Our findings suggest that a large proportion of Latina women in this study may have experienced depression and/or anxiety (46%), which appeared to be substantially related to delaying health care even in the presence of a chronic physical health condition (and in a sense controlling for health care coverage since most of the sample had coverage). Overall, the results suggest that mental health concerns were prevalent at the time of this study, even after controlling for acculturation, education, and age in this sample. It is also noteworthy that having a
hronic physical health condition was associated with delayed care after controlling for all other factors in the model. This finding has implications for adequate monitoring and management of chronic health conditions among Latinas. It is known that Latinos with chronic conditions report poorer management of chronic conditions, such as diabetes, and they are likely to delay care (Henderson 2002
). These reported findings are tempered by the sampling method and the inclusion of one new Latino destination area. These limitations affect the generalizability of these findings. However, there is evidence of significant variation in prevalence of psychiatric disorders across Latino sub-groups (Alegría, Mulvaney-Day, Torre, Polo, Cao, and Canino 2007
). New Latino destinations are only recently being studied, and if these findings are replicated, depression and/or anxiety represent an important factor in delaying health care.
Acculturation in this study was defined as level of adoption of the U.S. mainstream culture based on language use (which has been shown to be the best predictor of acculturation). In this study, acculturation, measured by a standardized scale unexpectedly was not associated with delay in care. This study's findings on acculturation were not congruent with the current literature (Guarnaccia, Martinez et al. 2002
), perhaps because the acculturation variable failed to measure relevant aspects of culture related to delay in care among women in this Latino population. Another explanation is that acculturation may be more relevant for a particular cohort. The three way interaction suggests that low acculturated women over the age of 40 who reported depression and anxiety are more likely to delay care. This was not found for younger women with low acculturation. It can be speculated that older women with low acculturation and depression and/or anxiety may have experienced specific factors such as more anxiety about language barriers, which may not be present in younger women. This finding warrants further exploration on the influence of age and acculturation.
This study did not find any association between place of birth and delay in care, which contradicts other research that found this association for delay in CVD-related screenings. That study was conducted among a predominantly Mexican population in an established Latino destination (Jurkowski 2006
). The finding in this study suggests that place of birth may have been a less relevant measure of acculturation for delay in health care for this sample.
Language barriers, as well as lack of health care insurance, lack of knowledge about what mental health services entail and about where to get services have been identified in the literature to be associated with use of mental health care (Guarnaccia, Martinez et al. 2002
). These aforementioned factors may be particularly salient for Latinos living in new Latino destinations. Considering the mental health care barriers in the literature that have been associated with delay and the results of this study, as rapidly growing Latino communities are increasing across the country, it is important to focus on new Latino destination populations. Therefore, this study's findings have implications that may reach beyond the Northeastern NY. Providers and other service professionals working in new Latino destinations need to understand and address the barriers to health care to serve the needs of this traditionally underserved population better. For example, in the study community, 41% of Latinas generally spoke mostly or only Spanish (Jurkowski and Ramos 2009
) and anecdotally reported preferring to speak Spanish when accessing their emotions. Although evidence suggests that Latinos tend not to believe in or widely seek psychotherapy, if a Latina in this new Latino destination decided to do so, lack of knowledge about mental health services is a barrier (Guarnaccia, Martinez et al. 2002
). Therefore, areas experiencing a large influx of new residents may want to consider researching resources and developing a resource guide that increases awareness of resources available for mental health and other related resources such as substance abuse and domestic violence hotlines.
Cultural competence among providers can also improve cost and patient satisfaction with quality of care (Zambrana, Molner et al. 2004
). However, culturally and/or language competent providers may not be available in new Latino destinations. For that reason, active involvement of appropriate stakeholders (i.e. government agency officials and service providers) in a coalition to address this problem would increase the potential for resource linkages to identify or develop strategies for increasing the number of culturally and/or language competent providers.
In preventing and treating mental health disorders and helping ethnic minority communities thrive socially and economically, evidence suggests that empowerment through community-building efforts is essential, with a focus on supporting and strengthening the problem-solving capabilities of residents (Minkler and Wallerstein 2003
; Santiago-Rivera, Arredondo et al. 2002
; Smokowski and Bacallao 2009
). In recent years, several community-based mental health projects have shown promise with Latinos in particular. A domestic violence prevention and intervention program for example, integrated clinical services with the involvement of lay Latino religious leaders (Smokowski and Bacallao 2009
). Another study used grass-roots tertulias
, support groups for Latinas with similar life stories and cultural backgrounds (Santiago-Rivera, Arredondo et al. 2002
). Alegría et al. (2008)
found that specific patient activation and empowerment interventions were effective in enhancing minority group patients' attendance and retention in treatment in community clinics (Alegría, Polo et al. 2008
Active participation of community advocates/partners (e.g., church leaders, school counselors, local community based organizations) and community members in the research process, through the application of a Community-based Participatory Research approach (Minkler and Wallerstein 2003
), may help identify the unique combination of barriers to healthcare utilization in new Latino destinations. Including the perspective and experiences of Latinas and people in the community who work with them in the research process and using the results of CBPR research for guiding development of mental health interventions will help ensure development of culturally-appropriate interventions.
Although this study had many strengths, including the unique population, the use of a CBPR approach, and the use of standardized variables, it had some limitations. We used a convenience sample based on snowball sampling, which limits generalizability of the findings, because it was the only feasible and affordable option to survey this hard to reach population (Faugier and Sargeant 1997
). Furthermore, the study was a cross sectional design and therefore we were unable to determine causal temporal relationships. Also, the data for this study were based on self-reports. While the mental health status variable was not a standardized scale of reported symptoms, women endorsing depression and/or anxiety were more likely to endorse specific symptoms of depression and/or anxiety, affording a measure of confidence in the self reports. The language-based acculturation scale used in this study (Delgado, Johnson and Treviño 1990
) and the use of place of birth as measures of cultural identity were limiting in that they were proxies for culture, not explicit measures of specific cultural beliefs related to use of health care. Finally, because our study population was predominantly Puerto-Rican, further research is needed to corroborate its relevance among other Latino sub-groups living in new Latino destinations.
Mental health and delay in health care are important health disparities issues among Latinos. Unfortunately, a research gap exists in understanding effective health interventions for Latinos, who have chronically low rates of mental health problem detection and low utilization rates for mental health care (Guarnaccia, Martinez et al. 2002
), as well as a for interventions to promote screenings for chronic diseases (Correa-de-Araujo, McDermott et al. 2006
; Edwards, Li et al. 2009
). More research is needed to identify successful intervention models. The literature also suggests that the mental health field has a dearth of CPBR research models for working with Latino populations, especially in new Latino destinations. Yet researchers and funding agencies, such as Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention, have promoted the use of CBPR to address health disparities (Viswanathan, Ammerman et al. 2004
). At the research field level, using a CPBR approach will move the Latino mental health field forward by providing a participatory model that other researchers can use to successfully involve their communities in research.