The Health Impact of Experiences of Discrimination, Violence, and Immigration Enforcement Among Latino Men in a New Settlement State.

Among Latinos in the United States, particularly in new settlement states, racial/ethnic discrimination, violence, and immigration enforcement contribute to health disparities. These types of experiences were explored among Latino men in North Carolina through quantitative assessment data ( n = 247). Qualitative in-depth interviews were also conducted with a subsample of Latino men who completed the assessment ( n = 20) to contextualize quantitative findings. Participants reported high rates of unfair treatment, discrimination or violence, and questioning about their immigration status. Having been questioned about one's immigration status was significantly associated with increased drug use (adjusted odds ratio [AOR] = 2.16; 95% confidence interval [CI] [1.07, 4.38]) and increased depressive symptoms (AOR = 2.87; 95% CI [1.07, 7.67]). Qualitative themes included: reports of frequent discrimination based on immigration status, race/ethnicity, and language; workplaces and police interactions as settings where reported discrimination is most common and challenging; frequent violent victimization; psychological consequences of experiences of discrimination and violence and concerns related to immigration enforcement for Latino men and their families; inter- and intra-community tensions; health-care services as safe spaces; use of coping strategies; and system-level approaches for reducing discrimination and violent victimization of Latinos. Findings point to the need to address underlying causes of discrimination and violence toward Latinos, particularly those related to immigration enforcement, to support health and well-being.

The Latino population in the United States continues to increase, particularly in new settlement states such as those in the Southeast. The Latino population in North Carolina (NC) is the sixth fastest-growing in the country (Ennis, Rios-Vargas, & Albert, 2011) and increased by about 2.4 times between 2000 and 2014 (Stepler & Brown, 2016). Compared to traditional settlement states (e.g., California, Texas, and New York) with more established Latino communities, new settlement states tend to have more recently arrived immigrant Latinos, may lack bilingual and bicultural infrastructures to meet the needs of Latinos, and are often more hostile to Latinos at both interpersonal and policy levels (e.g., local immigration enforcement) (Barrington, Messias, & Weber, 2012; Mann et al., 2016; North Carolina Institute of Medicine, 2003).

Discrimination, Violence, and Health

Latinos in the United States report high rates of discrimination and violence that can threaten health and well-being. Nationally, 34% of Latinos report that they or somebody they know experienced discrimination based on their race/ethnicity in the past 5 years (M. H. Lopez, Morin, & Taylor, 2010). In a survey of Latinos in new settlement states in the Southeast, 68% reported experiencing discrimination in daily life (Southern Poverty Law Center, 2009). Racial/ethnic discrimination has been linked to poorer health, including negative mental health outcomes (e.g., low self-esteem, psychological distress, depression, anxiety, and sleep problems); negative physical health outcomes (e.g., low self-rated general health status, negative diabetes-related outcomes, high blood pressure, and other cardiovascular health issues); and risk behaviors (e.g., smoking and alcohol use) among general populations and among Latinos specifically (American Psychological Association, 2016; LeBrón, Spencer, Kieffer, Sinco, & Palmisano, 2018; W. D. Lopez, LeBrón, Graham, & Grogan-Kaylor, 2016; Sirin et al., 2015; Williams, Neighbors, & Jackson, 2003).

Although rates of overall violence in areas with more recent Latino population growth are lower than in other areas, rates of violent victimization of Latinos are higher in those areas (26 per 1,000) than in areas with established or small Latino populations (16 to 20 per 1,000) (Xie & Planty, 2014). In NC, a Latino-serving mental health services provider reported that 50% of its patients had been victims of a crime (El Futuro, 2016).

Immigration Enforcement and Health

A growing body of research indicates that immigration enforcement also affects Latinos’ health and may be interconnected with experiences of discrimination. Nationally, about five percent of all Latinos report having been stopped and questioned about their immigration status by police, about a third know someone who has been deported or detained, and more than half worry that they or somebody they know could be deported (M. H. Lopez et al., 2010). Among Latinos who are not U.S. citizens or legal residents, 84% report that they worry about deportation and 45% report that they know somebody who has been deported or detained in the past year (M. H. Lopez et al., 2010). There are differences in experiences of immigration enforcement by gender, with Latino men reporting being questioned by authorities about their immigration status at rates four times as high as Latina women (M. H. Lopez et al., 2010).

