Thematic analysis
The following sections present the results of the qualitative data analysis. The themes were organized within four primary categories including: 1) Barriers and Facilitators to Health Care, 2) Health Behaviors and Coping Mechanisms, 3) Disease Management Strategies, and 4) Cultural Factors. Within these overarching themes were nested multiple codes including: Barriers, Community Positives and Negatives, Cost of Health Care, Positive and Negative Health Behaviors, Coping Mechanisms, Clinic Choice, Disease Management, Disease Perception, Medications, Signs of Illness, Role of Alternative Medicine, Role of Family, and Role of Religion. The interviews generated discussions related to uninsured, Latina immigrant women’s perceptions of access to health care and treatment or management strategies for various health conditions.
Barriers and Facilitators to Health Care
The Barriers and Facilitators to Health Care theme contained the following codes: Barriers, Community Positives and Negatives, and Cost of Health Care. While the study participants described different strategies for accessing care, the primary barriers included the high cost of services, especially for emergency room care, lack of health insurance, family and work responsibilities, and language barriers. These were all more pressing concerns affecting access than other potential barriers mentioned such as transportation or discrimination in health care encounters. Facilitators to health care included access to interpretation services, social support from friends and faith leaders, and availability of low-cost prescriptions. Regarding financial barriers, one participant stated, “One can afford to pay for the doctor’s office visit to know what is wrong with you, but not for the treatment.” (ID #1, age 35–39, Honduras).
Echoing these concerns, another woman explained that she could get an appointment for an eye exam but could not complete the surgery unless she paid $2600. She was unable to arrange for the provider to set up a payment plan and commented, “And so, they were going to make an appointment for my surgery, but I lost the appointment because I could not afford it. So, I told them I could not go, So, they just told me, ‘When you are ready.’” (ID #30, age 40–44, Mexico).
Another participant explained that they once had to pay a very high price for insulin at a pharmacy. However, this participant subsequently found insulin at a lower price at a Wal-Mart pharmacy for between $20 and $40 dollars and explained, “I had a bad experience the first time I went to fill my prescription for insulin. I went to Walgreens and just one vial was $163.” (ID #28, age 45–49, Mexico).
Additional complaints about perceived high costs of prescription drugs and health care services were frequent, particularly since participants did not have health insurance to offset the costs. For instance, some participants lamented the cost of health care and explained that they could not afford it because costs were not offset by health insurance. One participant stated, “It’s very expensive … just one doctor’s visit was $135 and then additionally I had to pay for the medicine. Basically, there went half of my weekly income.” (ID #24, age 40–44, Mexico). Another participant responded, “The big concern with our community is that doctor’s visits are very expensive. One doesn’t have the freedom to say, ‘I’ll just go’ because it’s a lot of money, and we don’t have health insurance.” (ID #2, age 50–54, El Salvador).
However, some participants did report that costs could be reduced at some clinics after submitting some paperwork to justify sliding scale fees. For example, one participant explained, “I had to fill an application, and then take it to have it approved, and then it was signed … I was originally being charged $400 and then I ended up with a $130 charge.” (ID #27, age 25–29, Mexico).
Nevertheless, the lack of insurance and high costs of health care could result in a failure to access care for those with serious illnesses or even lead them to return to their countries of origin to seek care. This sentiment was expressed by one participant.
Personally, what worries me is that if someone gets a serious illness, and because of lack of insurance or money it cannot be treated here. I have seen many people with children that were born abroad and since they don’t have medical insurance, if they happen to get cancer or leukemia they must go back to their country to die because, if there are no resources here, there are even less back home. (ID #4, age 30–34, Mexico).
Another participant expressed a similar attitude and replied, “Well, unfortunately we are seeking help because our earnings are so low. And if one gets sick one doesn’t want to be a burden on the government like they say, so we look for free care, and sometimes one needs to pay to get it [health care].” (ID #24, age 40–44, Mexico).
