access to health care among latinos of mexican descent in colonias in two texas counties

Access to Health Care Among Latinos of MexicanDescent in Colonias in Two Texas CountiesLarry Ortiz, PhD, MSW;1 Lydia Arizmendi, JD, MSW;2 and Llewellyn J. Cornelius, PhD, MSW1

ABSTRACT: Context: Critical to resolving the problemof health disparities among Latinos is examining the needswithin ethnic subpopulations. This paper focused on theunique challenges encountered by one ethnicsubpopulation—Latinos of Mexican descent living incolonias. Findings reaffirm the importance of lookingwithin ethnic subpopulations to understand thecomplexities of health disparities. Purpose: This paperreports on data collected measuring access to health careamong Latinos of Mexican descent living in severalcolonias in two southern Texas counties. Method:Observations are based on data gathered from a non-probability sample obtained through a face to facequestionnaire focusing on health care access. Personsliving in two Texas counties near the US border wereincluded in this sample, and demographic data werecompared to county, state and national statistics toexamine the comparability of the sample to similarpopulations. Findings: Findings from this snowballsample, N=271, suggested lower rates of health insurancecoverage compared to the Latino population nationwide,decreased patterns of preventive screenings for bloodpressure, diabetes, cholesterol, cancers (ie, breast, cervical,and prostate), and regular access to health care in Mexicoby slightly more than half the sample. Conclusions:Seeking care in Mexico may be a viable solution for manyindigent people of Mexican descent living in closegeographic proximity to the border because it surmountsthe political, cultural, linguistic, or economic barriers tohealth care services in the United States. Nonetheless,there are longer term questions regarding quality of careand health and wellness for this group of people.

According to the most recent census data,Latinos are the most populous minoritygroup in the United States. Latinos area disparate group of many types of ethnicgroups with various geographic roots in

Latin America and the Caribbean. The one commondenominator they share is Spanish as their native

language. The largest Latino group in the United Statesconsists of people of Mexican descent—representingapproximately 58% of this population (Note 1).1

The health and social service infrastructures are notfully prepared to handle the needs of this burgeoninggroup of Americans. This is particularly apparent in thearea of health care. Barriers to health care are numerousand include language and cultural differences, the lackof health insurance, the high costs of health care, andpolicies prohibiting recent immigrants from receivingpublicly subsidized health insurance.2 Although thesebarriers to adequate health care are present among allLatino groups,2 Latinos of Mexican descent tend to bethe least health-protected according to various indices(ie, lack of health care insurance, lowest number ofphysician visits, limited preventive care, and increasedlikelihood of encountering language and culturalbarriers).3,4,5 A key variable to consider in explainingthe decreased access to health care among US residentsof Mexican descent is employment. Mexican culture ishistorically agrarian, and unlike other Latino groupsand Anglo Americans, Latinos of Mexican descent aremore likely to be employed in farming, fishing, foodprocessing, and forestry.3,6 Unlike managerial,industrial, or professional positions, this employment isamong the lowest paid in America, paying only $7.10per hour on average.7 According to Monheit & Vistnes,8

almost 60% of all uninsured adults earn less than $10per hour. In the industries where Mexican Americansare employed, it is not uncommon to find seasonal

1University of Maryland, Baltimore, Md.2University of Texas Pan American, Edinburg, Tex.

Supported by a DRIF fund grant from the University of Maryland

School of Social Work. The authors recognize Ms. Dara Bergel,

University of Maryland School of Social Work, and Mr. Andres Ortiz,

St. Mary’s University, San Antonio, Texas, for their valuable

contributions to this research. For further information, contact: Dr.

Larry Ortiz, Associate Professor, University of Maryland School of

Social Work, 525 W. Redwood Street, Baltimore, MD 21201; e-mail

[email protected].

. . . . . Health Services: Border Communities . . . . .

