Working with Recent Immigrants and Migrants

PREVENTION WORKS! SUBSTANCE ABUSE PREVENTION FOR UNDERSERVED POPULATIONS: A RESOURCE KIT VI.f Recent Immigrants/Migrants Note An article included in the Prevention Works! Children Living in Stressful Environments Resource Kit (June 2008), “Children of Immigrants or in Bicultural Families,” examined the impact of this experience on children and their potential risks for substance abuse and mental health problems Although there is some duplication of that article in the information presented below, the two pieces are in many respects complementary Immigrants vs Migrants “Immigrants” are those “who come to a country to take up permanent residence,” according to Merriam-Webster’s online definition.1 Although the word is used sometimes interchangeably with “migrants,” the distinction Merriam-Webster makes between the two is that “migrant,” (from “migrate”) suggests temporary relocation from one country to another or from one area of a country to another in order to obtain work, often in agriculture.2 Thus, immigrants to the United States are more likely to settle in and begin adapting to the culture of a particular community, generally attempting to so legally Migrants move periodically, have limited interaction with established communities where they obtain temporary employment, and are much more likely to have entered the country without authorization to so Unfortunately, published data and other information about immigrants to the United States and migrants/migrant workers within U.S borders, including some government documents, use “immigrant” and “migrant” interchangeably, sometimes attributing the characteristics of one group to both However these two major groups are defined and their members counted, they are of increasing concern to States and communities everywhere In 2007, the nearly 10 million immigrants in California accounted for 27 percent of the total U.S immigrant population New York State was second, with 11 percent, followed by Florida and Texas with 10 percent each, and New Jersey with percent Together, the five States have 61 percent of the Nation’s total foreign-born population When it comes to unauthorized (a.k.a., illegal) migrants, the pattern is somewhat different California is Merriam-Webster Online Immigrant From http://www.merriam-webster.com/dictionary/immigrant (accessed June 9, 2010) Merriam-Webster Online Migrant From http://www.merriam-webster.com/dictionary/migrant (accessed June 9, 2010) still at the top of the list with by far the largest illegal population, an estimated 2,840,000, followed by Texas (1,702,000), Florida (1,012,000), Arizona (579,000), and New York (552,000) 3,4 While migrant workers are likely to continue gravitating to places where seasonal agricultural jobs are plentiful, traditional concentrations of foreign-born populations may be yielding to dramatic changes as increasing numbers of immigrants leave the largest cities and move to smaller towns and rural areas.5 As an example, between 1990 and 2006, North Carolina witnessed a startling 394 percent increase in the number of children of immigrants living in the State.6 There are shared risks and protective factors among these separate groups—language barriers are common to both, for example—but there are significant differences, as well, such as why children and adolescents may be drawn to substance abuse and where they may (or may not) be exposed to prevention messages Immigrants A Nation of Immigrants is not only the title of a book originally written by then Senator John F Kennedy and revised and reprinted several times following his assassination as President, but a familiar description of the United States of America as well With the exception of the descendants of the Nation’s indigenous population, those “first Americans,” known as American Indians, and descendants of Mexican citizens who resided in areas now included within U.S boundaries, all U.S citizens or their forbearers were born outside of the United States and arrived here as immigrants, either voluntarily or involuntarily in the case of those descended of slaves The process continues In the 21st century, the United States is accepting more legal immigrants as permanent residents than any other country.7 Immigrants are the fastest growing segment of the U.S population.8 The U.S Census Bureau places the total number of current U.S residents who were foreign born at 37,679,592, the highest number ever recorded.9 (See Figure 1.) Of this total, 47.1 percent are identified as Hispanic or Latino, more than half (59.8 percent) are married and speak English less than Advocates for foreign-born persons in the United States discourage referring to such individuals as “illegal migrants” or “illegal immigrants” because those labels may be stigmatizing and foster hostility toward these people It is important also to acknowledge that the migrant population includes U.S citizens Center for Immigration Studies (November 2007) Immigrants in the United States, 2007: A profile of America’s foreign-born population From http://www.cis.org/articles/2007/back1007.html#3 (accessed June 9, 2010) Urban Institute Research of Record (2010) Research area: Immigration From http://www.urban.org/toolkit/issues/immigration.cfm#findings (accessed June 9, 2010) Urban Institute Research of Record (2010) Children of immigrants: A statistical snapshot From http://www.urban.org/publications/901294.html (accessed June 9, 2010) China View (2006) U.S population hits 300 million From http://news.xinhuanet.com/english/200610/17/content_5215770.htm (accessed August 5, 2010) Centers for Disease Control and Prevention (March 1, 2006) Advance data from vital and health statistics, number 369 Physical and mental health characteristics of U.S and foreign-born adults: United States, 1998–2003 From http://www.cdc.gov/nchs/data/ad/ad369.pdf (accessed June 9, 2010) “very well” (52.3 percent), while almost a third of them (31.2 percent) live in what the agency describes as “linguistically isolated households.” Overall their earnings are low and poverty is high (15.9 percent) Among foreign-born families living in poverty, 19.1 percent include children below the age of 18 10 Leaving out foreign-born U.S residents who have already gained U.S citizenship, the U.S Department of Homeland Security reports that at the beginning of 2008, an estimated 12.6 million legal permanent residents (LPRs) had emigrated from other countries and about 8.2 million of them were eligible for naturalization.11 Also in 2008, more than million foreign-born people ages 18 and over were naturalized in the United States, having spent a median of years in legal permanent resident status before naturalizing More of them came from Mexico (22 percent) than from any other country; the next leading countries of origin were India (6.3 percent), the Philippines (5.6 percent), the People’s Republic of China (3.8 percent), and Cuba (3.8 percent) But countries as far-flung as Poland and Peru (1.4 percent each) contributed to the total.12 U.S Census Bureau American Factfinder (ND) American community survey: 2006–2008 American community survey 3-year estimates From http://factfinder.census.gov/servlet/STTable?