Abstract
The history of Latino farmworkers in the United States is long and complex. Economic forces and often-contradictory immigration policies have given rise to patterns of undocumented immigration from Mexico and Central America by individuals and families looking for work. This review uses a Critical Multiculturalism lens to explore the incidence of depression in Latino farmworkers; the link between depression symptoms and the experience of migration, acculturation, poverty, and agricultural work; and the role of culture, structural issues, primary care providers’ inadequate training in mental health issues, and work conditions in the under-detection of depression in this population. Recommendations for clinicians and researchers are offered to improve detection of depression in Latino farmworkers.
Introduction
The National Institute of Mental Health (2012) reported that approximately 6.9% of adults in America suffer from depression and that about 16 million individuals experienced at least one depressive episode in 2011. The most common symptoms of depression include fatigue, withdrawal from activities, impaired concentration, and a heightened sensitivity to a broad range of unpleasant somatic symptoms such as pain and tightness of chest (Simon, 2003). These symptoms often result in impairment in social functioning (Rapaport, Clary, Fayyad, & Endicott, 2005) and as a result, the effects of depression go beyond the intra-psychic individual experience of the sufferer and impact family members, employers, health care systems, and tax payers (Simon, 2003).
The direct costs of treating depression across the population are estimated to be upward of 20 billion dollars per year (Medical Expenditure Panel Survey, 2009). In addition, Kessler (2012) reported the estimated annual cost of the effect of depression on lost work productivity to be between 30.1 and 51.5 billion dollars in the United States (Kessler, 2012). However, one group of workers not often considered in the literature are Latino farmworkers, a population disproportionally affected by depression in comparison with the general population (Olfson et al., 2000). Thus, the purpose of this literature review is to (a) describe critical multiculturalism theory (CMT; May & Sleeter, 2010), a theoretical foundation that helps to deconstruct the disparities that Latino farmworkers experience in relation to depression in comparison to majority populations; (b) provide a brief history of Latino farmworkers in the United States; (c) discuss the risk factors and prevalence of depression, as well as the structural and cultural issues that have been linked to under-detection of depression in Latino farmworkers in the United States and low utilization for health care services; and (d) offer recommendations that may benefit providers and researchers who can better serve Latino farmworkers based on the outcomes from this literature review.
CMT
CMT has origins that date back to the 1990s and is the integration of critical race theory (Delgado, 2001), critical pedagogy (McLaren, 1998), and anti-racist education (May & Sleeter, 2010). CMT first appeared in the field of Education to address the inadequacies of multicultural education, and more recently, it has been associated with achieving a higher degree of cultural competency in the field of Social Work (Nylund, 2006). Hall (1994) posited that merely looking at or celebrating differences between people does not change the structure of power that marginalizes minority ethnic individuals. Rather, we must be moved to investigate the “otherness” of marginalized populations by having an open dialogue from the perspectives of all the different histories, life experiences, languages, family and peer cultures, and values to bring into focus how our differences are socially and politically constructed. CMT tenets emphasize the examination of unequal power relations by critiquing and exposing the role of institutionalized inequities (May & Sleeter, 2010) and advocate toward the active involvement of naming and challenging all forms of social injustice (Berlak & Moyenda, 2001).
Through this literature review, we assess the “otherness” (Hall, 1994) of the migrant and seasonal Latino farmworkers in an effort to understand the manifestation of depression as well as the dynamics that influence assessment and detection for depression. The researchers acknowledge the influence of the power of the dominant discourse on the lives of Latino farmworkers (described below through the history of migrant and seasonal farmworkers) and recognize that power differentials exist based on many factors including citizenship, race, social class, gender, nationality, sexuality, and capitalism. Hall (1994) stated that “we speak from a particular place, out of a particular history, and out of a particular experience . . .” suggesting that a people’s discourse is shaped by those people’s lived experience. Hall supported the importance of speaking from the multiple voices that make up our social system. This literature review attempts to capture the lived experience of depression in the Latino farmworker population. However, in order to better understand the current experiences and concerns (i.e., prevalence of depression) of Latino farmworkers, the history of farmworkers in the United States must first be explained.
The History of Farmworkers in the United States
After the abolition of slavery in 1865, thousands of African Americans were freed from the hands of their oppressors with many seeking work in other sectors of the economy. Through this movement, farmers in the United States needed to find other sources of cheap labor, given that free labor was no longer an option, in order to remain financially viable (Vivian, 2005). By the 1840s, American farmers had established a network of contractors in China to bring Chinese citizens to work in agricultural industries (Guerin-Gonzales, 1994). Chinese immigration was followed by new waves of immigrants from Japan, India, Pakistan, and Mexico that continued to supply cheap labor for American farmers (Martin, 2015).