Latinos have reported that immigration enforcement policies, including those that involve collaboration between local law enforcement and federal immigration authorities, compound existing distrust of services and condone racism and promote racial profiling. These policies also create practical barriers to accessing and utilizing health-care services (e.g., fear of driving even to seek needed health services); promote relying on nonmedical sources of care; and, thus, negatively impact physical and mental health for adults and children, including those with and without documentation (Mann et al., 2016; Rhodes et al., 2015). Fears and high stress levels related to potential deportation, lack of required forms of documentation (e.g., valid driver’s license), interactions with law enforcement, and racial profiling have been linked with poor health outcomes among Latinos, including increased cardiovascular risk, drug and excessive alcohol use, and mental health conditions such as depression, anxiety, and posttraumatic stress disorder (Hatzenbuehler et al., 2017; Kline, 2017; W. D. Lopez et al., 2017; Martinez et al., 2015; Torres et al., 2018).

Social Determinants of Health Framework

The social determinants of health framework recognizes the role that environmental contexts, including socioeconomic and political mechanisms, have in influencing health behaviors, health outcomes, and health disparities. This framework also emphasizes the importance of using policy and systems change at multiple levels to address social determinants of health (Solar & Irwin, 2010). There is a need to better understand how contextual factors such as discrimination, violence, and public policies (e.g., immigration enforcement) affect the health of vulnerable or marginalized communities such as Latinos, particularly among specific settings and subgroups, and to identify potential multilevel responses to promote health equity. The limited number of existing studies on the health effects of discrimination among Latinos have been concentrated in urban areas in traditional settlement states (Araújo & Borrell, 2006). Additionally, despite disproportionate rates of being questioned by authorities about their immigration status (M. H. Lopez et al., 2010), previous studies have not focused on Latino men.

In these analyses, mixed quantitative and qualitative methods were used to explore Latino men’s experiences related to discrimination, violence, and immigration enforcement in NC and the impact of these experiences on their health and well-being, and to identify what Latino men say should be done to address these social determinants of health.

Method

Quantitative Assessment

Sample

Data used in quantitative analyses came from the baseline assessment from the evaluation study of HoMBReS Por un Cambio, a lay health advisor HIV prevention intervention among predominantly immigrant Latino men in recreational soccer teams in NC (Rhodes, Leichliter, Sun, & Bloom, 2016). The study was developed and carried out by a long-standing community-based participatory research partnership comprised of community members, community organization representatives, and academic researchers. Inclusion criteria included being ≥18 years old; self-identifying as male; self-identifying as Latino; and speaking Spanish.

Data collection

At the beginning of the study, baseline data were collected from all study participants (N = 247) using a Spanish-language, quantitative assessment by study staff who were bilingual and bicultural. The assessment took about 45 min to complete.

Measures

The assessment included items comprising demographics, psychosocial constructs, and behavioral scales that had been validated within immigrant Latino populations previously. Most items had binary, categorical, or Likert-scale response options.

Demographics

Age, education, country of origin, and age at time of migration were measured using self-report items similar to other studies with this population (Rhodes et al., 2012; Rhodes, Hergenrather, Bloom, Leichliter, & Montaño, 2009). Education was dichotomized as having a high school diploma or equivalent or higher and having less than a high school diploma or equivalent. Country of origin was dichotomized as being from Mexico and being from another country. Migration age was dichotomized as 16 or younger and after age 16.

Predictors

Reported experiences of unfair treatment based on race/ethnicity were measured using the item, “Since coming to the United States, I often have the feeling that I am being treated unfairly because of my ethnicity” (De Vogli, Ferrie, Chandola, Kivimäki, & Marmot, 2007). Reported experiences with discrimination and violence based on race/ethnicity were measured using the item, “Since coming to the United States, have you ever experienced discrimination or been the victim of violence due to your race?” (Krieger, Smith, Naishadham, Hartman, & Barbeau, 2005). Both items used a 4-point response format from strongly disagree to strongly agree and were dichotomized as strongly disagree or disagree and agree or strongly agree. Questioning about immigration status was measured by a single yes/no item, “Have you been questioned about your immigration status?”