_bm=y&geo_id=01000US&-qr_name=ACS_2008_3YR_G00_S0501&-ds_name=ACS_2008_3YR_G00_ (accessed June 9, 2010) 10 Center for Immigration Studies (November 2007) Immigrants in the United States, 2007: A profile of America’s foreign-born population From http://www.cis.org/articles/2007/back1007.html#3 (accessed June 9, 2010) 11 U.S Department of Homeland Security, Office of Immigration Statistics (October 2009) Population estimates: Estimates of the legal permanent resident population in 2008 From http://www.dhs.gov/xlibrary/assets/statistics/publications/ois_lpr_pe_2008.pdf (accessed August 5, 2010) 12 U.S Department of Homeland Security (March 2009) Naturalizations in the United States: 2008 Annual flow report From http://www.dhs.gov/xlibrary/assets/statistics/publications/natz_fr_2008.pdf (accessed August 5, 2010) Not only does the process of immigration adding to the population of U.S citizens continue but it plays an essential role in maintaining the Nation’s population size, its total workforce, and its ratio of working-aged people to the population of retired people they must help support and care for As the author of one text on the subject put it, “If we have zero immigration with today’s low birthrates the American population would eventually begin to shrink.”13 However, this may be an oversimplification of the complex business of projecting and managing population sizes through immigration policies The United Nations includes six dramatic scenarios for changes in the U.S population from 1995 to 2050 in a 2001 publication available in six languages and the subject of some subsequent media controversy The final scenario proposes 5.2 persons ages 15 to 64 for each person ages 65 or older in the United States throughout those 55 years and estimates that this would require an average of 10.8 million immigrants annually.14 Key Issues in Immigrant Health A sad reflection on the health environment in the Nation is that, in general, the health of foreign-born immigrants is better than that of native-born Americans While there are differences between those from different countries of origin, immigrants tend to have lower mortality rates and longer life expectancies; they are less likely to have circulatory diseases, overweight/obesity, and some cancers Equally troubling is that assimilation/acculturation into mainstream American culture erodes these health advantages The longer immigrants remain in the United States the less healthy they become.15 An example of the superior health of new immigrants is that immigrant black adults are less likely to show signs of serious psychological distress than African Americans who were born in the United States Also, they are less likely to be current smokers or obese and have lower rates of such chronic diseases as hypertension and cardiovascular disease Similarly, although they report having limited access to healthcare and tend to be uninsured, Hispanic immigrant adults are much healthier than their U.S.-born counterparts They have lower rates of bed disability days, are less likely to smoke or to be obese, and are less likely to show symptoms of serious psychological distress; their hypertension and cardiovascular disease prevalence is lower than for their native-born counterparts It may be that selectivity plays some part in these patterns, since the health of immigrants to this country tends to be much better than the health of people who 13 Williams, M E (Last modified June 6, 2010) Immigration From http://en.wikipedia.org/wiki/Immigration_to_the_United_States#cite_note-13 (accessed June 9, 2010) 14 United Nations, Department of Economic and Social Affairs, Population Division (2001) Replacement migration: Is it a solution to declining and aging populations? Chapter 4.B.8: United States From http://www.un.org/esa/population/publications/ReplMigED/USA.pdf (accessed August 5, 2010) 15 Zhao, X., Cai, X., George Mason University (2009) PowerPoint presentation: Health information disparities between U.S.- and foreign-born populations HINTS Data User Conference 2009 From http://hints.cancer.gov/hints2009/zhao.pdf (accessed June 9, 2010) remain in their home countries.16 But whatever accounts for the superior health of immigrants is no longer as effective after they reach this country Historically, immigrants flocked to America’s great urban centers where they could hope to find jobs and affordable (although often substandard) housing The cities also had big public hospitals and other health resources that could meet at least some of the needs of the immigrant population But much has changed in recent times and the foreign-born U.S population is not only reaching record levels, it is leaving the big cities for smaller communities and spreading across the suburban and rural landscapes 17 How their healthcare needs will be met in these new settings is uncertain The youngest immigrants may pose an added challenge to current healthcare resources The following statement from the Urban Institute’s Web site page, “Research Area: Immigration” (http://www.urban.org/toolkit/issues/immigration.cfm#findings), suggests the potential impact of America’s increasing immigrant youth population on the entire healthcare and social services system, including substance abuse prevention: Immigration is changing the composition of the Nation’s child population: one in five U.S children and one in four low-income children has an immigrant parent Since so many immigrants work in low-wage jobs without benefits, their children face greater risks of poverty, economic hardship, and lack of access to health insurance, public benefits, child care, and other services Effects of Acculturation on Immigrant Substance Abuse Adapting to American culture does not necessarily mean increased substance use for all immigrants An analysis of data in the National Health Interview Survey, reported in 2005, concluded that, in general, the foreign-born population of the United States remains less likely to use and abuse alcohol than native-born Americans.18 16 Centers for Disease Control and Prevention (March 1, 2006) Advance data from vital and health statistics, number 369: Physical and mental health characteristics of U.S.