In 1931, the Midwestern and Southern plains experienced a severe 8-year drought that became known as the “Dust Bowl.” The long-standing drought resulted in financial hardships that displaced thousands of Americans, who were forced from their home states into a more lucrative state, mostly into California (Hurt, 1981). During this significant migration of Americans from one part of the United States to another, the need for and supply of Mexican laborers to farmlands across the United States slowed down (Martin, 2015).
The lives of the Dust Bowl migrants depicted in the novel Grapes of Wrath prompted President Franklin D. Roosevelt to propose legislation to change the working conditions of agricultural workers by ending what was known as “agricultural exceptionalism” (Martin, 2015). Agricultural exceptionalism was a term used to describe the laws that excluded the agricultural sector from labor laws that protected the rights of workers (Martin, 2015). Through the doctrine of agricultural exceptionalism, American farmers were legally able to pay substandard wages, continue to employ child labor, and deny their workers’ compensation for lost wages due to injuries and claims arising from workplace accidents (Luna, 1998).
Unfortunately, Roosevelt’s legislation coincided with severe economic challenges and a shortage of unskilled labor associated with World War II, forcing him to set aside his agricultural reform. Instead, he began negotiating a guest worker program with the Mexican government (Martin, 2015). By 1942, the governments of the United States and Mexico signed the Bracero program agreement, which supplied cheap labor to American farmers and was in effect for 22 years. During this time, approximately 4.6 million Mexicans became temporary workers in U.S. agriculture (Massey & Liang, 1989).
In 1964, the Mexican government ended the Bracero program over concerns of exploitation and abuse of Mexican workers (Massey & Liang, 1989). Over the next two decades, farmers relied on labor via a wave of illegal immigrants from Mexico that were encouraged by an unofficial “open door” policy from the United States that allowed a small number of legally admitted immigrants and “ignored” the massive entry of undocumented individuals (Vivian, 2005). During this time, the United States allowed unauthorized entry to thousands of Mexican nationals who would then be arrested by the immigration law enforcement agency and then delivered to American farmers as a source of cheap labor (Vivian, 2005). The small number of immigrants, who were being legally admitted for temporary farm labor during this time, was admitted under provisions of the H-2 visa program enacted by the U.S. Congress in 1952 (Immigration and Naturalization Act, 1952).
In 1986, the U.S. Congress passed the Immigration Reform and Control Act (IRCA), and with it, two special programs; the Special Agricultural Workers program (SAW) and the Replenishment Agricultural Worker program (RAW; Vivian, 2005). The SAW program was designed to prevent labor shortages from the enforcement of IRCA (Massey & Liang, 1989). The SAW program provided a means for individuals who were able to prove that they worked at least 90 days in agriculture to apply for a Temporary Worker Card, and after 3 years, they could apply for permanent residency (Massey & Liang, 1989). Understanding that once farmworkers obtained permanent residency status, they were going to pursue employment in other sectors of the economy, the U.S. Congress also authorized the RAW program, which authorized the admission of temporary workers whenever a shortage of farm labor was identified (Massey & Liang, 1989).
In addition to the SAW and the RAW programs, IRCA also contained a provision to modify the H-2 visa program, which is the visa classification for admission of temporary workers in the United States (Vivian, 2005). The changes in the H-2 visa program increased the number of temporary workers for farmers who were able to show that they were unable to recruit domestic workers (Vivian, 2005). Under this program, temporary workers have been permitted to stay in the United States up to 10 months at a time and then they must return to their country of origin before they were eligible to apply for a new H-2 visa (Martin, 2015). Approximately 150,000 temporary nonimmigrant workers are admitted annually in the United States under the H-2 visa program (Hanson, 2007).
By 2010, increases in the educational level of the U.S. population had created a shortage in the laborers needed in farming industries, particularly on farms that maintain labor-intense crops. This shortage of native-born laborers has resulted in the need for farmers to hire foreign workers via the H-2 visa program or as undocumented foreign workers (Hanson, 2010). Once again, economic conditions have made it necessary for American farmers to rely on temporary workers from Mexico and Central America in order to remain financially viable (Hanson, 2010). Unfortunately, the social and working conditions continue to expose farmworkers to risk factors for mental health problems, most particularly, depression (Grzywacz et al., 2006).