Health behaviors and outcomes

The primary behavioral and health outcome variables included perceived health status, drug use, alcohol use, depressive symptoms, and condom use. Perceived health status was measured using an adaptation of a widely used item that asks participants to rate their health compared to other people their age based on a 5-point scale from excellent to poor and was dichotomized as excellent, very good, or good and fair or poor (Centers for Disease Control and Prevention [CDC], 2017). Drug use was measured based on whether participants reported using any illicit drugs in the past 12 months (i.e., marijuana, cocaine, crack, and other, using an open-ended free response item). Two separate indicators were used to measure alcohol use. Typical week drunkenness was measured using a single item, “In a typical week how many days do you get drunk?” (O’Brien et al., 2006; Rhodes et al., 2012). Heavy episodic drinking was measured using the standard item, “Considering all types of alcoholic beverages, how many times during the past 30 days did you have five drinks or more on an occasion?” (CDC, 2017). These two items were both dichotomized for these analyses as any drunkenness vs. none and any heavy episodic drinking vs. none. Depressive symptoms were measured using the Center of Epidemiological Studies Depression Scale, a widely used 20-item scale (α = 0.85). As recommended, clinically significant depressive symptoms were defined as a score of 16 or higher (Radloff, 1977). Condom use was measured based on whether participants reported using a condom the most recent time they had vaginal or anal sex with a woman or anal sex with a man.

Data analysis

Sample demographics, predictor variables, and health outcomes were summarized using descriptive statistics, including frequencies and percentages or means, standard deviations, and ranges. Random-effects logistic regression models were used to fit bivariate and multivariate models of health outcomes. Participants’ soccer team was treated as a random effect to account for intra-team correlation, since members within the same soccer team are likely to be more like one another than they are to be like members of other soccer teams (Murray & Short, 1996). Bivariate models were generated for each predictor and health outcomes. All predictors that were significant at p < .10 in the bivariate analyses were included in the multivariate models. All multivariate models accounted for demographic variables. Odds ratios and adjusted odds ratios (AOR) and their 95% confidence intervals (CIs) were calculated for the predictor variables. All regression models were estimated in SAS Version 9.4 using the PROC GLIMMIX procedure (SAS Institute, Inc., 2011). A two-sided p-value < .05 was considered statistically significant.

Qualitative Interviews

At the end of the study in 2016, individual in-depth interviews were conducted with a subset (N = 20) of study participants who had participated in the quantitative assessment to explore qualitatively their experiences related to discrimination and violence. These participants were selected to include a diverse range of experiences reflective of the larger sample.

Standardized interview guides were developed in Spanish with careful consideration to wording, sequence, and content, and included open-ended questions related to immigration, experiences of discrimination toward the participant himself or members of his family or community, experiences of violent victimization, the impact of these experiences on the participant, and potential approaches to reducing discrimination and violence toward Latinos. The interview guide is outlined in Table 1.

Table 1.

Domains and Abbreviated Sample Items From In-Depth Interview Guides.

Background How would you describe what life is like in North Carolina?Discrimination Tell me about any experiences you have had being discriminated against in the United States. Tell me about any experiences of your children or spouse being discriminated against in the United States. How has discrimination in the United States affected you and your family on a day-to-day basis? How does discrimination affect Latinos in the United States?Violence and victimization Tell me about any times you have been the victim of violence in the United States. Tell me about any times you have observed violence against other Latinos.Impact of discrimination and violence Tell me about how you have been treated where you go for health care. How do your experiences with discrimination or violence affect how you access and use health-care services? How does discrimination affect your housing? How does discrimination affect your seeking help in an emergency? How does discrimination affect your child’s education? How does discrimination affect your experience at work? How does discrimination affect your ability to get where you need to go? Your transportation?Conclusion and recommendations Overall, how do you think Latinos are treated in the United States? What do you think would be ways to help prevent discrimination against Latinos and other minorities in the United States?

Each interview was digitally recorded with participant permission and conducted in Spanish by a native Spanish-speaking male study staff member who was trained and experienced in qualitative data collection and Latino and immigrant health research. Interviews averaged 54 min (range = 26–80) in length.

The digitally recorded interviews were transcribed verbatim into English by a professional transcriptionist who was bilingual and bicultural. Transcripts were analyzed using constant comparison, an inductive approach to developing grounded theory (Charmaz, 2006). Study team members read and reread transcripts, identified emerging themes, and came together to revise, refine, reconcile, and interpret themes and subthemes iteratively.

Ethics approval was obtained from the Institutional Review Board of Wake Forest School of Medicine (approval number: IRB00005451). Written informed consent was obtained from participants using a Spanish-language informed consent form. Participants received $30 USD for completing the baseline assessment and an additional $50 USD for participating in the qualitative interview.