- and foreign-born adults: United States, 1998–2003 From http://www.cdc.gov/nchs/data/ad/ad369.pdf (accessed June 9, 2010) 17 Urban Institute (2010) Research of record research area: Immigration From http://www.urban.org/toolkit/issues/immigration.cfm#findings (accessed June 9, 2010) 18 Szaflarski, M and Cubbins, L.A (2005) Alcohol use and place of birth: A study of the U.S immigrant population Paper presented at the annual meeting of the American Sociological Association, Marriott Hotel, Loews Philadelphia Hotel, Philadelphia, PA Online From http://www.allacademic.com/meta/p23212_index.html (accessed June 9, 2010) However, other studies find increases, sometimes dramatic increases, in substance abuse among immigrants as they acculturate For example, an examination of Washington State’s Hispanic population published in 2008 found19: ● Acculturated Hispanics were more than 13 times as likely to report current illegal drug use and more than times as likely to report current hard drug use as nonacculturated Hispanics; and ● Acculturated Hispanics were more than twice as likely to report current binge drinking and more than three and one-half times as likely to report drinking continuously for days in a row without sobering up In general, the youngest members of immigrant families are the quickest to assimilate into their new surroundings The discrepancies between their degree of acculturation and that of their parents and other older relatives appear to play a factor in their increased vulnerability to alcohol and drugs On the other hand, several studies have found that maintaining strong ties to one’s original culture (although adapting to and functioning well in the new setting) to be protective In 2009, the Community Anti-Drug Coalitions of America (CADCA) summarized recent findings along these lines from a study of hundreds of Hispanic/Latino ninth graders in Southern California.20 Migrant/Migrant Worker According to the United Nations, in a worldwide context, “The term migrant worker refers to a person who is engaged or has been engaged in a remunerated activity in a state of which he or she is not a national.”21 A 2005 estimate placed the international migrant population between 185 and 192 million, or approximately percent of the world population, a number comparable to the population of Brazil.22 In the United States, a migrant worker is someone who generally works away from home (if he or she has a home) and may be referred to as a foreign worker if, as is frequently the case, their place of origin is outside the country Many are recent arrivals lacking legal work visas 19 Scott, A., Mosher, C., Smith, C and Florence, J (2008) Effect of acculturation on patterns of Hispanic substance use in Washington state Journal of Drug Issues 38 (1) From http://www.allacademic.com//meta/p_mla_apa_research_citation/1/7/5/6/4/pages175643/p175643-1.php (accessed June 9, 2010) 20 Community Anti-Drug Coalitions of America National Coalition Institute’s Research Into Action: (May/June 2009) Acculturation impacts Hispanic adolescents’ risks of substance abuse From http://www.cadca.org/files/2009-06-Acculturation.pdf (accessed June 9, 2010) 21 United Nations General Assembly (1990) International convention on the protection of the rights of all migrant workers and members of their families From http://www.un.org/documents/ga/res/45/a45r158.htm (accessed August 5, 2010) 22 Wikipedia, as reported by Answers.com (ND) United Nations convention on the protection of the rights of all migrant workers and members of their families From http://www.answers.com/topic/united-nations-convention-on-the-protection-of-the-rights-of-allmigrant-workers-and-members-of-their-families (accessed on August 5, 2010) Establishing exactly how many people are in the United States without legal status at any given time is impossible, given that their arrivals and departures are not documented and that they are believed to be significantly undercounted in the Census and other surveys A center supported by the Pew Charitable Trusts has published one set of estimates; according to this, based on 2000 Census data, the March 2005 Current Population Survey (CPS), and the monthly CPS through January 2006, there were between 11.5 million and 12 million unauthorized migrants living in this country in 2006 Of America’s 37 million foreign-born population, undocumented migrants represent 30 percent (11.1 million) Between 25 percent and 40 percent of unauthorized migrants are people who have overstayed their visas; the rest are categorized by immigration officials as “EWIs”— entries without inspection.23 An estimated 56 percent, or 6.2 million, of these unauthorized migrants came to the United States from Mexico, with another 2.5 million (22 percent) from all other Latin American countries combined About 3.1 million children, or 64 percent of all the children in unauthorized families, were American citizens because they were born in the United States An additional 1.8 million children in these families were unauthorized.24 It should be noted that there are foreign-born people in the United States who have Employment Authorization Documents (EADs), which are issued by the Department of Homeland Security, and who may be considered “authorized” in some sense Of unauthorized migrants, between million and 1.5 million are under several “quasi-legal” categories, such as those with Temporary Protective Status (TPS) or Extended Voluntary Departure (EVD), as well as those applying under these statutes Another 250,000 persons await decisions about their applications for asylum About 600,000 have applied for “green cards” or LPR status Those related to or engaged to marry U.S citizens make up about 100,000 more people awaiting legal permanent residency Most of those in these categories will probably receive permanent legal status at some point.25 23 Passel, Jeffrey F., Pew Hispanic Center Research Report (March 7, 2006) The size and characteristics of the unauthorized migrant population in the U.S.