The Journal of Rural Health 246 Vol. 20, No. 3

employment or reliance on day labor and employers

who pay in cash to avoid payment of benefits and taxes

and documentation of immigrant status.3 Therefore, in

light of the cultural traditions that characterize agrarian

labor, the low wages paid in this industry, and

employer strategies to avoid paying benefits, the low

number of persons of Mexican descent obtaining health

care benefits is of little surprise.The current study reports on the health care access

of Latinos of Mexican descent in rural Texas, focusing onresidents in two colonias in two border counties.Colonias, which are rural unincorporated subdivisionslocated along the US-Mexico border, are among thepoorest communities in the nation.9 It is estimated thereare 1,800 of these communities along the Texas-Mexicoborder.10 Situated near but outside the boundaries ofmost border cities and towns, these loosely incorporatedcommunities often lack potable water, sewer anddrainage systems, electricity, and paved roads. Thesecommunities are home to an estimated 500,000 workingpoor, who in the midst of a booming border economyfueled by international free-trade agreements, often livewithout basic services.9,10 The population in colonias isalmost exclusively of Mexican descent, young,multigenerational, with a relatively high number ofpeople per household. Most colonia residents work inagriculture, either obtaining seasonal work locally ortraveling the country as migrant workers. There arevery few health clinics in these communities and almostno private physicians. Some better organized coloniasmay have community centers where periodically ruralhealth professionals visit to conduct health educationand screenings, but these services are generally ‘‘hit andmiss’’ and highly dependent on funding from eithergovernmental agencies or private foundations.

Little research has been done on the access to healthcare among Latinos of Mexican descent living in ruralareas. What research there is suggests that access is pooror limited and due to three variables: poverty and itsassociation with lack of health insurance, culturalbarriers, and public policy that deters recent immigrantsand language minorities from seeking health care.

The focus of this study was to explore the usualsources of health care and patterns for obtainingpreventive care among Latinos of Mexican descentliving in colonias in southern Texas. Considering thisgroup is poor, rural, with limited access to modernhealth facilities, and poorly educated, they are at higherrisk for contracting chronic long-term diseases, whichpotentially would bring economic catastrophe to theirfamilies. Because the lack of preventive care increasesthis risk for severe illness, there is a high level of interestin preventive health care for this population.

Literature ReviewLow incomes, poverty and its consequence, and

lack of health insurance have been associated withseveral studies identifying barriers to adequate healthcare among Latinos of Mexican descent. Several studiesfocusing on cancer screenings and follow-up identifycosts and no health insurance as a barrier for thispopulation. Lobell, Bay, Rhoads, and Keske11

investigated barriers to breast and cervical cancerscreening among Mexican American women. In thenonrandom sample, the authors report low incomes andno insurance as one variable in their model predictingwomen likely to procure cancer screening and those notinclined to do so. Wu, Black, and Markides,12 using datafrom the Hispanic Established Population for theEpidemiological Study of the Elderly, found lack ofhealth insurance as a variable in predicting who amongolder Mexican American women are likely to participatein cancer screening. Similar findings were reported byBuller, Modiano, Guernsey de Zapien, Meister,Saltzman, and Hunksaker,13 who used a multistageprobability sample of 366 Mexican American womenbetween the ages of 18 and 40 in southern Arizona tostudy the relationship between a community-basedcancer education program and follow-up screenings.Costs of health care were associated with healthinsurance and identified as a predictor for womenreturning for annual screenings.

Parchman and Byrd14 and Trevino, Trevino,Medina, Ramirez, and Ramirez15 found in cross-sectional studies in El Paso and San Antonio,respectively, that the greatest predictor to receivinghealth care among Mexican Americans was health carecoverage, even more than medical need. Trevino andcolleagues found that it did not matter whether theinsurance was private or public; those with insurancereported better health care access than those without.

Other variables identified as barriers to health careaccess for Latinos of Mexican descent were knowledgeof health and communication. Lobell et al.11 and Bulleret al.13 found that communication and knowledge ofhealth factors were predictors in cancer screenings.Those who perceived themselves as possessing limitedcommunication skills were unlikely to participate incancer screening tests. The same was true for thosewhose knowledge of the disease was limited. Torrez16

found that for many elderly Mexican Americans,complicated forms and/or information presented to thepatient that was unclear was a common barrier that keptthem from obtaining health care services. Similarly,Hunt, de Voogd, Akana, and Browner17 found thatlanguage and communication barriers were a majorexplanation for Mexican American women not


Ortiz, Arizmendi and Cornelius 247 Special Issue/Summer 2004

returning for follow-up appointments after a positivePap test result.