Risk Factors for Depression in Latino Farmworkers
It is estimated that there are approximately 3 million to 12 million individuals employed as migrant and seasonal farmworkers in the United States and that about 60% live below poverty level (Winkelman, Chaney, & Bethel, 2013). Factors that contribute to farmworkers’ conditions of poverty include the fact that farmwork tends to be seasonal and dependent on weather conditions, as well as the low wages that are characteristic of farmwork (Carroll, Samardick, Bernard, Gabbard, & Hernandez, 2005). Arcury et al. (2005) documented that poverty, along with the high mobility inherent in the seasonality of farmwork, renders farmworkers vulnerable to depression, anxiety, and other health conditions. Beyond poverty, several other structural, social, and cultural variables have been linked to depression in Latino farmworkers. One such variable is acculturation stress.
Acculturation stress has been defined as the stress experienced by immigrants that results from the tension between the norms, values, and beliefs of the culture of origin and those of the host culture (Caetano, Ramisetty-Mikler, Caetano Vaeth, & Harris, 2007). For Latinos in general and farmworkers in particular, acculturation stress related to life conditions in the United States can result in social maladjustment, psychopathology, and substance abuse (Smokowski & Bacallao, 2007); depression and suicidal ideation (Gonzales, Knight, Morgan-Lopez, Saenz, & Sirolli, 2002; Torres, 2010); family dysfunction and negative expectations (Hovey & King, 1996); and self-derogation (Vega, Gil, Warheit, Zimmerman, & Apospori, 1993). English language competence and racial discrimination have also been identified as acculturation stressors (Romero & Roberts, 2003).
Prevalence and Detection of Depression Among Latinos
Latino farmworkers are at high risk for developing depression (Georges et al., 2013) and they are also unlikely to seek mental health services (Lewis-Fernandez, Das, Alfonso, Weissman, & Olfson, 2005) due to a variety of cultural, social, and structural challenges (Georges et al., 2013). Olfson et al. (2000) reported that low socioeconomic status (SES) Latinos in the United States (who include farmworkers) are twice as likely to experience mental health disorders (23.2%) as compared with non-Hispanic Whites (11.8%), and there is evidence that Latinos experience persistent and more severe depressive symptoms throughout their lives than non-Hispanic Whites and African Americans (Liang, Xu, Quiñones, Bennett, & Ye, 2011). The disparity in prevalence rates for depression among Latino farmworkers (compared with other Latinos or other races) seems to vary from state to state, for example, depression has been reported to affect approximately 20% of Latino farmworkers in California (Alderet, Vega, Kolody, & Aguilar-Gaxiola, 1999), whereas research from the Midwest reported prevalence at 37.8% (Hovey & Magaña, 2003), and 41.6% in North Carolina (Hiott, Grzywacz, Davis, Quandt, & Arcury, 2008). Unfortunately, research findings suggest that depression is under-detected among Latinos and that Latinos with mental health symptoms may be underutilizing mental health services (Pincay & Guarnaccia, 2007) for a variety of reasons including (a) primary care providers’ (PCPs) inadequate assessment for depression and (b) low utilization of health care services by Latino farmworkers. Below are details pertaining to the complexities from both patient and providers that contribute to the underreporting of depression among Latino farmworkers.
PCP factors in under-detection of depression
Latino farmworkers who struggle with mental health symptoms are more likely to attempt to get their mental health needs met in a primary care setting opposed to a mental health context (Georges et al., 2013); however, PCPs are often insufficiently trained to screen for depression (Vega, Rodriguez, & Ang, 2010). Schmaling and Hernandez (2005) reported that PCPs failed to recognize (i.e., detect) depression in about 80% of primary care patients, who were predominately Mexican immigrants. One of the reasons that account for the under-detection of depression in Latino farmworkers includes language differences in how depression symptoms are expressed by Latinos as compared with non-Hispanic Whites (Lewis-Fernandez et al., 2005). Interian, Ang, Gara, Rodriguez, and Vega (2011) reported that language differences between patients and their PCP might lead to poor patient-provider communication hindering PCPs ability to detect depression symptoms.
Other reasons associated with PCPs’ low rates of detection include the limited time PCPs have with each patient (Mitchell & Coyne, 2007). This may lead PCPs to prioritize their attention to somatic symptoms and fail to recognize symptoms of depression (Lake, 2008). Furthermore, Lake (2008) posited that PCPs’ limited training in mood disorders may lead them to think that depression symptoms do not warrant intervention, or that they do not have the time to tend to what they perceive as minor conditions as they struggle to meet the high demands of medical practice.