—estimates based on the March 2005 current population survey From http://pewhispanic.org/files/reports/61.pdf (accessed on August 5, 2010) 24 Passel, Jeffrey F., Pew Hispanic Center Research Report (March 7, 2006) The size and characteristics of the unauthorized migrant population in the U.S.—estimates based on the March 2005 current population survey From http://pewhispanic.org/files/reports/61.pdf (accessed on August 5, 2010) 25 Passel, Jeffrey F., Pew Hispanic Center Research Report (March 7, 2006) The size and characteristics of the unauthorized migrant population in the U.S.—estimates based on the March 2005 current population survey From http://pewhispanic.org/files/reports/61.pdf (accessed on August 5, 2010) Key Issues in Migrant Health26 Depression is common among farmworker adults where it is often related to isolation, economic hardship, and weather conditions In addition, poverty, stress, mobility, hard labor, substandard and overcrowded living conditions, physical discomfort and lack of recreation make farmworkers vulnerable to high risk behavioral activities, such as substance abuse… 27,28 —National Center for Farmworker Health, Inc “The health status of migrant farmworkers is at the same standard of most Third World Nations, while the country in which they work, the United States, is one of the richest Nations on earth,” according to a national nonprofit organization focused on this population 29 Little is known about the health of those who enter the United States without required authorization prior to their arrival Once in the country, several factors make migrants particularly vulnerable to depression and other mental health problems and to substance abuse, including self-medication These include poverty, mobility, difficult living and working conditions, conflicts relating to acculturation, skewed perceptions of mental illness, discrimination, and cultural isolation A 2000 study documented a 26.7 percent incidence of psychiatric disorders among a sample of male Mexican farmworkers in California.30 A national survey of migrant women showed that approximately 20 percent had experienced physical or sexual abuse during the previous year.31 These factors increase migrants’ risk for illness and injury as well, and health problems are likely to progress to advanced stages before migrants attempt to seek help In 1962, President John F Kennedy authorized the Migrant Health Program, which is administered by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA) and consists of a national network of migrant health 26 A more detailed article on “Migrant Workers” (including a brief bibliography) from the Encyclopedia of Public Health can be accessed at either http://www.enotes.com/public-health-encyclopedia/migrant-workers or http://www.answers.com/topic/migrant-worker (accessed June 9, 2010) 27 Not all migrants who are in the United States without official permission are farmworkers, and not all farmworkers are undocumented migrants However, the enormous American agricultural industry depends on cheap labor, much of it provided by unauthorized visitors to the United States and such employment has always been a major attraction, motivating unauthorized entry into this country 28 National Center for Farmworker Health, Inc (ND) About America’s farmworkers: Farmworker health From http://www.ncfh.org/?pid=4&page=7 (accessed March 19, 2010) 29 National Center for Farmworker Health, Inc (ND) Facts about farmworkers From http://www.ncfh.org/docs/fs-Facts%20about%20Farmworkers.pdf (accessed March 19, 2010) 30 Alderete, E., Vega, W.A., Kolody, B., and Aguilar-Gaxiola, S (2000) Lifetime prevalence of risk factors for psychiatric disorders among Mexican migrant farmworkers in California American Journal of Public Health 90: 608–614 From http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446194/ (accessed June 9, 2010) 31 National Center for Farmworker Health, Inc (2002) Migrant health issues; monograph series; domestic violence series: by Rachel Rodriguez, Ph.D., R.N., F.A., A.N., Assistant Professor, School of Nursing, University of Wisconsin—Madison From http://www.ncfh.org/docs/06%20-%20domestic.pdf (accessed June 9, 2010) clinics 32 There are 154 of these federally funded Migrant Health Centers, most operated under the auspices of community-based organizations.33 According to HRSA, its Migrant Health Centers now serve “more than one quarter of all migrant and seasonal farmworkers in the United States.”34 This suggests that nearly three-quarters (about million) of migrant and seasonal farmworkers in the United States are not receiving such services Providing healthcare and prevention to transient migrant farmworkers presents an obvious challenge Programs and services must attempt to provide care and information that is sensitive to the special cultural, financial, and occupational needs of farmworkers Many migrant workers have little or no English-language literacy Most farmworkers cannot participate in daytime programs without losing income or employment and few can provide their own transportation Whether on farms or in cities, people who fear legal penalties and possible deportation because they lack required documentation for their presence in the United States tend to avoid programs and services likely to draw attention to their unauthorized status Continuity of care is a major concern in migrant health A farmworker may only be in one location briefly so, for issues requiring ongoing attention, followup must be carefully planned Portable records with detailed treatment information are often given to farm workers to present to other healthcare facilities as they travel Electronic data-transfer systems also allow centers to communicate information such as immunization records and tuberculosis treatment Substance Abuse Among Immigrants/Migrants in the United States Information about the use of alcohol, tobacco, and other drugs among immigrants to the United States is