Help-seeking behaviors, which are often culturallybased, figure prominently into the patterns of accessinghealth care among Latinos of Mexican descent. When isthe time to obtain health care? What is the role ofpreventive health care? And, what is considereda primary source of preventive care? For example,preventive health screenings and routine physicals areviewed as discretionary types of health care amongsome Latinos of Mexican descent14,18 and therefore, areless likely to be pursued as a priority. This is trueespecially for the uninsured poor. Norms for health careestablished in one’s social environment are a majorpredictive factor.13,19 If others in the social milieu onlyseek care when they are ‘‘really ill,’’ then one may notalways view ‘‘manageable’’ symptoms as motivation forobtaining care.20,21 For example, Borrayo and Jenkins18

found that many women of Mexican descent wereresistant to obtaining preventive health care based ona typical cultural belief that if one feels healthy, there isno need to go to the doctor. This belief is grounded inthe notion that one goes to the doctor when sick.Seeking medical help when not sick is to risk losingone’s feelings of being healthy. However, Gonzalez22

found that among a sample of poor Mexican AmericanSpanish-speaking women, teaching breast examinationin a culturally sensitive manner increased self-efficacyand improved their chances of participating in this levelof preventive care.

For some Mexican Americans, ethnomedical sourcesand ethnopractitioners (ie, folk healers) are culturallyacceptable sources of preventive care and preferred as analternative to preventive western medicine because thesesources are a better cultural fit, more accessible, and lessexpensive. For example, prayers, use of herbs, and folkmedicine have been documented in the literature asalternatives or as adjuncts to health care among someMexican American samples. Prayer and herbal remediesare reported in a few studies as primary forms ofprevention,20,21,23,24 but Hunt, Arar, and Akana23 reportthat in the diabetes population they sampled, theseforms of treatment were not viewed as an alternative tothe medical management of the disease but as a support,primarily to reduce anxiety. Those seeking care froma folk healer, most likely a curandera, were few innumber. Padilla, Gomez, Biggerstaff, and Mehler25

report a rather sizable number of Mexican Americans intheir Denver study who reported seeking care froma curandera. However, these tended to be specific toparticular types of symptoms such as head and stomachaches, nerves, and fright. Other studies found care fromfolk healers almost negligible.23,24 But, Iniguez andPalinkas5 found that their sample used ethnomedical

sources and practitioners because (1) they weredissatisfied with the primary care they were receiving inmedical clinics and offices, (2) they were satisfied withthe traditional cultural alternative, and (3) the cost ofcare was less expensive.

A well established pattern among many MexicanAmericans is traveling to Mexico for their health care,dentistry and pharmaceuticals.13,26 Several factorsexplain this behavior: low costs, no language or culturalbarriers (as one of the authors heard said, ‘‘They justunderstand the Mexican body better over there’’), andless bureaucracy. Typically, this pattern has beenobserved in older, poor Mexican Americans who arenoncitizens, have no health insurance, and live close tothe border. However, Iniguez and Palinkas5 found thispattern mostly among legal residents or those born inthe United States. Undocumented people were lesslikely to go to Mexico because of fear that their statuswould be discovered at the border and they would bedeported. The care they receive there tends to be asa need presents and short term, without follow-ups fortreatment of chronic conditions.

Health insurance is identified in the literature asa predictor for pursuit of care among Latinos of Mexicandescent. Other factors (eg, knowledge of health,language, and preference for culturally compatible formsof preventive health) also explain health access practices.In the current study, the researchers were interested inobserving whether these patterns for seeking preventivehealth care might be the same among a sample ofresidents living in somewhat isolated communities,colonias, along the US-Mexico border.

MethodsThis study was designed to explore adult health

care access and patterns of preventive care amonga snowball sample (N ¼ 271) of Latinos of Mexicandescent 18 years and older who resided in 2 colonias insouthern Texas counties, adjacent to the US border (Starrand Hidalgo counties). The sample included MexicanAmericans and Mexican immigrants, regardless of legalstatus (citizenship was not ascertained for this study).Ten administrators who previously worked in thecommunity as promotoras or union organizers for theUnited Farm Workers Union were hired and trained toconduct face-to-face interviews in either therespondents’ homes or another setting of their choice.One month before the administration of the survey(September 2002), the administrators received severalhours of training on the intent of the study, maintainingconfidentiality, use of the instrument, and how to locatesubjects. They used a snowball method of attaining thesample, canvassing neighborhoods, churches,



community centers, and other social gatherings to locateinitial respondents and referrals for other potentialrespondents. Each survey administrator was paid $15for each survey they completed; in addition,participants were given a $15 gift certificate to a localgrocery chain in southern Texas.