Results

Participant characteristics and findings from participants in the quantitative assessment (N = 247) and qualitative interviews (N = 20) are presented. Significant associations were identified between questioning about immigration status and some behavioral and health outcome variables. Eight themes emerged from the qualitative interviews.

Participant characteristics

The average age of participants was 27 (range = 18–54). Most participants had less than a high school diploma or equivalent (n = 191; 78.3%), were originally from Mexico (n = 191; 82.7%), and had entered the United States after age 16 (n = 157; 66.8%). Over half of participants (n = 133; 54.3%) reported experiencing unfair treatment based on race/ethnicity since arriving in the United States, and nearly half reported experiencing discrimination or violence based on race/ethnicity (n = 101; 41.1%) and having been questioned about their immigration status (n = 107; 43.7%). Ninety percent of participants (n = 213; 89.5%) rated their health as excellent, very good, or good. Nineteen percent of participants (n = 46; 18.6%) reported using any illicit drugs in the past 12 months and a higher percentage reported typical week drunkenness (n = 106; 47.3%) and heavy episodic drinking in the past 30 days (n = 123; 55.9%). Twenty-seven percent of participants (n = 33; 27.1%) reported clinically significant depressive symptoms and nearly half (n = 95; 48.7%) reported condom use the most recent time they had sex. Select participant characteristics are presented in Table 2.

Table 2.

Select Participant Characteristics.

Characteristic	Mean ± SD or n (%), as appropriate
Age in years (n = 247)	26.9 (±7.17; range 18–54)
Education (n = 244)
High school or higher	53 (21.72)
Less than high school	191 (78.28)
Country of origin (n = 231)
Mexico	191 (82.68)
Other[a]	40 (17.32)
Age at time of migration to United States in years (n = 235)
16 or under	78 (33.19)
Older than 16	157 (66.81)
Experienced unfair treatment because of race/ethnicity (n = 245)
Agree or strongly agree	133 (54.29)
Disagree or strongly disagree	112 (45.71)
Experienced discrimination or violence because of race/ethnicity (n = 246)
Agree or strongly agree	101 (41.06)
Disagree or strongly disagree	145 (58.94)
Questioned about immigration status (n = 245)	107 (43.67)
Perceived health status (n = 238)
Excellent, very good, or good	213 (89.50)
Fair or poor	25 (10.50)
Drug use in past 12 months (n = 247)	46 (18.62)
Typical week drunkenness (n = 224)	106 (47.32)
Heavy episodic drinking in past 30 days (n = 220)	123 (55.91)
Clinically significant depressive symptoms (n = 122)	33 (27.05)
Condom use (n = 195)	95 (48.72)

Note. aGuatemala, El Salvador, Honduras, United States, and Peru. SD = standard deviation.

Bivariate and multivariate analyses

Having been questioned about immigration status was significantly associated with increased odds of past 12-month drug use (AOR = 2.16; 95% CI [1.07, 4.38]) and clinically significant depressive symptoms (AOR = 2.87; 95% CI [1.07, 7.67]) in the multivariate analyses, which were adjusted for age, education, country of origin, and age at time of migration, and other covariates as presented in Table 3. No significant associations were identified in the bivariate analyses between having been questioned about immigration status and perceived health status, typical week drunkenness, heavy episodic drinking, or condom use, or between unfair treatment or experiences of discrimination or violence and any of the outcome variables of interest.

Table 3.

Bivariate and Multivariate[a] Analyses.

Covariate	Drug use in past 12 months		Depressive symptoms
	OR (95% CI)	AOR (95% CI)	OR (95% CI)	AOR (95% CI)
Experienced unfair treatment because of race/ethnicity	1.15 [0.59, 2.27]	–	1.42 [0.63, 3.21]	–
Experienced discrimination or violence because of race/ethnicity	0.78 [0.39, 1.57]	–	1.23 [0.54, 2.80]	–
Questioned about immigration status	2.21 [1.12, 4.36]*	2.16 [1.07, 4.38]*	2.81 [1.12, 6.66]*	2.87 [1.07, 7.67]*

Note. aAdjusted for age, education, country of origin, and age at migration to the United States. OR = odds ratio; CI = confidence interval; AOR = adjusted odds ratio.

p < .05.

Similar to the larger sample, the majority (n = 19) of the interview participants were born in Mexico. At the time that interviews were conducted, those participants who were foreign-born reported living in the United States for an average of 13 (range = 3–20) years and in NC for an average of 12 (range = 3–20) years.