limited Such data that does exist is not collected on a regular schedule and may not reflect new and emerging trends For example, the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Office of Applied Studies (OAS) issued an analysis of substance abuse among immigrants generally and among those from 16 specific countries of origin in March 2005.35 The content is comprehensive and detailed, but is based on data in SAMHSA’s National Surveys on Drug Use and Health for the years1999 through 2001, something to keep in mind when applying its valuable findings in a current context 32 Current access to information about the Migrant Health Program is available at http://bphc.hrsa.gov/about/specialpopulations.htm (accessed June 9, 2010) 33 National Center for Farmworker Health, Inc (ND) About community and migrant health centers From http://www.ncfh.org/?pid=6 (accessed June 9, 2010) 34 Health Resources and Services Administration (ND) The health center program: Special populations Migrant health center From http://bphc.hrsa.gov/about/specialpopulations.htm (accessed June 9, 2010) 35 Office of Applied Studies (March 2005) Immigrants and substance abuse: Findings from the 1999–2001 National Surveys on Drug Use And Health From http://www.oas.samhsa.gov/immigrants/immigrants.htm#2.1 (accessed June 9, 2010) General conclusions about immigrants from the 16 countries in the SAMHSA analysis: ● The prevalence rates of past-month alcohol use, past-month binge drinking, past-month heavy drinking, and past-year alcohol use were lower for foreign-born persons compared with U.S.-born individuals Male immigrants have higher rates of alcohol use than females, and younger ages were associated with an increased risk for alcohol use Being married lowered the odds that immigrants would drink ● Foreign-born persons living in the United States had lower rates of past-month (2.9 percent) and past-year (6.0 percent) use of any illicit drug use when compared with U.S.-born individuals (6.6 percent for past-month and 11.5 percent for past-year use) ● Past-month marijuana use was lower among foreign-born individuals living in the United States (1.7 percent) than among U.S.-born persons ages 18 or older (5.1 percent) ● Tobacco use rates also were generally lower among immigrants than among U.S.-born persons ages 18 or older Past-month tobacco use prevalence was lower among foreign-born respondents living in the United States (20.4 percent) than among U.S.-born individuals (32.8 percent) The SAMHSA report includes one observation on immigrant substance abuse patterns that partially mirrors what has been noted about immigrant health in general: As a group, immigrants arrive in the United States with lower rates of substance abuse than their American-born counterparts For many immigrants, acculturation and assimilation may narrow and eliminate these rate differences over time, although this is not true for every category of substance abuse and may not occur equally among all immigrant groups It is unclear whether selectivity plays a part; whether those who re-settle in the United States are more likely, less likely, or just as likely as others from their native countries to drink, smoke, or use illicit drugs One possible element in any such selectivity could be a requirement for physical and mental examination of persons seeking permission to enter the country, set down in the Immigration and Nationality Act (INA) In its broad interpretation of the INA, the Immigration and Naturalization Service (INS) may deport immigrants with a history of drug abuse or addiction, whether or not such persons have ever been convicted on a drug-related charge, if they admit to even one use of an illegal drug in the previous years.36 It may be that some potential immigrants not attempt legal entry due to this policy But there are factors, such as the typical age of new arrivals, their marital status, their educational and economic levels, and the substance abuse norms in their countries of origin, that can help explain some differences between immigrant substance abuse with that of those born and raised in the United States 36 Mautino, K (January 2002) Immigrants, immigration, and substance use and abuse Journal of Immigrant Health, (1) From http://www.springerlink.com/content/h5u74w898qnm6266/fulltext.pdf? page=1 (accessed June 9, 2010) 10 Migrant Substance Abuse Given the stresses and hardships experienced by those who are in this country without legal documentation and status, it would be surprising if their rates of substance abuse were not higher than that of the general population But evidence to support this assumption is rare, and what there is may not provide an accurate, current picture of how unauthorized migrants use drugs and alcohol and what problems arise from such use In October 2001, the National Center for Farmwork Health, Inc issued a series of 10 monographs on migrant health topics, one of which reviewed published studies of migrant mental health and substance abuse.37 The first study cited a 2000 examination of stressors gleaned from interviews with Mexican migrant farmworkers in Michigan and Ohio, produced a laundry list of barriers (e.g., language, geographical isolation) and horror stories (e.g., swimming across polluted waters or walking extremely long distances in the desert, lack of running water, lower wages than what was agreed) difficult for many Americans to imagine Understandably, other studies reviewed in the monograph suggest that migrants “…may use alcohol and other drugs as coping mechanisms In other words, they may use alcohol and other drugs to offset the stressors of migrant life, boredom, and feelings of depression and anxiety.” Other studies discussed in the National Center for Farmworker Health monograph suggest significantly more and heavier drinking among migrant males, in particular One, a 1994 sampling of migrant men in northern California, reported an average of 10 drinks per episode on the weekends A study published in 2000 reported an alcohol abuse prevalence rate of 12.2 percent among Mexican migrant men in Fresno County, CA, compared with a general population estimate of 7.0 percent at the time The same study estimated that rates of alcohol abuse among migrant men were 12 times those of migrant women A conclusion of this monograph reviewing substance abuse and mental