February 2008, Vol 98, No. 2 | American Journal of Public HealthNandi et al. | Peer Reviewed | Research and Practice | 1
⏐ RESEARCH AND PRACTICE ⏐
Objectives. We assessed access to and use of health services among Mexican-
born undocumented immigrants living in New York City in 2004.
Methods. We used venue-based sampling to recruit participants from loca-
tions where undocumented immigrants were likely to congregate. Participants
were 18 years or older, born in Mexico, and current residents of New York City.
The main outcome measures were health insurance coverage, access to a regu-
lar health care provider, and emergency department care.
Results. In multivariable models, living in a residence with fewer other adults,
linguistic acculturation, higher levels of formal income, higher levels of social
support, and poor health were associated with health insurance coverage. Fe-
male gender, fewer children, arrival before 1997, higher levels of formal income,
health insurance coverage, greater social support, and not reporting discrimina-
tion were associated with access to a regular health care provider. Higher levels
of education, higher levels of formal income, and poor health were associated with
emergency department care.
Conclusions. Absent large-scale political solutions to the challenges of un-
documented immigrants, policies that address factors shown to limit access to
care may improve health among this growing population. (Am J Public Health.
Access to and Use of Health Services Among
Undocumented Mexican Immigrants in a US Urban Area
| Arijit Nandi, MPH, Sandro Galea, MD, DrPH, Gerald Lopez, JD, Vijay Nandi, MPH, Stacey Strongarone, JD, and Danielle C. Ompad, PhD
Between 1990 and 2000, the United States at-
tracted almost one third of the world’s immi-
grants, and the total number of foreign-born
residents in the United States increased by
57%.1,2Contributing to the overall increase in
the foreign-born population has been a rapid
rise in the number of undocumented immi-
grants living in the United States. Since the
mid-1990s, more undocumented than legal
immigrants have arrived each year.3These
trends hold true for people arriving from Mex-
ico, the leading country of birth among foreign-
born residents of the United States. As of
March 2004, approximately one half of Mexi-
cans living in the United States were undocu-
mented, accounting for 5.9 million (57%) of
the 10.3 million undocumented immigrants es-
timated to be living in the United States.3
Identifying and studying undocumented im-
migrants is so challenging that a paucity of evi-
dence exists about the health status of undocu-
mented immigrants in the United States.4The
best available evidence suggests that undocu-
mented immigrants may represent a vulnerable
population at higher risk for disease and injury
than either documented immigrants or native-
born US citizens.1,5–16Yet, despite early recogni-
tion of the potential vulnerability of undocu-
mented immigrants and their rapidly increasing
prevalence in the United States, the determi-
nants of access to and use of health services in
this group remain poorly understood.1 7,18Most
research about access to health services among
undocumented immigrants has used samples
of immigrants of diverse origins and of vary-
ing immigration status; although these studies
generally find that the legal status of undocu-
mented immigrants is an important barrier to
accessing health services,6,1 7,19,20little is
known about the demographic, economic, so-
cial, and health-related determinants of access
to and use of health services by undocu-
We assessed the determinants of access
to and use of health services among
undocumented Mexican immigrants living in
New York City, where the Mexican foreign-
born population increased by 275% between
1990 and 2000.21The Behavioral Model for
Vulnerable Populations22was used as a theo-
retical framework for our hypothesis that the
likelihood of health insurance coverage, ac-
cess to a regular health care provider, and
emergency department care among undocu-
mented immigrants living in New York City
is shaped by a hierarchy of predisposing
characteristics. These characteristics include
temporally distal determinants such as socio-
demographic factors (e.g., education) and im-
migration factors (e.g., year of entry into the
United States) and are likely to influence ac-
cess to health services through more proxi-
mal enabling (e.g., income) and health-need
The sampling frame consisted of adults
(18 years or older) from all 5 boroughs of
New York City who reported being born in
Mexico. Participants were recruited in com-
munities with large populations of Mexican
immigrants. Venues were selected by a 2-
step procedure. First, we used US Census
data to identify the 12 neighborhoods in the
city, as defined by the New York City De-
partment of City Planning, with the highest
concentrations of Mexican immigrants.2,21
Second, we conducted at least 2 walk-
throughs of all streets in each of the 12
neighborhoods on different days and at
different times of day to identify neighbor-
hood venues with heavy volumes of foot
traffic that might prove amenable to con-
Outreach workers trained in data collec-
tion recruited participants between October
8 and December 5, 2004, with street out-
reach techniques common in research in-
volving immigrant populations6,23–25and
other hard-to-reach populations.26,27Partici-
pants qualified for the study if they reported
being 18 years or older, born in Mexico,
and current residents of New York City.
http://www.ajph.org/cgi/doi/10.2105/AJPH.2006.096222The latest version is at
Published Ahead of Print on January 2, 2008, as 10.2105/AJPH.2006.096222
American Journal of Public Health | February 2008, Vol 98, No. 2 2 | Research and Practice | Peer Reviewed | Nandi et al.
⏐ RESEARCH AND PRACTICE ⏐
TABLE 1—Sample Characteristics and Bivariate Associations Between Covariates of
Interest and Prevalence of Access to Insurance and Regular Providers and Receipt of Care
in an Emergency Department Among Undocumented Immigrants Born in Mexico: New York
Care in an
% Total Sample,n (%)%
431 (100.0) 10.536.513.0
Less than high school
High school or GED
At least some college
Other adults in the residence,no.
Year immigrated to United States
Linguistic acculturation/preference levela
Social acculturation/preference levela
Total formal income in past year,b$
Legal income not reported
.17 .11 .71
Twenty-minute interviews were conducted
in either English or Spanish by trained and
supervised interviewers who used translated
and back-translated structured question-
naires. Fewer than 2% of interviews were
conducted in English.
Predisposing factors, defined as character-
istics that incline people to use health
services, included sociodemographic charac-
teristics and immigration factors. Socio-
demographic characteristics included age,
gender, educational attainment, marital sta-
tus, number of children, and number of
other adults living at the current residence.
We inquired about the respondents’ legal
status and the year they first entered the
United States and dichotomized year of
entry as before or after January 1, 1997, to
reflect relevant changes in US legislation.10
We assessed levels of acculturation with a
modified version of the 12-item Welfare Re-
form Baseline Interview acculturation mod-
ule, developed for use among Hispanic pop-
ulations.28Linguistic acculturation was
assessed by 7 of the 8 items that asked
about the preference for other languages as
compared with English (e.g., “What language
do you usually speak with friends?”). The
item on “language spoken” was excluded be-
cause it lacked variability. We assessed social
acculturation with the 4 items that asked
about preference for Mexican, Latino, or
Hispanic groups as compared with other
groups in a variety of social contexts (e.g.,
“Your close friends are . . .?”). The Cronbach
alpha for items used in both scales was 0.92.
The linguistic and social acculturation scores
were summed and divided into thirds for
Enabling factors, defined as characteris-
tics that enable or impede use of health
services, were measured by asking respon-
dents about their economic and social re-
sources. Respondents reported income
earned in the formal economy (i.e., re-
ported and taxed income, including public
assistance) and in the informal economy
(i.e., nonreported and nontaxed income).
For the analysis, we categorized both for-
mal and informal income as none, $1 to
$10000, $10001 to $20000, more than
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American Journal of Public Health | February 2008, Vol 98, No. 210 | Research and Practice | Peer Reviewed | Nandi et al.
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