In addition, because of high medication prices, some patients do not refill their medications, leading to unfortunate outcomes from chronic conditions, such as uncontrolled hypertension. In some cases, patients had to set up payment plans due to their lack of prescription drug coverage. One participant explained, “It’s expensive…it’s a lot of money so sometimes one doesn’t buy the medicine one needs because it’s too expensive. If we get the generic it’s cheaper…In some supermarkets, some prescriptions are free.” (ID #2, age 50–54, El Salvador). Another participant stressed the importance of payment plans by stating, “Well that medicine is costly, but I had to find a way to get it even though the cost was excessive…I had to set up a monthly payment plan.” (ID #3, age 35–39, Mexico).
In addition to costs of seeking a doctor and affording one’s medication, several participants discussed work/life balance issues and the lack of social support as barriers to care. One participant stated, “I am taking care of my children and I don’t have anyone to help me here [in this country].” (ID #7, age 30–34, Mexico). Another participant responded, “Sometimes, well, most of the time we are at work. I go to work and dedicate my time to my job, so my health is affected.” (ID #9, age 50–54, Mexico).
There was a complicated relationship between work and health. One woman explained, “they don’t eat healthy, but they work a lot.” (ID #25, age 25–29, Mexico), indicating that many Latinos spend a considerable amount of time working, with little time to take care of themselves or exercise. Women reported work as both a motivating factor for staying healthy and as a cause of poor health, “We’re so involved with our jobs and we work, work, work, and leave our health for last.” (ID #15, age 35–39, Mexico).
An additional barrier to accessing care was language difficulty. This affected women’s confidence to make medical appointments and understand all the information conveyed during a typical visit. Even though some participants had tried to learn English, they ultimately were not successful. One participant explained, “The issue of language…and many people say, ‘You have been here for so many years, why don’t you learn [English]?’ Well, there are those who have that capacity to learn and then there are those that cannot speak another language.” (ID #9, age 50–54, Mexico). Another participant expressed frustration with the language barrier by stating, “For instance communication, their Spanish and our English [needs to improve] so that we can understand each other; sometimes the language barrier results in nothing getting done.” (ID #13, age 30–34, Guatemala). Another participant responded, “Yes, it is a big, big barrier because I do not speak English well.” (ID #8, age 40–44, Mexico).
Despite it not being a major barrier to care, access to interpreters or information provided in Spanish and lack of transportation was a source of stress for participants, as one participant stated, “I think that because there are less Latino people in this state … in other states with so many Latinos that are accustomed to see this, and here where they battle with people if they don’t speak English well, people get stressed out, and I have noticed this.” (ID #7, age 30–34, Mexico). Another participant stressed the importance of having interpreters available by stating, “If they had just told me: ‘just a minute let me check’ but I could see that they were just passing my piece of paper back and forth and no one told me what was going on … I felt very sad because I needed (interpreter) assistance and no one could help.” (ID #9, age 50–54, Mexico). Regarding transportation, one participant identified the barrier by explaining, “Well, that is an obstacle here, there is no public transportation.” (ID #17, age 60–64, Mexico).
On the other hand, in terms of facilitators to health care, some participants reported that they had not felt discrimination in health care facilities and received interpretation assistance and prescription drug discounts. One participant stated, “Well, yes they gave me an interpreter” (ID #29, age 55–59, Mexico). Another explained, “Well, you can get free medical visits. That helps a lot, the Latino communities … there are times in the community, if they have the medicine, they will give it to you in the pharmacy for free.” (ID #2, age 50–54, El Salvador).
Health Behaviors and Coping Mechanisms
The Health Behaviors and Coping Mechanisms theme contained the following codes: Positive Health Behaviors, Negative Health Behaviors, and Coping Mechanisms. The participants’ health behaviors were heavily influenced by the barriers and facilitators operating in their daily lives. The most common negative health behavior reported was unhealthy dietary habits. This negative behavior was discussed as being a consequence of the cultural transition from their native countries in Latin America to the US, where food was natural and not processed or frozen and served as a protective effect against disease.