Qualitative themes

Eight themes related to experiences of discrimination and violence, emerged from the interviews. These themes, along with select participant quotations, are presented in Table 4.

Table 4.

Qualitative Themes and Select Quotations From In-Depth Interviews.

1. Unfair treatment is frequently based on immigration status, race/ethnicity, and language. “According to what we hear in the news, experiences we have had, and what people have told me, because I am an immigrant I am not wanted in this country. Many people say that Latinos go into their houses to rob them and things like that.” (Participant [P] 5)“Even if [a Latino] did have documents, that person would still be discriminated against. There have been instances when even the police have mistreated American citizens just because they looked Latino.” (P13)“I have seen instances where one doesn’t know how to speak English, and others don’t try to understand you. They just say, ‘I don’t speak Spanish’ and they won’t serve you because you are Latino.” (P6)2. Discrimination at work and within police interactions is most common and most challenging to address. “My boss was a White man and was always asking us why we came to this country without knowing English, and telling us that we should not be here. There was no reason for him to say that because we were doing the work. But what could one do? Nothing. Since [my coworkers’] documents were not in order, they were scared that they would get fired, and it is very difficult to find another job when you don’t have documents. I was also scared and decided it was better to stay quiet. You remain silent, endure it, and say, ‘It’s fine.’” (P13)“[The police] see you are Latino, get behind your car, check the car’s plate, and stop you.” (P8)“My eight year-old already gets it. He says, ‘Daddy, don’t go fast,’ or, ‘Don’t go that way because the police will get you, and I don’t want you to go to jail.’ That’s his fear.” (P9)3. Experiences of violent victimization are common among Latino men. “Here in the house, they came and assaulted us, one had a gun in his hand. Just because we are Latino. Latinos carry money. So that’s what they go for. Latinos are easy to assault or easy to do something to, and Latinos won’t say anything [to the police].” (P1)4. Discrimination impacts the well-being of Latino men and their families. “There are times when I cannot find work because of my status, because of my appearance, because I don’t have 100 percent fluency in English. It affects me because I cannot give my children what I want to and what they deserve. Same thing goes for my son, because of his appearance. The moment that he goes and asks for a job at McDonald’s, he will get it. But if he goes to ask for a job at an office or executive place, even though he has documents and studied at a university, if an American person is there and my Mexican son, they are going to give the job to the American. It’s like going with your hands tied behind your back.” (P18)5. Inter- and intra-community tensions exist. “In schools you see that White people fight Latinos, Latinos with Black people, and a culture is formed in which there are differences between races.” (P12)“My son complained that a boy [at school] discriminated against him for being Mexican. My son is a citizen, and the boy told him to go back to his country. I don’t know why he was sure that my son is not legal here. He was Latino, just like us.” (P7)6. Health-care services, such as health departments, are perceived as safe places. “When we go to places like the health department or the hospital, whether you have a social security number or not, you get seen and you have the same rights as any other person.” (P1)“Since one doesn’t speak English, there is a delay in being seen because they need a person there to translate. But I haven’t felt discriminated against that way. They are nice.” (P3)7. A range of strategies are used to cope with discrimination and the threat of violence, including limiting activities to Latino-only spaces. “Avoiding places where there are many White people and Black people. It’s better to go where there are more Hispanics.” (P4)“My reaction is to not say anything, let the person say or do what they are going to, and not do the same thing [i.e., discriminate in return]. I don’t grant it much importance. I just think of myself and my family and don’t care what happens after that.” (P5)8. System-level approaches are recommended for reducing discrimination and violent victimization of Latinos. “I would like it if the government would give us opportunities to be in this country through immigration. I think that would relieve the discrimination against us because they think that, because we are not in the system, we are criminals and bad people.” (P3)“[Discrimination could be prevented] by educating people. There are many ignorant people, and they could be doctors or have a college degree, but it doesn’t matter. If they are not educated about this, they are still closed-minded.” (P4)

Theme 1: Unfair treatment is frequently based on immigration status, race/ethnicity, and language

Interview participants reported that they were discriminated against for being immigrants (regardless of status), noting that many non-Latinos felt that Latino immigrants were taking jobs away from those who were born in the United States or perceived Latinos as criminals. Some commented that the divisive political context at the time of the interviews (e.g., media coverage of the anti-immigrant rhetoric of Donald Trump’s 2016 presidential campaign) further contributed to a xenophobic climate. Participants also described how their immigration status affected them on a more systematic level, with limited employment options and eligibility for public services for those who are undocumented.