The questionnaire used to measure access wasa modification of the instrument used by Lou Harrisand Associates27 for a Commonwealth Fund nationalsurvey of minority health. Though many of the itemsfrom the survey were used in this study, thequestionnaire was translated into Spanish by twoMexican American translators from the region using theforward and back translation techniques recommendedby Zambrana,28 to ensure that the nuances of the targetpopulation were reflected in the translation. More than90% of the surveys were administered in Spanish.No personal identifiers were recorded in the dataset;therefore the project qualified for and received anexemption from the University of Maryland’sinstitutional review board before the analysiswas completed.

FindingsThe colonias in the Texas counties of Starr and

Hidalgo are among the poorest communities in the

United States. Starr County is listed as the poorest ruralcounty in the State of Texas, with an estimated povertyrate of 46.7% in 2000.29 Starr County is also classified bythe US Department of Agriculture as a county withpersistent poverty and dependency on federal transferpayments.30 As depressing as this may already seem,the conditions for the residents of the Starr and Hidalgocounty colonias in the sample were even worse thanthose for the other residents of Starr County (Table 1)and other communities. Eighty percent of therespondents in the colonias had family incomes less than$15,000, compared to 45.7% of the residents of StarrCounty. Nearly 70% of the adult respondents in thecolonias did not have a high school diploma, comparedwith 24.4% of the adults in the state of Texas and 19.6%of the US population. Close to half (44.2%) of therespondents in the colonias reported themselves as beingin fair or poor health, compared with 20.1% of theresidents in the State of Texas and 14.7% of the USpopulation. Forty-two percent of the respondents inthese colonias were uninsured, compared with thenational average of 36% for Mexican Americans. Giventhese challenges, how do the respondents in thesecolonias fare in terms of their ability to obtain health carewhen they need it? And, what types of patterns arethere for obtaining preventive health care? The data that

Table 1. Comparison of Study Population (N 5 271) to Other Communities in theUnited States (Percent)

Characteristics

Colonia Residents inStarr and Hidalgo

Counties (N 5 271)Starr County

Overall*Hidalgo County

Overall*State ofTexas* United States*

Education

,high school degree 69.0 65.3 49.6 24.4 19.6

Income

,$15,000 80.0 45.7 31.0 17.0 15.8

Primarily speaksSpanish 79.0 90.4 82.3 27.0 10.7

U.S. Born 32.0 62.2 69.5 85.0 87.7

Perceived health status

Fair/poor 44.2 . . . . . . 20.1y 14.7yInsurance status

Uninsured 42.0 . . . . . . . . . 36.0�

* Data for all rows except Uninsured is for the general US population and is from the 2000 US Census: American Fact Finder,http://factfinder.census.gov/home/saff/main.html?_lang5en. Data for Percentage Uninsured applies to Mexican-Americans only.

y Data from the 2002 Behavioral Risk Factor Surveillance System. Source: Centers for Disease Control and PreventionBehavioral Risk Factor Surveillance System Selected Metropolitan/Micropolitan Area Risk Trends,http://apps.nccd.cdc.gov/brfss-smart/SelQuickViewChart.asp.

� Mexican-Americans only. Source: National Center for Health Statistics, 1998 Health United States, 1998. Hyattsville,Md: National Center for Health Statistics.



follow examine these questions of where these residentsgo for health care when they need it, as indicated by thelocation of their usual source of care.31 These findingsare descriptive in nature and not designed forhypothesis testing. However, cross-tabulations wereused to demonstrate various patterns of health care bylocation, Mexico or United States.