health studies of migrant populations was: “High levels of pathology have been found for depression, anxiety, alcohol abuse, and violence toward women and children In addition, preliminary data suggest that some migrant farmworkers may be at risk for suicide.” More recent evidence of elevated alcohol abuse rates among male migrant farm workers came from interviews conducted among Latino farmworkers in North Carolina in June and July 2005.38 All but one of the participants were born in Mexico; 92.7 percent claimed Mexico as their permanent home Over one-quarter (26 percent) completely abstained from alcohol, but 27 percent reported frequent heavy drinking, or drinking five or more alcoholic beverages two or more times per month The authors concluded that more than one-third of [migrant] farmworkers may be alcohol-dependent 37 National Center for Farmworker Health, Inc (October 2001) Monograph series: Migrant health issues Produced for the national advisory council on migrant health From http://www.ncfh.org/docs/00-10%20%20monograph.pdf (accessed June 9, 2010) 38 Grzywacz, J.G., Quandt, S.A., Isom, S and Arcury, T.A (2007) Alcohol use among immigrant Latino farmworkers in North Carolina American Journal of Industrial Medicine, 50: 617–625 From http://www.ncfhp.org/pdf/alcoholnc.pdf (accessed August 5, 2010) 11 In an attempt to corroborate that Mexican migrant workers in the United States have elevated levels of substance abuse when compared to other citizens of Mexico and to provide perspective on the issue, Guilherme Borges, DSc., of the National Institute of Psychiatry and the Metropolitan Autonomous University, Mexico City, Mexico, and his associates interviewed a sample of 5,732 participants in the Mexican National CoMorbidity Survey.39 Many had either migrated in order to work or had family members who had done so Based on their interview responses, Dr Borges and his colleagues concluded that “…migrant laborers in the United States and respondents with family members currently working in the United States were more likely to have used alcohol, marijuana, cocaine, and other illicit drugs at least once in their lives; more likely to have met the criteria for substance abuse; and more likely to meet the criteria for substance abuse in the current year than were other Mexicans.” Use of methamphetamine and cocaine may be more common among migrant workers than it is in the general population and is known to contribute to migrant vulnerability to HIV/AIDS.40 The California-Mexico Epidemiological Surveillance Pilot was a binational project conducted in 2004 and 2005 to assess the HIV/STI vulnerabilities and risk behaviors of Mexican migrants living in rural and urban areas in California Among its findings: For men, the percentage of methamphetamine/cocaine use in the past year was 21 percent overall Methamphetamine and cocaine use was reported by percent of the women in the sample Symptoms of depression and use of alcohol were common among those reporting methamphetamine and cocaine use.41 Mexican drug traffickers represent a minor part of the immigrant/migrant population in the United States but have a major role in the Nation’s substance abuse story While it does not appear that most of those who enter without documentation in search of jobs are involved in the drug trade, the Drug Enforcement Administration reports use of some migrant workers to smuggle drugs into this country.42 39 Borges, G., Medina-Mora, M E., Breslau, J., and Aguilar-Gaxiola, S (October 2007) The effect of migration to the United States on substance use disorders among returned Mexican Migrants and families of migrants American Journal of Public Health, 97 (10) From http://ajph.aphapublications.org/cgi/reprint/97/10/1847 (accessed June 9, 2010) 40 As noted in the April 2006 Prevention Works! Methamphetamine: Resource Kit, “Initially, methamphetamine decreases fatigue and appetite, heightens attention, and increases activity and respiration, creating feelings of high energy.” It also helps people engaged in work that is physically demanding and tedious remain alert and productive The drug is cheap, easy to obtain, and long-lasting, among other reasons why it might be appealing to migrant workers 41 Hernández, M.T., Sanchez, M.A., Ayala, L., Magis-Rodríguez, C., Ruiz, J.D., Samuel, M.C., et al (2009) Methamphetamine and cocaine use among Mexican migrants in California: The California-Mexico epidemiological surveillance pilot AIDS Education and Prevention, 21, Supplement B, 34–44 From http://www.atypon-link.com/GPI/doi/pdf/10.1521/aeap.2009.21.5_supp.34?cookieSet=1 (accessed June 9, 2010) 42 U.S Drug Enforcement Administration DEA Brifs & Backgrounds: State Fact Sheets 12 Elements of Effective Substance Abuse Prevention for Immigrants (and Migrants) Most evidence-based programs were not designed specifically for immigrant or migrant populations and may be inappropriate to the unique challenges and needs of this audience But programs may be culturally tailored so as to reflect the perspectives of these groups and meet their needs Key elements of such cultural tailoring include43: ● Reflect cultural themes that have been identified across racial/ethnic groups; ● Acknowledge differences in cultural attitudes relating to alcohol and drugs; ● Recognize cultural differences in parenting characteristics, parenting strategies, parent-child expectations, and strategies for parental monitoring and discipline; ● Involve parents: Parents must be involved in substance abuse prevention/intervention for immigrant youth Programs that strengthen family bonds and improve communication can counteract the weakening of parental control associated with acculturation; ● Go where they are: Parents of immigrant youth may be more receptive to prevention information from schools than from community agencies or other service organizations; and ● Identify immigrant/migrant children at risk: Assess children for symptoms of culture shock, emotional distress, adjustment problems, fear, and identity confusion One reason why immigrants may not participate in substance abuse prevention is their lack of familiarity with the system; they may not know how to access prevention programs, or not know they exist Second, stigma is a powerful barrier; cultural stigma attached to mental health and substance abuse problems may keep immigrants