Participants emphasized that Latinos also faced discrimination or mistreatment based on their physical appearance as racial/ethnic minorities or their language use. One participant worried that his U.S.-born son would have trouble finding work when he grew up because he looked Latino, despite his being a U.S. citizen. Participants also described how staff at local businesses and health and social service providers got frustrated when Spanish-speaking Latinos did not understand what they were saying and did not make an effort to understand and help non-English speakers.

These multiple, intersecting factors intensified experiences of discrimination, and participants shared that at times it was difficult to tease out the reason or reasons why they were being discriminated against. Participants noted that these types of discrimination affect Latino men in particular. They perceived that their Latina female partners were not exposed to as much discrimination because their female partners often did not work outside the home and did not spend as much time in non-Latino spaces as they did.

Theme 2: Discrimination at work and within police interactions is most common and most challenging to address

Participants described experiencing discrimination in all aspects of their lives. However, reported experiences of differential treatment and prejudice related to work and local police were most prevalent and had the greatest impact on them.

Participants reported challenges finding work because job options were limited, not only due to their immigration status, but also because they felt employers often did not hire them because of their race/ethnicity. In many cases, participants were not called back after applying or interviewing for a job and were left wondering whether this was based on their qualifications or discrimination. One participant reported applying for a job where the supervisor specifically said that he preferred a White employee.

When they were able to get jobs, participants described differential treatment by employers, including being asked to do harder work, being paid less, and having to work longer hours than non-Latino employees; being treated poorly by supervisors; and being blamed when equipment malfunctioned. In addition, participants experienced hostility and disrespect from non-Latino coworkers or from passersby while working in road construction, in the form of racial/ethnic slurs and teasing. For example, some participants reported often being told by coworkers that they should “go back to Mexico.”

Participants reported feeling that they had few rights in the workplace and did not know where they could get assistance regarding these types of incidents. Participants were often afraid to leave their job or file a complaint with their employer when mistreated because they felt that they had no legal recourse due to their immigration status and feared that they would not be able to find another job. Participants believed that employers took advantage of the vulnerability of undocumented workers.

Similarly, participants described negative experiences with local police. Several reported experiencing racial profiling while driving, including being followed or pulled over by police; participants believed that police assumed that Latinos were driving drunk or without a license. Participants who had reported crimes and victimization to the police felt that police had put “obstacles” in the way of investigation (e.g., saying that the participant did not provide enough information about the incident) and did not seem to fully investigate participants’ reports. Some had never heard back from police about the outcome of the investigation.

Accordingly, participants were reluctant to interact with police, even when they had been victimized, because they did not think police would take them seriously, and thought that police would favor the other person involved if that person was non-Latino. Participants also worried that going to the police after experiencing violence or other crime could lead to negative consequences for themselves or their families because of their immigration status.

Theme 3: Experiences of violent victimization are common among Latino men

Many participants shared that they or someone that they knew had been a victim of violence and/or that they had witnessed a violent crime against another Latino. Experiences of violence took place in or near victims’ homes or in public settings such as gas stations or local business parking lots. Participants usually described the perpetrators of these violent crimes as non-Latino people who victims had not previously met. Robbery, often by a person who was armed, was also reported as common. Some crimes seemed to be motivated based on the fact that the victim was Latino; participants noted that Latinos may be perceived as easy targets because perpetrators know that Latinos are often paid in, and may be carrying large amounts of, cash and assume that Latinos will not report crimes to police.

Theme 4: Discrimination impacts the well-being of Latino men and their families

Participants reported that experiences of discrimination and violence affected their life in important ways, as it was tiring to frequently experience fear and rejection. Many also described a state of constant worry related to being discriminated against based on their race/ethnicity or potential detention or deportation based on immigration status, and reported that they and their families had become isolated, withdrawing from their communities, staying inside their homes, and limiting the places that they went.

Participants who were fathers worried about the impact of discrimination and immigration enforcement on their children, noting that some had experienced teasing or violence at school related to their race/ethnicity or perceived immigration status or were anxious about the possibility of their parents being pulled over by the police or deported. Participants worried about their children’s future and reported concerns that their children’s future educational and employment opportunities would be limited because of discrimination based on their race/ethnicity.