Slightly more than half of the respondents in thecolonia sample (50.9%) indicated that a provider inMexico was their usual source of health care. Factorsrelating to the convenience of care (travel time), whetherthey had a regular doctor as their usual source of care,and measures of preventive health care use werecorrelated with the selection of a provider in Mexico astheir usual source of care (Tables 2 and 3). Respondentsin the colonias with a usual source of care in Mexico were

Table 2. Factors Associated With Having a UsualSource of Care (USOC) Site in Mexico

CharacteristicUSOC

Mexico (%)USOC

Texas (%)

Total 50.9 49.1

Age

18�38 54.5 45.538þ 59.7 40.3

Place of birth

United States 46.7 53.3Mexico 54.3 45.7Central America 66.3 33.3

Perceived health status

Good/excellent 48.3 51.7Fair/poor 55.0 45.0

Type of health insurance

Private insurance only 55.3 44.7Public Insurance only 54.3 45.7Public and private insurance 56.7 45.3

Barriers to care

Have to pay too much forhealth care 58.3 41.7

Language differences 53.3 46.7Lack of translators 46.7 53.3Too much paperwork 51.6 48.4

Travel time to health care provider**

,30 minutes 44.3 54.730þ minutes 49.1 47.6

Access to transportation

Always/most of the time 50.0 50.0Sometimes/none of the time 52.3 47.7n 138 133

** P,.01.

Table 3. Receipt of Selected Services at UsualSource of Care (USOC) by Site of Care

CharacteristicUSOC

Mexico (%)USOC

Texas (%)

Regular doctor/health care professional at USOC*

Yes 45.8 54.2No 62.6 37.4

Blood pressure checked*

Yes 46.1 53.9No 58.4 41.6

Blood sugar checked***

Yes 42.4 57.6No 62.7 37.3

Cholesterol checked*

Yes 43.5 56.5No 59.4 40.6

Complete physical***

Yes 35.8 64.2No 63.0 37.0

Vision test**

Yes 40.9 59.1No 57.8 42.2

Pap smear

Yes 47.1 52.9No 57.7 42.3

Mammogram***

Yes 35.4 64.6No 59.5 40.5

Prenatal care**

Yes 37.0 63.0No 59.0 41.0

Prostate exam*

Yes 28.6 71.4No 57.8 42.2

Mental health counseling

Yes 35.0 65.0No 54.1 45.9

Provider spoke to you about smoking, drug/alcohol**

Yes 47.6 52.3No 37.0 63.0

Provider spoke to you about diet, weight and exercise

Yes 50.0 50.0No 61.0 39.0

Provider spoke to you about birth control/condom use

Yes 50.0 50.0No 56.3 43.7n 138 133

* P,.05; ** P,.01; *** P,.001.



more likely to travel more than 30 minutes to see theirprovider (49.1 versus 44.3%, chi-square ¼ 8.65, P,.05)(Table 2). Those with a usual source of care in Mexicoalso were more likely to not have a regular doctor attheir usual source of care (62.6% versus 45.8%, P,.05)(Table 3). Neither age nor country of origin wasassociated with obtaining health services in Mexico(Table 2), as has been suggested in other studies. Thesample was generally split in terms of age, with youngerand older persons seeking care in Mexico and theUnited States at roughly the same rate. The same wastrue regarding place of birth; although there was a slightpercentage edge toward seeking care in the country ofone’s birth, there was no statistical significance. Finally,respondents in the colonias who had a usual source ofcare in Mexico were less likely to receive a bloodpressure check, a blood sugar level check (to screenfor diabetes), a cholesterol level check, a vision test,a mammogram, prenatal care or a prostate exam(P,.05) (Table 3).

DiscussionObtaining health care in Mexico for poor rural

residents of colonias in southern Texas appears to bea viable option that removes many of the other barriersto health care discussed in the literature, as the driveover the border involves minimal time, no prohibitivelegal policies, and no differences in language or culture.In addition to the above, respondents report satisfactionwith this care. Basic preventive care, however, is lessroutine in Mexico, leading the researchers to believe thatthis sample is inclined to pursue health care when theyexperience a health problem and not as a routinefunction of living. There is also speculation that thehealth care professionals seen in Mexico may actually bepharmacists who have broad discretions inadministering medicines and considered among thesample as ‘‘front line’’ health care providers. However,in our sample, very few respondents indicatedobtaining care from ethnopractitoners, whereas a sizableportion, 33%, indicated using herbal substances asa preventive source of care, and 30% indicated usingprayer for healing; neither of these practices wereassociated with site of care being Mexico or Texas. Thefindings concerning diabetes, cholesterol, and cancerscreenings seem especially problematic. The largemajority of Latinos of Mexican descent in this sampledoes not get these tests whether they receive care inTexas or Mexico. Barriers identified in the literaturereview associated with cancer screenings seem to beconsistent with findings in this study. More research inthis area is warranted. It appears that obtaining healthcare among this sample is on an as-needed basis. Is

health care better or worse for the rural residents ofMexican descent? In this context, being able to go toMexico for health care helped these residents overcomeone of the barriers to care (the lack of a usual source ofcare in the United States). However, even though theseresidents have a usual source of care to go to in Mexico,the question of quality of care, especially in the longterm, remains unanswered.