and migrants from acknowledging that they and their children are at risk for such problems Finally, unauthorized migrants often avoid contact with health and social services of any kind because they fear discovery and deportation However, according to Migrant Health Promotion, a project begun in 1983 by an association of Catholics, “Many farmworkers work with local, regional, and national organizations to improve conditions and health for all farmworkers and their families…unions utilize tools such as collective bargaining and boycotts to acquire livable wages and better working conditions Unions also inform the 43 McLean Leow, D., Goldstein, M., McGlinchy, L (2006) A selective literature review: Immigration, acculturation & substance abuse Education Development Center, Inc From http://cac.hhd.org/pdf/edc_final_report_11_27_06.pdf (accessed June 9, 2010) 13 general public about farmworker issues, while continuing to organize and support farmworkers resisting exploitation.”44 Also, authorized by the 1962 Migrant Health Act, the Health Resources and Services Administration—HRSA—supports a network of Migrant Health Centers According to the National Center for Farmworker Health, Inc., “Collectively these health centers operate more than 500 satellite service sites, and comprise a loosely knit network of independent organizations serving migrant and seasonal farmworkers.” The Center maintains a clickable map that provides full contact information for these centers, located in nearly every State, at http://www.ncfh.org/?pid=6 Facts ● Eleven percent (31.1 million) of people living in the United States are originally from another country.45 ● The foreign-born population in the United States increased by more than half between 1990 and 2000.46 ● Children of immigrants are the fastest growing segment of the U.S population under age 18.47 ● Forty percent of children with immigrant parents have Mexican family origins These children account for 50 to 81 percent of children in immigrant families in 12 States, including Arizona, California, Colorado, Idaho, Nevada, and New Mexico in the West; Alaska in the Northwest; Oklahoma and Texas in the South; and Illinois, Kansas, and Nebraska in the Midwest.48 44 Migrant Health Promotion (2005) Farmworker communities: Farmworkers in the United States From http://www.migranthealth.org/farmworker_communities/farmworkers_in_us.php (accessed June 9, 2010) 45 Malone, N., Baluja, K.F., Costanzo, J.M and Davis, C.J (December 2003) U.S census brief: The foreign-born population: 2000 Publication C2KBR-34 Washington, DC: U.S Census Bureau From http://www.census.gov/prod/2003pubs/c2kbr-34.pdf (accessed June 9, 2010) 46 Malone, N., Baluja, K.F., Costanzo, J.M and Davis, C.J (December 2003) U.S census brief: The foreign-born population: 2000 Publication C2KBR-34 Washington, DC: U.S Census Bureau From http://www.census.gov/prod/2003pubs/c2kbr-34.pdf (accessed June 9, 2010) 47 Van Hook, J (December 2003) Poverty grows among children of immigrants in U.S Washington, DC: Migration Policy Institute From http://www.migrationinformation.org/Feature/display.cfm?ID=188 (accessed June 9, 2010) 48 Hernandez, D.J., Denton, N.A and Macartney, S.E (April 2007) Children in immigrant families—The U.S and 50 States: National origins, language, and early education Publication #2007-11 Washington, DC: Child Trends From http://www.fcd-us.org/usr_doc/Children_in_Immigrant_Families_Brief.pdf (accessed June 9, 2010) 14 ● Sixty-eight percent of children in immigrant families live with parents who have been in the United States for 10 or more years.49 ● Seventy-nine percent of children in immigrant families, or four in five, are American citizens.50 ● As of 2000, more than one-fifth of children of immigrants were classified as poor, compared with 15 percent of children of U.S.-born parents Among children of Mexican immigrants, the largest and most disadvantaged national origin group, one-third were poor.51 ● Recent teenaged immigrants are less likely than other teenagers to drop out of school.52 ● While new immigrants were found to be less likely to engage in substance use than the U.S.-born population, those who had been here for 10 years or longer reported similar drug use as native-born residents.53 Resources Federal Resources Culture and Prevention http://ncadi.samhsa.gov/features/multicultural/ This site contains a collection of prevention publications and products from SAMHSA’s Health Information Network that address various ethnicities and cultural identities 49 Hernandez, D.J., Denton, N.A and Macartney, S.E (April 2007) Children in immigrant families—The U.S and 50 States: National origins, language, and early education Publication #2007-11 Washington, DC: Child Trends From http://www.fcd-us.org/usr_doc/Children_in_Immigrant_Families_Brief.pdf (accessed June 9, 2010) 50 Hernandez, D.J., Denton, N.A and Macartney, S.E (April 2007) Children in immigrant families—The U.S and 50 States: National origins, language, and early education Publication #2007-11 Washington, DC: Child Trends From http://www.fcd-us.org/usr_doc/Children_in_Immigrant_Families_Brief.pdf (accessed June 9, 2010) 51 Van Hook, J (December 2003) Poverty grows among children of immigrants in U.S Washington, DC: Migration Policy Institute From http://www.migrationinformation.org/Feature/display.cfm?ID=188 (accessed June 9, 2010) 52 National Institutes of Health (NIH), National Institute of Child Health and Human Development (August 17, 2006) Population distribution and movement Bethesda, MD: NIH From www.nichd.nih.gov/publications/pubs/council_dbsb_2003/sub7.cfm (accessed June 9, 2010) 53 Brown, J.M., Council, C.L., Penne, M.A and Gfroerer, J.C (March 2005) Immigrants and substance use: Findings from the 1999–2001 National Surveys on Drug Use and Health Rockville, MD: SAMHSA, Office of Applied Studies From http://www.nichd.nih.gov/publications/pubs/council_dbsb_2003/sub7.cfm (accessed June 9, 2010) 15 Private Resources American Psychiatric Association (APA): Latino Mental Health http://www.healthyminds.org/More-Info-For/HispanicsLatinos.aspx This section of the APA’s HealthyMinds.org public information Web site offers Latino mental health facts, statistics, brochures, and expert opinions, as well as links to additional Hispanic health resources Center for Migration and Development Woodrow Wilson