Theme 5: Inter- and intra-community tensions exist

Participants described challenges with both Whites and African Americans/Blacks in their daily interactions, including discrimination and the use of slurs about being Latino or an immigrant and perpetration of violence or crime toward Latinos. Participants described discrimination and prejudice from other Latinos. For example, some experienced mistreatment in the workplace by employers who were also Latino, and participants reported discrimination from other Latinos fulfilling gatekeeper roles at health and social service agencies, such as at the front desk at local clinics or determining eligibility for health benefits. Participants also stated that their children had been teased or bullied or had gotten in to physical fights with other Latino students at their schools based on their country of origin or perceived immigration status.

Theme 6: Health-care services, such as health departments, are perceived as safe places

Participants described generally positive experiences seeking health-care services for themselves and their families. Participants endorsed the idea that health-care service providers were required to serve all people, and some emphasized that pharmacies had to serve them because they were paying for their medications like other customers. Participants stated that they felt comfortable using health-related emergency services in ways that they were not comfortable using police services. Some participants shared that they were more comfortable at a smaller clinic within the local community that was run by a Latino physician.

Participants did report some challenges with local health-care services, such as long wait times sometimes attributed to delayed availability of a Spanish-language interpreter. Participants said that they felt that they or their children were not called back to be seen by a provider until the participants indicated to staff that they were going to leave the facility if they had to wait any longer. Participants described negative experiences applying for health benefits, such as being made to feel badly for seeking public assistance for health-care needs. In addition, although most health-care services were perceived as safe, participants expressed concerns about leaving the house and potential encounters with police that may occur en route to accessing these services.

Theme 7: A range of strategies are used to cope with discrimination and the threat of violence, including limiting activities to Latino-only spaces

Participants described specific strategies they used to cope with the threat of discrimination and violence. One such strategy used by participants was to reduce potential exposure by spending most of their time in Latino-only spaces, such as living in predominantly Latino neighborhoods, going to Latino health-care service providers, and shopping at Latino-owned stores. Similarly, participants noted that they had become more reserved in recent years, avoided drawing attention to themselves, and were cautious about the people with whom they and their families spent time. Other participants emphasized the importance of not letting discrimination bother them and staying positive by focusing on working hard and taking care of their family. Those who reported experiencing high levels of discrimination at work emphasized maintaining boundaries between work and family life.

In some cases, participants sought to address incidents of discrimination by advocating for themselves and their families through more formal mechanisms. For example, participants explained that when their children were mistreated based on race/ethnicity or immigration status at school, they spoke with their children’s teacher or with the parents of the other student who treated their children this way.

Theme 8: System-level approaches are recommended for reducing discrimination and violent victimization of Latinos

Participants mentioned immigration reform or a pathway to legal status as a way of reducing discrimination against Latinos, noting that the current immigration system and political climate reinforce the notion that immigrants are criminals. Participants emphasized that it was necessary to educate and raise awareness among children and adults of all races/ethnicities about discrimination and its impact, as even those with high levels of formal education lacked understanding about Latinos’ experiences of discrimination. However, in spite of the multiple challenges participants faced related to discrimination and violence, several described feeling optimistic about the future for themselves and for their children. Participants noted that younger generations seemed to be less prejudiced and hoped that the general population would become more accepting as Latino populations continued to grow.

Discussion

Overall, participants reported high rates of unfair treatment based on race/ethnicity, experiencing discrimination or violence based on race/ethnicity, and being questioned about their immigration status. In-depth interviews, which were designed to capture the breadth of possible experiences and not quantify them, provided detail about the types, settings, and impact of discrimination, violence, and questioning about immigration status. Future research should explore these experiences further, including to document prevalence estimates.

These findings reflect national-level trends. According to a recent survey, one-sixth to one-third of Latinos reported that they had experienced discrimination when applying for jobs or at work; that they had been unfairly stopped or treated by police, with a higher percentage of Latino men reporting these types of experiences than Latina women; that they had experienced slurs about their race/ethnicity; that they or a family member had experienced violence because they were Latino; that they had avoided medical care, calling the police, or carrying out normal tasks such as driving because of concerns about discrimination or interacting with authority figures; and that they had considered moving because of discrimination (Robert Wood Johnson Foundation, 2017). Participants’ experiences also echoed findings among other racial/ethnic minority groups in the United States. In particular, qualitative themes related to interactions with police were similar to experiences documented among African American/Black men, who report high rates of being pulled over unfairly while driving and for whom stress related to racial profiling has been linked to health outcomes such as depression (English et al., 2017; Kendrick, Anderson, & Moore, 2007).