Findings from this survey are not generalizable toLatinos of Mexican descent or the population ofcolonia-dwelling residents because the sampling strategydid not use random selection or assignment. Neither canthese findings be generalized to urban dwelling personsof Mexican descent or Mexican immigrants. But giventhe rural orientation and cultural traditions along withthe tendencies to work in agricultural industries, thepattern of health care among this group, regardless ofplace, rural or urban, is likely undifferentiated. Healthcare access often reflects labor patterns. Becauseaggregate health care data are not available todifferentiate rural Latinos of Mexican descent fromurban ones, it is unknown whether their health careaccess differs. These findings in this study suggestpatterns of health-seeking behavior among thosesampled, the strategies employed by this group toobtain health care services, and their state of health care.Results from this study support other studies that foundthat barriers to quality health care, especially the typethat includes preventive health care, are related to lowincome, no health insurance, insufficient culturallycompetent health education, health and welfare policiesdesigned for exclusiveness, and limited access to healthcare services.

Notes1. This paper uses the terms Mexican American and persons or

Latinos of Mexican descent. When using the term MexicanAmericans, the authors are following the terms used by otherresearchers or as reported in census data. However, for thepurposes of our study, the term person of Mexican decent is mostappropriate for at least three reasons. One, our sample includespeople who are Mexican Americans and Mexican immigrants,regardless of legal status. We did not ascertain the citizenship orimmigration status of subjects. Two, in light of our study’s location,this distinction of citizenship and immigrant status is artificial formany people. The border is a line that does not separate culture,family, or behavioral norms. Three, in this setting, social class is a farmore determining factor in terms of access to health care thancitizenship or residency status. Though citizenship does indicateaccess to state publicly funded health care, it is not a factor indetermining site of health care in our study. In fact, numericallymore people receiving publicly funded health insurance seek care inMexico than in Texas.



References1. US Census Bureau. The Hispanic Population: Census 2000 Brief.

Suitland, Md: US Census Bureau; Available at: http://www.census.gov/prod/2001pubs/c2kbr01-3.pdf. Accessed July 2, 2002.

2. National Council of La Raza. NCLR Agenda for Hispanic Families: APublic Policy Briefing Book. Washington, DC: National Council ofLa Raza; 2003.

3. Cornelius LJ, Ortiz L. Is being ‘‘the largest’’ Latino Ethnic Groupenough to ensure Mexican Americans equity of access to healthcare? In: Davis K, Bent-Goodly T, eds. The Color of Policy.Alexandria, Va: Council on Social Work Education; 2003.

4. Hispanic Times Magazine. Medical care reviewed for HispanicAmericans. Hispanic Times Magazine 1998;19(3):41.

5. Iniguez E, Palinkas L. Varieties of health services utilization byunderserved Mexican American women. J Health Care PoorUnderserved. 2003;14(1):52-69.

6. Knouse SB, Rosenfield P, Culbertson AL, eds. Hispanics in theWorkplace. Newbury Park, Calif: Sage Publications; 1992.

7. Bureau of Labor Statistics. 1999 National Industry-SpecificOccupational Employment and Wage Estimates SIC 07 - AgriculturalServices. Available at: http://stats.bls.gov/oes/1999/oesi2_07.htm#b45-0000. Date accessed July 1, 2002.

8. Monheit AC, Vistnes J. Research Findings 2: Health Insurance Statusof Workers and Their Families, 1996. Rockville, Md: Agency forHealth Care Policy and Research, 1996. AHCPR Pub. 97-0065.Accessed July 23, 2003, at: http://www.meps.ahrq.gov/papers/rf2_97-0065/rf2.htm; 1996.

9. Arizmendi L, Ortiz L. (forthcoming) Neighborhood andcommunity organizing in colonias: a case study in the de-velopment and use of promotoras. J Comm Prac.

