (go to the toilet) more often than usual? 35. Have your palms been sweating a lot? 36. Have you had difficulty in swallowing as if there was a lump in your throat? 37. Have you been feeling gitty or dizzy? 38. Have you had a bitter taste in your mouth? 39. Has your whole body felt heavy? 40. Have you had a burning sensation when passing urine? 41. Have you been hearing a buzzing noise in your ears or head? 42. Has your heart felt weak or sinking? 43. Have you suffered from excessive wind (gas) or belching? 44. Have your hands or feet felt cold? FOR MEN ONLY45. Have you had difficulty getting full erection? 46. Have you felt that you have been passing semen in your urine? Using a 0 to 10 scale, where 0 means no interference and 10 means very severe interference, think about the month or longer in the past 12 months when your “Nervios” was most severe. What number describes how much your Nervios interfered with: Household chores (e.g., cleaning, shopping, taking care family) _____(Number 0-10)Quality of your work _____(Number 0-10)Social life and relationship with others _____(Number 0-10)V.4 Cultural Concept of Distress: Ataque de Nervios 1. Have you ever had an “Ataque de Nervios” where you felt totally out of control? Yes No (777) DK (999) REFIf Yes, ask Have you had an “Ataque de Nervios” where you felt totally out of control within the past 12 months?Yes No (777) DK (999) REFIf Yes, ask How many “Ataque de Nervios” where you felt totally out of control have you had during the past 12 months? ______________ (number of “Ataques de Nervios”)Earlier you mentioned having an episode or nervous attack when you felt totally out of control. During that episode did you: Yes(1)No(2)DK777REF9991. Shout a lot? 2. Have crying attacks? 3. Break things or become aggressive? 4. Get very angry or in rage? 5. Feel very scared or frightened? 6. Become hysterical?7. Tremble a lot?8. Fell strange like it was not you who was doing this?9. Have a period of amnesia?10. Get dizzy?11. Fall to the floor with a “seizure”?12. Have heart palpitations (your heart beats hard)?13. Have chest tightness or heat in your chest? 14. Faint or feel on the verge of fainting? 14. Try to hurt yourself or attempt suicide? Using a 0 to 10 scale, where 0 means no interference and 10 means very severe interference, think about the month or longer in the past 12 months when your episode of losing control or nervous attack was most severe. What number describes how much the episode or nervous attack interfered with: Household chores (e.g., cleaning, shopping, taking care family) _____(Number 0-10)Quality of your work _____(Number 0-10)Social life and relationship with others _____(Number 0-10)Did this episode of losing control or Ataque de Nervios occur as the result of any of the following situations? Yes(1)No(2)DK777REF9991. Receiving bad news. Specify: 2. Death of a family member. 3. Family problem or conflict. Specify: 4. Marital problem5. Natural disaster or accident. Specify: 6. Frightening, disturbing or irritating event. Specify: 7. Strong emotion such as sadness or ange. 8. Worries9. Assault or physical or sexual abuse10. Economic problem11. Illness or physical condition. Specify: 12. Use of alcohol or drugs13. Another situation. Specify: V.5 Contextual Concept of Distress: Ulysses Syndrome (Adapted from DSM-V cultural formulation interview (CFI)Contextual definition of the problem: 1. In a few words, how would you describe your experience as an undocumented immigrant to others? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. What troubles you most about being an undocumented immigrant? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. On a scale from 0 = no stress to 10=most distress, how much distress do you experience from being undocumented? Please describe. ____________________________________________________________________________________________________________________________________________________________Contextual effect on identity:4. How do you feel about being undocumented? ____________________________________________________________________________________________________________________________________________________________VI. Risk FactorsVI.1 Pre-migration Loss/trauma QuestionnaireI would like to ask you some questions about matters that you may have experience prior to immigrating to the United States or as a result of coming to live in the United. Please tell me YES, if this is something you have experienced. For statements indicated as YES, please tell me how much these experiences are upsetting you or causing you difficulties in any way. Have you experienced: YESNot at allA littleQuite a bitExtremely1. Leaving your house/home 2. Leaving your land 3. Leaving your country 4. Leaving your possession or animals behind 5. Change in your role/position in your family or community 6. Change in who you can call on for support and assistance 7. Change to the type of work you do 8. Change in how you are treated by other people 9. Long separation from a family member 10. Death of a family member 11. Long separation from friends or community members 12. Death of a friend or community member 13. Been cut off from Familiar food 14. Been cut off from hearing, speaking or seeing your language 15. Been cut off from traditional or religious ceremonies important to you 16. Been cut off from familiar music or song 17. Been cut off from important family values or traditional values 18. Been cut off from your dreams for the future or plans for your life 19. Been cut off form your hopes for your family 20. Been cut off from your beliefs about how life should be Have you lost…21. Some freedom, choice or autonomy in your life 22. Some of your health or sense of wellbeing 23. Some of your wealth or inheritance 24. Some opportunities you previously looked forward to In addition to the aforementioned losses, are there any other looses that you experienced prior to immigrating to the U.S. and that are extremely upsetting to you? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________VI.2 Migration traumaHarvard Trauma Questionnaire: Trauma experienced only scaleWe will now ask you some questions about traumatic experiences that you or your family experienced prior to, during your migration to the U.S. or while living in the U.S. Please tell me if you or your family has experience any of these events. Family refers to nuclear, as well as extended family. If these memories are too disturbing, please stop at any time. Have you experienced or witnessed:Trauma you or a family member experiencedExperiencedWitnessed1. Lack of food or water2. Ill health without access to medical care3. Lack of shelter4. Imprisonment/detention/deportation (Circle the ones that apply)5. Serious injury. Specify: 6. Combat situation. Specify: 7. Brain washing. Specify: 8. Rape or sexual abuse (e.g., by smugglers, authorities). Specify: 9. Forced isolation from others10. Being close to death. Specify: 11. Forced separation form family members12. Murder of family or friend13. Unnatural death of family or friend14. Murder of stranger or strangers 15. Lost or kidnapped16. Torture (e.g., physical abuse). Specify: 17. Threatened by dangerous animals Total In addition to the aforementioned hurtful or traumatic events, are there any other hurtful or traumatic events that you or your family experienced prior to, while crossing the border to come to the US or while living in the U.S.? Specified if experienced or witnessed. VI.3 Post-migration living difficulties Problems of living Questionnaire Below is a list of living difficulties that immigrants who have arrived in the U.S. sometimes experience. Have you experience any of these difficulties in the last 12 months (a year)? Have you experienced: Was not a problem/Did not happenA small problemModerately serious problemA serious problemStill a problem today1. Unable to return home in an emergency2. Fear/threat of [deportation]. Specify: 3. Concern for family in country of origin4. Unemployment (Difficulty finding jobs)5. Insufficient money to buy food, necessary clothes, pay rent. 6. Loneliness and boredom7. Communication difficulties (e.g., limited English language)8. Separation from family 9. Feeling isolated from others10. Poor access to treatment for health problems 11. Poor access to emergency medical care12. Poor access to long-term healthcare 13. Poor access to dental care14. Poor access to counseling/mental healthcare15. Bad work conditions. Specify: 16. Discrimination 17. Difficulties obtaining help from charities18. Difficulty getting help from social services 19. Conflict with immigration officials20. Interviews by immigration officials21. Limited access to traditional foods from your country22. Delay in the immigration legal process 23. Difficulties adjusting to cultural life in the US. Specify: EXTRA24. Difficulties with transportation25. Inability to have frequent communication with family/friends back home26. Conflict with other ethnic groups in the US. Specify:27. Overall, how do you feel about your life in the United States ?Very satisfiedSatisfiedUnsatisfiedVery unsatisfiedNoneIn addition to the aforementioned living difficulties, are there any other difficulties that you have experienced during the past 12 months?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ VII. Protective Factors VII.1 Family Intactness 1. What is your marital status? (1) Married or living as married Ask: Did your spouse immigrate with you to the U.S.? Yes No REF If YES, ask: Do you live with or near you spouse? Yes No REF If NO, ask: Is you spouse left behind in your country of origin? Yes No REFDivorcedWidowedSeparatedSingle, never been married(777) DK(999) REF2. Do you have children? Yes Ask: How many? ________ Sons _________ Daughters Ask: Did your children immigrate with you to the U.S.? Yes No REF If YES, ask: Do your children live with or near you? Yes No REF If NO, ask: Do you have any children left behind in your country of origin? Yes No REF (2) No (777) DK (999) REF3. Do you have parents or siblings left behind in your country of origin? YesNo DKREF4. Do you live in a mixed-immigration status family? A mixed-immigration status family is a family in which members vary in their immigration legal status. For example, a child may be a U.S. citizen, but the parent may be undocumented. YesNo (777) DK (999) REFVII.2 Sense of Community Sense of Community Index IIThe following questions about community refer to: the community that you live in, as well as the group of people with whom you interact and engage in your regular activities (e.g., work, church, children’s school).How important is it to you to feel a sense of community with other community members?123456Prefer not to be part of this communityNot important at allNot very importantSomewhat importantImportantVery importantHow well do each of the following statements represent how you feel about your community?Not at allSomewhatMostlyCompletely1. I get important needs of mine met because I am part of this community.2. Community members and I value the same things. 