A general theme emerged that these women had greater access to inexpensive fresh fruits and vegetables in their native countries compared to the US. As a result, Latina immigrants experienced dietary changes and limitations that contributed to negative health behaviors. Additionally, participants acknowledged an unhealthy excess of fat consumption. For example, regarding dietary preferences, one participant replied, “We Latinos eat tortillas, a lot of tortillas, a lot of bread and a lot of grease.” (ID #17, age 60–64, Mexico). Another participant answered, “I had a lot of bloating, because of so much flour, bread, and tortilla.” (ID #26, age 35–39, Mexico). Another participant explained a generational shift in eating habits that were linked with overall health.
[Regarding parents and grandparents] They didn’t get sick like we do today. No, they never ate grease, on the contrary, they ate food without grease, and they never said, my foot hurts, my back, like that, and they weren’t fat, because they were exercising all the time, one hour to walk to the plaza [outdoor market], all the time. (ID #6, age 40–44, Mexico).
Participants were generally able to identify desired positive health behaviors such as drinking lots of water, eating a healthy diet, and getting enough physical activity. During the interview process, many women also identified several preventive measures they would take to stay healthy including blood pressure screening, Pap tests, mammograms, taking vitamins, and getting eight hours of sleep on average. For example, one woman responded, “I believe in a daily thirty-minute walk, going to the gym or whatever it may be, the key is to keep moving.” (ID #5, age 40–44, Mexico).
Strategies for managing depression and anxiety included coping mechanisms for self-help as well as helping others. None of the women sought professional psychological care or medication and relied instead on activities such as listening to music, knitting, reading, exercising, and cleaning to distract themselves from negative thoughts. For example, one participant stated, “The rest of my family is back in Mexico, so I try to listen to music or read, because I really like to read.” (ID #28, age 45–49, Mexico). Some women attributed their anxiety or depression to social isolation experienced from living in a non-Latino community due to language barriers and separation from family in their home countries. In addition, there was fear related to crime and immigration enforcement, as well as consternation when people exhibited racist attitudes. Since the interviews occurred during the 2016 Presidential election season, participants were very sensitive to the anti-immigrant rhetoric on display in the Republican campaign. One participant stated, “Well, I feel worried … how things are going here. They are talking about how Trump is going to remove all the Latinos, and he will get them all out.” (ID #28, age 45–49, Mexico). Another participant expressed fear by stating, “When my girls come home the older one scolds me: ‘Mom, why are all the blinds closed?’ I answer, ‘I like everything closed because it makes me feel better (safer)!’” (ID #30, age 40–44, Mexico). Another participant observed overt discrimination in public places by explaining one instance, “They answer rudely in the stores, and they answer in a loud voice so that everyone around can’t help but hear the answer. This bothered me.” (ID #1, age 35–39, Honduras).
Women also helped each other cope by activating their social networks, visiting family and friends, and assisting one another with navigating life in the US. Many women identified their faith community as a source of social support. Attending church services and joining women’s groups were also identified as coping mechanisms for improving mental health. One participant replied, “We only speak a little English, so we gravitate to other new immigrants. It makes me feel good when I can help other women with whatever I can.” (ID #28, age 45–49, Mexico).
The support they received in their church from fellow church members helped to improve women’s mental health and served as a safety net. One participant explained, “I go on Sundays and we learn in a group, we gather once a month, we are all women. And we pray, we share. That helps a lot with our mental health.” (ID #24, age 40–44, Mexico). Another participant stressed the importance of social support by stating, “I have pastors and brothers of my church to help me.” (ID #21, age 30–34, Honduras).
Disease Management Strategies
The Disease Management Strategies theme contained the following codes: Clinic Choice, Disease Management, Disease Perception, Medications, and Signs of Illness. Study participants identified 15 different clinic choices in the Charleston area, the most common being an uptown free clinic, health department clinics, the university hospital and hospital emergency rooms. The uptown free clinic was listed most often because 13 of the 30 interviews were conducted there. A common theme that emerged was the idea of “shopping around” from clinic to clinic based on cost, language access and available services to avoid the high cost of emergency room care.