Language factors
Some of the most significant difficulties in adequately assessing for depression in Latino farmworkers are related to language issues (Carroll et al., 2005). Most migrant workers are from Mexico (84%) and they speak Spanish as their primary language (Mehta et al., 2000). However, there is wide variability of regional dialects. For example, some farmworkers speak Mixteco, Tarasco, Quiche, and other dialects as their primary language and their Spanish language skills are limited (Alderet et al., 1999). To complicate matters further, farmworkers generally have low educational levels. Quandt, Arcury, Early, Tapia & Davis (2004) reported that in their sample of farmworkers primarily from Mexico, 46% had an elementary school level of education and 45% had between 6 and 9 years of schooling. Therefore, the terminology often used to assess for depressive symptoms makes it difficult for farmworkers to understand what is being asked, thereby making standardized depression instruments and even formal clinical interviews, depending on the clinician’s command of language variations, lack relevance or value (Lewis-Fernandez et al., 2005).
Low utilization
Difficulty in detecting depression in Latino farmworkers has been linked to their low participation in the health care system (Arcury et al., 2005). Low participation in health care is in part attributed to structural barriers (Arcury et al., 2005; Carroll et al., 2005; Ricketts, 2000), English language competency (Carroll et al., 2005), and low literacy (Lewis-Fernandez et al., 2005). Structural barriers that account for Latino farmworkers’ low utilization of mental health services include (a) high mobility rates as they migrate with the seasonal agricultural cycles (Arcury et al., 2005), (b) lack of health insurance (Carroll et al., 2005), and a limited number of health care facilities in the rural areas where these individuals live and work (Ricketts, 2000), but perhaps most influential are (c) cultural factors associated with mental health and mental illness.
The mobility rate for Latino farmworkers is a significant concern related to low utilization of health care services. When farmworkers are forced to move following the agricultural cycles, they are unable to establish ties with the communities where they work and therefore may be under-informed as to medical and mental health services available to them (Arcury et al., 2005). In addition, most Latino farmworkers live and work in rural areas away from cities and towns where mental health clinics are usually located (Ricketts, 2000), thereby significantly limiting their ability to learn about services available to them and being able to access them.
A second reason for low utilization has to do with lack of income to pay for expensive health care costs as well as lack of insurance. Because most Latino farmworkers tend to be poor (Winkelman et al., 2013), they are also likely to lack health insurance making mental health services unaffordable to them (Carroll et al., 2005). It is estimated that at least 75% of Latino farmworkers and 90% of their children do not have health insurance (Carroll et al., 2005). Despite being unable to pay for health insurance, Latino farmworkers often do not qualify for Medicaid coverage either because they are undocumented or because they don’t meet other eligibility requirements (Arcury & Quandt, 2007).
A third reason for under-utilization of mental health services by Latino farmworkers are the cultural factors associated with mental health and mental illness. Several health beliefs that are common among Latino farmworkers can often lead to low utilization of mental health services and therefore under-detection of depression. For example, farmworkers often postpone or fail to seek medical treatment when they attribute the cause of their problems to folk health beliefs such as “humor” (an imbalance between hot and cold qualities of the body, the environment, food, and herbal remedies); mal de ojo (the evil eye), susto (fright), or caida de mollera (a term used to describe an infant’s inability to eat due to the belief that the roof of the mouth cavity caves in), or when they believe that the use of traditional herbal remedies will resolve their health concern (Poss & Rangel, 1997). Similarly, Guarnaccia, Canino, Rubio-Stipec, and Bravo (1993) found that Latinos experiencing depression might report an inability to control their mood, emotional reactivity, difficulty coping, and excessive worrying. Latino immigrants usually referred to these symptoms as “nervios” or “susto” (Falicov, 1999). Thus, in cases where cultural health beliefs are incongruent or in contradiction with the Western model of health and illness, individuals refrain from endorsing depression symptoms when they access health care services and attempt to heal in ways that are congruent with their beliefs about the cause of symptoms (Garcés, Scarinci, & Harrison, 2006). These cultural expressions of depression-related symptoms have important consequences in how Latino farmworkers respond to depression screening tools (Caplan et al., 2013).
Cultural beliefs common among Latino immigrants in the United States have also been thought to influence the manner in which Latinos respond to depression screenings (Caplan et al., 2013). Among these beliefs is the attribution of mental illness to spells and witchcraft (Falicov, 1999); the belief that the onset and course of illness is out of one’s control, God’s punishment for ill will, or destiny (Falicov, 1999). All of these beliefs are referred to in the literature as fatalism and are believed to negatively affect help-seeking behaviors because individuals do not trust that conventional treatment will be effective (Chavez, Hubell, Mishra & Vladez, 1997).