3. This community has been successful in getting the needs of its members met. 4. Being a member of this community makes me feel good. 5. When I have a problem, I can talk about it with members of this community. 6. People in this community have similar needs, priorities, and goals. 7. I can trust people in this community8. I can recognize most of the members in this community. 9. Most community members know me. 10. This community has symbols and expressions of memberships such as clothes, signs, art, architecture, logos, landmarks and flags that people can recognize. 11. I put a lot of time and effort into being part of this community. 12. Being a member of this community is a part of my identity.13. Fitting into this community is important to me. 14. This community can influence other communities. 15. I care about what other community members think of me16. I have influence over what this community is like. 17. If there is a problem in this community, members can get it solved. 18. This community has good leaders. 19. It is very important to me to be a part of this community. 20. I am with other community members a lot and enjoy being with them. 21. I expect to be part of this community for a long time. 22. Members of this community have shared important events together, such as holidays, celebrations or disasters. 23. I feel hopeful about the future of this community. 24. Member of this community care about each other. How many years and months, have you lived in your community? ___________years _____________ monthsVII.3 ReligiosityHovey (1999) How religious are you? Not at all religiousSlightly religiousSomewhat religiousVery religious 777. DK999. REFHow much influence does religion have upon your life? Not at all influentialSlightly influentialSomewhat influentialVery influential 777. DK 999. REFHow often do you attend church? NeverOnce or twice a yearOnce every two or three monthsOnce a monthTwo or three times a monthOnce a week or more777. DK 999. REFVII.4 English Language Proficiency (Items from the NLLAS)PoorFairGoodExcellentDon’t knowRefused1. How well do you speak English?12347779992. How well do you read English?12347779993. How well do you write English?1234777999That’s my last question. Thank you very much for taking the time to participate! Before we finish let me emphasize again that your answers cannot be identified with any of your personal information. Everyone’s answers will be combined to give us information about the quality of life and mental health of undocumented Latino immigrants in San Diego and nearby areas. We appreciate your time and effort. Here are 3 coupons. Here is how it works (Interviewer explains the referral process). Referral coupon numbers given to subject: Envelope #: ____________________________Coupon # 1: __________________________________Coupon # 2: __________________________________Coupon # 3: __________________________________VIII. Interviewer’s observations Adapted from CITI Interviewer Observation form (IO)1. Overall, in your opinion how honest was the respondent to the questions? Very honestHonestSomewhat honestNot very honestNot honest at allNot sure2 How well did the respondent understand the questions? ExcellentGoodFairPoor3 How was the respondent’s cooperation during the interview? ExcellentGood FairPoor4 How much effort did the respondent put into answering the questions? A lotSomeVery littleNone5 Did the respondent behave as if he/she was hallucinating (e.g., hearing voices, seeing visions, giggles to self)YesNo6 Did respondent have any other type of behavioral or emotional responses that struck you as very inappropriate or very unusual? (e.g., laughed at odd times, became angry or fearful at times, talk to him/herself, acted overly familiar, acted hostile)? Yes. If yes, describe: ______________________________________________________________________ No7 Were there any interruptions during the interview? Yes. If yes, describe: ______________________________________________________________________No 8 Did the participant expressed any concern about sensitive/personal information? Yes. If yes, describe: ______________________________________________________________________No 9 Did the participant expressed any other concern about his/her participation in this study? Yes. If yes, describe: ______________________________________________________________________No10 Describe setting where the interview took place (i.e., public restaurant, library, medical office, SDSU)_________________________________________________________________________________________________________11 What time was the interview completed? 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