Some participants reported no clinic preference and could not remember when they last saw a doctor. Participants were wary of incurring debt from an emergency room visit and used it as a last resort. Participants also reported discrimination in clinic waiting rooms due to language barriers and their uninsured status. When asked about dental care, most women had not found an affordable solution, so they avoided going to the dentist in the US. One participant stated, “When I travel to Mexico that’s when I get dental cleanings and checkups.” (ID #24, age 40–44, Mexico). Some local clinics offer free screenings but not free treatments or preventive care. Other clinics only offer free emergency tooth extractions.
Women reported motivating factors for managing their health as well as their thought processes for deciding how to manage their health. A common motivator for these women was their families. They wanted to stay healthy, so they would be able to continue taking care of their children. Another motivating factor for these women was to prevent the progression of chronic diseases, such as high blood pressure and diabetes, which were the most prevalent chronic conditions among participants. As one woman explained, “The doctor told me to exercise, for my blood pressure.” (ID #30, age 40–44, Mexico). Another offered a comment, “I used to be overweight, but since then I decided to walk and walk.” (ID #27, age 25–29, Mexico).
Many women described similar disease management processes for deciding when and how to visit a doctor for their health concerns. At the first sign of illness, they typically consult friends or family members, and many participants explained that they would try alternative medicine first to feel better before visiting a doctor. One participant explained, “Well the first thing we do is ask our aunt or grandparent, ‘these are my symptoms, what could it be?’ before going to the doctor. Then they tell us a remedy and we try it, and if that doesn’t work then we go to the doctor.” (ID #25, age 25–29, Mexico).
Most women reported having a threshold for when they decide to visit a doctor. One participant stated, “If my knee hurts, I sit down for a while and keep doing my work. But if I have a fever or vomiting… that’s when I go to the emergency room.” (ID #24, age 40–44, Mexico). Another participant described her treatment strategy, “Well if something hurts… you wait until you feel really sick and then you run to the doctor. In the meantime, you take a pill or something.” (ID #26, age 35–39, Mexico).
When asked where they get their medications, 14 women reported using Wal-Mart as a primary pharmacy choice for over-the-counter medications. One participant from El Salvador reported difficulties obtaining a prescription from a large chain drugstore by showing a passport for identification. Six women referenced tiendas mexicanas (Mexican stores) as a source of over-the-counter medicines, and one participant referenced a former bad habit of buying antibiotics at one of these stores and not taking the medicine correctly. A general theme from these interviews is the idea of self-medication in which women attempt to self-treat their health problems before going to a doctor for a prescription. These women also “shop around” at different pharmacies that offer certain medicines for free, such as free blood pressure medicines at one grocery store chain. Finally, women often choose generic or off-brand medications instead of name-brands as a cheaper option. One participant explained, “In the past we bought [antibiotics] at the Mexican store, but I’ve gotten rid of that bad habit because it didn’t always help.” (ID #15, age 35–39, Mexico). Other participants mentioned shopping at the Mexican grocery stores for their over-the-counter medications. Finally, another woman implied that if the generic was not available, the brand-name prescription medicines were too expensive, as one participant stated, “Sometimes I don’t buy the medicine, because it’s very expensive. But if you go for the generic, it’s cheaper.” (ID #2, age 50–54, El Salvador).
Responses around signs and symptoms of illness served as indicators and cues to action that would cause women to acknowledge their health condition and seek care or treatment. In general, women reported that symptoms are signs of illness from their bodies. One participant explained, “You know your body and you know when something is not right.” (ID #28, age 45–49, from Mexico).
The top three most important community health concerns reported by study participants were: 1) diabetes, 2) obesity, and 3) cancer. When ranking these health concerns, women recalled family history and referenced people they knew in the community with certain diseases. Participants also discussed perceived causes of disease, such as poor nutrition, drinking soda and lack of exercise. One participant explained, “Many people drink a lot of soda, too much soda. They’ll get diabetes and keep drinking soda.” (ID #2, age 50–54, El Salvador).