In these analyses, a significant relationship was identified between having been questioned about one’s immigration status and increased odds of drug use and depressive symptoms. However, no statistically significant relationship was identified between reported unfair treatment and discrimination or violence based on race/ethnicity and any of the outcome variables measured (i.e., perceived health status, drug use, alcohol use, depressive symptoms, and condom use). These findings may reflect differences in the contexts in which unfair treatment, racial/ethnic discrimination or violence, and being questioned about one’s immigration status might occur. The experience of being singled out based on perceived immigration status may lead to more pervasive and ongoing concerns over which Latino men may feel that they have less control (e.g., the threat of deportation) while experiences of unfair treatment and discrimination or violence may be more limited to when Latino men are in a specific location or interacting with a specific person. The qualitative data from this study further support this potential explanation; Latino men described avoiding certain settings (e.g., neighborhoods or businesses) where they reported experiencing or thought they were more likely to be exposed to unfair treatment or discrimination or violence as a strategy for coping with these experiences. However, they reported that immigration-related concerns heavily impacted their lives, particularly at work and when driving, two contexts that are more difficult to avoid. Further research is needed to test and tease apart these explanations.

Although a relationship was identified between being questioned about immigration status and drug use, a similar relationship was not identified between this predictor variable and other outcome variables, including other types of substance use such as alcohol. This may be because alcohol was used more socially as opposed to as a form of coping within this sample.

The interview data also demonstrate that reported unfair treatment, discrimination, violence, and issues related to immigration status are interconnected. For example, participants described being racially profiled by police while driving and explained that police pulled them over at least in part because they assumed that Latino men were undocumented. Also, participants reported that others may feel fewer inhibitions about mistreating Latino men and Latino men may feel limited in their ability to report or seek help regarding these experiences, believing they have little recourse due to their race/ethnicity and/or immigration status.

Additionally, these findings suggest an intersection between Latino men’s reported experiences of unfair treatment, discrimination, and violence; concerns related to immigration status; and mental health. The impact of these experiences may be heightened due to the roles that Latino men often play as a primary earner, driver, and family member who interfaces most with non-Latino institutions. Thus, Latino men may experience particularly high levels of depression, anxiety, and other psychological effects of discrimination, violence, and immigration enforcement.

Limitations

Because all quantitative variables were measured at the same time point, it is not possible to conclude causality. Also, this study was limited to Latino men living in NC, and the sample was predominantly from Mexico and may not reflect the heterogeneity of Latino populations as a whole. However, sample demographics were consistent with those of the Latino population in NC in terms of country of origin, age, educational attainment, and Spanish-language use. Furthermore, given the increase in Latino populations in new settlement states like NC in the United States and that study findings align with national data, they may be relevant to Latino health in other new settlement communities, especially as emerging data suggest that reported discrimination and fear of immigration enforcement have intensified among Latinos across the country since the 2016 election (Artiga & Ubri, 2017). Finally, the perception of health-care services, such as health departments, as safe spaces among participants who completed the in-depth interviews may have been impacted by their participation in the HoMBReS Por un Cambio intervention, which included a focus on accessing public health departments.

Conclusion

The results of this study highlight the need for multilevel responses to health disparities. While this study did not specifically explore experiences of discrimination and violence at the structural level, participants reported both individual or interpersonal discrimination (e.g., offensive comments or negative assumptions based on their race/ethnicity) as well as experiences that were indicative of more institutional discrimination (e.g., in settings such as the workplace or police interactions). Consistent with the social determinants of health framework, participants suggested that systems and policy changes may be needed to address the health impacts of contextual factors such as discrimination, violence, and the threat of immigration enforcement. Interview participants emphasized comprehensive immigration reform as a strategy to address stress related to immigration status and associated health issues and also to reduce discrimination and victimization of Latinos. Findings related to inter- and intra-community tensions also point to the potential for coalition-building across Latino subgroups and communities of color (e.g., Latinos and African Americans/Blacks), as well as consciousness raising among Whites and other non-Latinos, to collaboratively address discrimination and violence. This study suggests that in order to promote health equity and improve health outcomes for vulnerable or marginalized communities, change is needed across sectors and in settings outside of those typically associated with health and health care, including measures to reduce systemic discrimination in areas such as employment, law enforcement, and immigration policy.