School of Public and International Affairs http://cmd.princeton.edu/index.shtml Among other subjects, the Center promotes and disseminates research on children of immigrants, including the Children of Immigrants Longitudinal Study This study, begun in 1992, examines the adaptation process of the second generation of immigrants in the United States Connecting Across Cultures http://cac.hhd.org/ This project addresses the needs and strengths of underserved immigrant and refugee families and children as they adjust to life in the United States It examines increased health risk behaviors such as alcohol abuse, cigarette smoking, and illicit drug use among acculturated immigrants and the effects of acculturation on substance use and related health and safety issues Drugs & Alcohol: Immigrant Perspectives DVD http://www.miph.org/store/drugs-alcohol-immigrant-perspectives-dvd Co-produced by the Minnesota Prevention Resource Center, the Minnesota Department of Human Services, and the Twin Cities Public Television Minnesota Channel, the video includes interviews with members of three immigrant cultures: Somali, Latino, and Hmong, about alcohol and drugs in their adopted new country, the United States National Center for Children in Poverty Columbia University Mailman School of Public Health http://nccp.org/topics/immigrantfamilies.html The Center conducts research and makes policy recommendations to promote strong, nurturing, economically secure families who support healthy child development A topic section within the Web site addresses immigrant families 16 National Center for Cultural Competence (NCCC) Georgetown University Center for Child and Human Development http://www11.georgetown.edu/research/gucchd/nccc/ The mission of NCCC is to increase the capacity of health and mental health programs to design, implement, and evaluate culturally and linguistically competent service delivery systems It conducts several technical assistance and capacity-building projects and offers resources in both English and Spanish for health professionals National Center for Farmworker Health, Inc http://www.ncfh.org/ The Center’s 2002 series of monographs on migrant health issues includes Mental Health & Substance Abuse By Joseph D Hovey, Ph.D., Director, Program for the Study of Immigration and Mental Health, University of Toledo http://www.ncfh.org/docs/04%20-%20mental.pdf Strategies/Programs A Selective Literature Review: Immigration, Acculturation & Substance Abuse http://cac.hhd.org/pdf/edc_final_report_11_27_06.pdf This literature review was guided by the following four research questions: (1) Who are today’s immigrants? (2) What challenges are commonly faced by immigrants? (3) How immigration and acculturation impact substance abuse among adolescent immigrant populations? and (4) What types of interventions and services are needed to help youth and their families deal with substance abuse and addiction? Community Anti-Drug Coalitions of America’s (CADCA’s) Coalition Institute: Cultural Competence http://www.cadca.org/category/coalition-resourcestools/cultural-competence CADCA’s Coalition Institute Web site offers a cultural competence section that includes a primer for coalitions, articles, presentations, and links Creating Lasting Family Connections (CLFC)/Creating Lasting Connections http://nrepp.samhsa.gov/ViewIntervention.aspx?id=82 This program, included in SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP), is a family-focused program to build the resiliency of youth ages to 17 years and reduce the frequency of their alcohol or drug use CLFC is designed to be implemented through a community system such as in churches, schools, recreation centers, and court-referred settings In this model, a community advocate team teaches the program facilitators about local cultural issues, which helps them adapt the intervention to the needs of the community Materials are available in English and Spanish 17 National Institute on Alcohol Abuse and Alcoholism (NIAAA) Social Work Curriculum on Alcohol Use Disorders Module 10F: Immigrants, Refugees, and Alcohol http://pubs.niaaa.nih.gov/publications/Social/Module10FImmigrants&Refugees/Module1 0F.html This researcher-developed professional education module discusses immigrant and refugee psychosocial issues and conceptual models for alcohol use It explains how to analyze and apply the results of empirical studies and recognize the implications and ethical considerations for practice with immigrant populations Points of Wellness—Partnering for Refugee Health and Well-Being Program http://www.refugeewellbeing.samhsa.gov/ Points of Wellness is a health promotion and disease prevention program to assist organizations concerned with the well-being of refugees The philosophy of the initiative is to help develop and implement physical and mental health promotion and disease prevention activities and programs within, and specifically tailored to, refugee communities Selective Prevention Interventions: The Strengthening Families Program http://archives.drugabuse.gov/pdf/monographs/monograph177/160-207_Kumpfer.pdf Demonstration, evaluation, and replication over the past years have shown that the Strengthening Families Program is effective for culturally diverse youth living in high-risk families Some of these children may have no actual behavioral or emotional problems, but their multiple risk factors raise their risk for later substance abuse, delinquency, and school problems This intensive 16-week family skills training program involves the children in a social skills training program, the parents in a behavioral parent training program, and the entire family in behavioral family therapy This program is in review for inclusion in SAMHSA’s NREPP 18 ... Applied Studies (March 2005) Immigrants and substance abuse: Findings from the 1999–2001 National Surveys on Drug Use And Health From http://www.oas.samhsa.gov /immigrants/ immigrants.htm#2.1 (accessed... problems may keep immigrants and migrants from acknowledging that they and their children are at risk for such problems Finally, unauthorized migrants often avoid contact with health and social services... group, immigrants arrive in the United States with lower rates of substance abuse than their American-born counterparts For many immigrants, acculturation and assimilation may narrow and eliminate