One participant mentioned that she did not want to take ownership or identify with her disease. She commented, “I don’t like to say my diabetes. The diabetes, it’s not mine, I don’t want to make it mine.” (ID #12, age 35–39, Mexico).
There were mixed responses for women’s perceived control over their own health. Some women believed they had control over their health, while others expressed less control. For example, one participant stated, “Yes, I think I do have [control]. Sometimes I don’t act on it, but I know that I can, I’m just careless sometimes.” (ID #23, age 35–39, Mexico). Another stated, “I don’t have much [control] because I’m not doing everything that I need to do.” (ID #6, age 40–44, Mexico).
Cultural Factors
The Cultural Factors theme contained the following codes: Role of Alternative Medicine, Role of Family, and Role of Religion. The role of the family was discussed by most interview participants. Women admitted that when they were sick, they were very depressed because they could not help with housework or attend to their children, expressing traditional gender norms. For example, one participant stated, “I’m like the motor of my family. If I’m sick my home doesn’t function, I don’t work, I don’t cook, I don’t clean I just lay down. This makes you feel bad.” (ID #24, age 40–44, Mexico).
While participants valued the advice of their elder relatives for treatment advice, many women were very dependent on their children for English assistance. Since participants did not speak English very well, they often relied on their children to translate for them in many situations. One participant explained, “Yes, thanks to God, my children have been teaching me to speak English… I want to feel better and be happy with my children. And, the children, they go with you and translate for you… they help you.” (ID #19, age 35–39, Guatemala). Another participant also expressed a similar sentiment by stating, “[My daughters] translate for me, and sometimes, when I need to go to the doctor, I say: ‘When you get home from school, we’re going to the doctor’ [they say] ‘Okay’ and they translate for me.” (ID #30, age 40–44, Mexico).
Most participants spoke about the role of religion in their life and the importance of prayer. One participant stated, “Always everything that I need and when I feel stressed out, what I do is ask her (Virgin of Guadalupe, Patron of Mexico). I pray to her always.” (ID #4, age 30–34, married, Mexico).
Participants felt a sense of community in their churches and a relief from the outside stressors. One participant expressed this sentiment well by stating, “Yes, going to church relaxes me in other words, I love coming to church, to pray for my family, for my sons and daughters, and well for everything…we forget all our problems.” (ID #26, age 35–39, Mexico).
Study participants also employed several home remedies to possibly delay or avoid having to take on the extra out-of-pocket costs that a clinic visit would entail. For example, one participant stated, “Well, my natural remedies. For example, when I’m sick with the flu, my mom always told me to put orange peel and lemon peel to boil with cinnamon. ‘Drink this to get rid of your cold’… yes, yes, various things my mom gave us. ‘If your ear hurts, add oregano.’” (ID #15, age 35–39, Mexico).
Others provided a lot of information about remedies, including specific instructions for recipes. One participant explained,
I make chamomile tea, mint tea, and for anxiety and nerves I make the one of the seven herbs with valerian root…And for the kidneys I use arnica and that plant called horse tail. You boil a quart of water add a pinch of arnica and three threads of that plant. Then boil all that for a few minutes, cool it in a pitcher and drink that water all day and use it for any other cooking that requires water. (ID #4, age 30–34, Mexico).
Some would also opt to use the services of a sobandera, or folk healer, who employs massage and natural remedies to heal the sick. One participant explained, “I know several people who have gotten better. My friend suffered with back pain, so she went to see a folk healer and now she is better.” (ID #25, age 25–29, Mexico). Another participant discussed her experience, “I used to go to a folk healer, and she would rub me with some creams like Vaporub.” (ID #20, age 45–49, Mexico).
Finally, participants also expressed the cultural belief in certain folk illnesses, with one participant explaining the case of mal de ojo, or ‘evil eye.’ She explained, “When someone is vomiting and having constant diarrhea, this is evil eye. There is a special herb that can be used to cure it to stop the diarrhea and vomiting.” (ID #6, age 40–44, Mexico).