Another important cultural factor influencing the accurate screening and diagnosis of depression is the stigma associated with the disorder. Depression is often seen as the result of having “weak character” (Caplan et al., 2013) and therefore Latinos may find it more socially acceptable to endorse somatic symptoms rather than accepting to be weak and endure the social stigma. Unexplained somatic symptoms that include trembling, heart palpitations, paralysis, fainting, numbness or tingling, chest pains, dizziness, and difficulty breathing have been identified as a common expression of depression (Guarnaccia et al., 1993) among Latino immigrants. Unexplained somatic symptoms associated with depression have also been found to be more common among persons who are lower SES, of lower education, and of an older age (Escobar, Rubio-Stipec, Canino, & Karno, 1989).
Clinical Practice and Research Recommendations
A number of depression screening instruments have been translated into Spanish to better help providers in assessing for mental health needs of Latino immigrants (Reuland et al., 2009). Some of these instruments include the Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996), the Centers for Epidemiological Studies–Depression scale (CES-D10; Radloff, 1977), the Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001), the Geriatric Depression Scale (GDS; Yesavage et al., 1982), the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden & Sagovsky, 1987), and the Post-Partum Depression Screening Scale (PDSS; Beck & Gable, 2000). However, the literature assessing the effectiveness of these instruments in monolingual Spanish speakers living in the United States is limited (Reuland et al., 2009) and insufficient. Thus, the following recommendations for clinicians and researchers are proposed.
Recommendations for clinicians
As of the time of this study, depression is still under-detected in primary care settings. It is recommended that health care workers be alert to medically un-explained somatic symptoms presented by Latino farmworkers and when these symptoms are identified, members of the health care team need to relate this information to the PCP. There is evidence that when Latino farmworkers are asked directly about mental health problems, they are more likely to disclose their symptoms than if they are not asked (Lake, 2008). The health care system places significant burdens on PCPs; therefore, it is important that all members of the health care team be educated and trained to assist PCPs in the identification of depression. Behavioral health providers (BHPs) can also play an active role in improving the detection of depressive symptoms in primary care. Forming collaborative relationships with the PCPs and their teams working in their catchment area, BHPs can help educate and train PCPs. BHPs and PCPs can also secure permission for the disclosure of information so that they can maintain ongoing communication about clients/patients in need of further assessment, further improving mental health for Latino farmworkers.
Recommendations for researchers
Researchers invested in the mental health of Latino immigrants and Latino farmworkers could greatly enhance the utility of their research efforts by adopting a CMT perspective (Nylund, 2006) as they design their research projects. Such a perspective can assist researchers in questioning the adaptation of screening instruments, clinical practices, and research methods to “fit” populations in need. Such questioning can lead to the rectification of previous misunderstandings about the mental health, family, and social processes of Latino farmworkers. Similarly, a CMT perspective might also lead to the development of models of health and illness that grow directly from the life experience of the population of interest, hence interrupting the pattern of subordination and cultural colonization of Latino farmworkers. Social justice in research is better served when there is a true investment of resources into learning about the needs of marginalized populations. The rapid growth of the Latino population indicates that the mental health care system stands to experience significant pressure to meet their mental health needs. Failure to do so will just displace this pressure to other social systems such as health care, law enforcement, and community life.
Conclusion
This review of the literature revealed that depression is under-detected in Latino farmworkers and evidence was provided that reflects that specific cultural factors account for low utilization for mental health services by Latino farmworkers. Beyond cultural factors, the literature also showed that PCP factors that include inadequate training, busy schedules, and patient-provider communication issues are also linked to PCPs’ low rates of detection. In addition, structural factors such as poverty, lack of health insurance, and social and geographic isolation have been associated with under-utilization of health care services by Latino farmworkers and thereby under-detection of depression. Using CMT, this literature review investigated the “otherness” of Latino farmworkers and attempted to understand the unique factors that make accurate detection of depression difficult (Hall, 1994). Continuing the practice of translating clinical procedures and screening tools developed by and for the majority to minority populations, such as Latino farmworkers, further marginalizes this vulnerable population. In addition, developing and using measures without cultural awareness can result in mis- or under-identification and worsening of symptoms. Persistent under-detection and under-treatment will continue to result in poor depression outcomes for Latino farmworkers, weakening their families and communities if clinicians and researchers do not take further action.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.