10. Ramos IN, May M, Ramos KS. Environmental health training ofpromotoras in colonias along the Texas-Mexico border. Am J PublicHealth. 2001;91(4):568-570.

11. Lobell M, Bay RC, Rhoads KV, Keske B. Barriers to cancerscreening in Mexican-American women. Mayo Clin Proc.1998;73(4):301-308.

12. Wu ZH, Black SA, Freeman JL, Markides KS. OlderMexican-American women and cancer screening: progress towardtargets for healthy people 2000. Ethn Dis. 2001;11(4):645-51l.

13. Buller D, Modiano MR, Guernsey de Zapien J, Meister J,Saltzman S, Hunsaker F. Predictors of cervical cancer screening inMexican American women of reproductive age. J Health CarePoor Underserved. 1998;9(1):76-95.

14. Parchman M, Byrd T. Access to and use of ambulatory health careby a vulnerable Mexican American population on the U.S.-Mexicoborder. J Health Care Poor Underserved. 2001;12(4):404-414.

15. Trevino RP, Trevino FM, Medina R, Ramirez G, Ramirez RR.Health care access among Mexican Americans with differenthealth insurance coverage. J Health Care Poor Underserved.1996;7(2):112-121.

16. Torrez DJ. Health and social service utilization patterns of MexicanAmerican older adults. J Aging Stud. 1998;12(1):82-99.

17. Hunt LM, Arar NH, Akana LL. Herbs, prayer, and insulin. Use ofmedical and alternative treatments by a group of MexicanAmerican diabetes patients. J Fam Pract. 2000;49(3):216-223.

18. Borrayo E, Jenkins S. Feeling healthy: So why should Mexicandecent women screen for breast cancer? Q Health Res2001;11(6):812-823.

19. Hargraves MA. Immigrants needing health care in Texas. Tex Med.1996;92(10):64-77.

20. Zuckerman MJ, Guerra LG, Drossman DA, Foland JA, GregoryGG. Comparison of bowel patterns in Hispanics and non-Hispanicwhites. Dig Dis Sci. 1995;40(8):1763-1769.

21. Katerndahl DA, Realini JP. Panic disorder in Hispanic patients.Fam Med. 1998;30(3):210-214.

22. Gonzalez JT. Factors relating to frequency of breastself-examination among low-income Mexican American women.Implications for nursing practice. Cancer Nurs. 1990;13(3):134-42.

23. Hunt LM, de Voogd KB, Akana LL, Browner CH. Abnormal Papscreening among Mexican-American women: impediments toreceiving and reporting follow-up care. Oncol Nurs Forum.1998;25(10):1743-1749.

24. Peifer KL, Hu T, Vega W. Help seeking by persons of Mexicanorigin with functional impairments. Psychiatr Serv.2000;51(10):1293-1298.

25. Padilla R, Gomez V, Biggerstaff SL, Mehler PS. Use ofcuranderismo in a public health care system. Arch Intern Med.2001;161(10):1336-1340.

26. Angel RJ, Angel JL, Markides KS. Stability and change in healthinsurance among older Mexican Americans: longitudinalevidence from the Hispanic established populations forepidemiologic study of the elderly. Am J Public Health.2002;92(8):1264-1271.

27. Lou Harris and Associates. National Comparative Survey of MinorityHealth Care. The Commonwealth Fund. New York: Lou Harris andAssociates; 1994.

28. Zambrana RE. Cross Cultural Methodological Strategies in theStudy of Low Income Racial Ethnic Groups. In: Grady ML, ed.Primary Care Research: Theory and Methods. Rockville, Md;US Department of Health and Human Services; 1991.

29. State of Texas, Window on State Government, Texas Comptrollerof Public Accounts, Rural Texas in Transition. Accessed July 23,2003, at: http://www.window.state.tx.us/specialrpt/rural/2character.html. 2001.

30. US Department of Agriculture, Economic Research Service Un-derstanding Rural America. Accessed July 23, 2003, at: http://www.ers.usda.gov/publications/aib710/aib7101.htm. 2003.

31. Andersen RM, Aday LA, Lyttle CS, Cornelius LJ, Chen MS.Ambulatory Care and Insurance Coverage in an Era of Constrant;1987. Chicago, Il: Pluribus Press.



access to health care among latinos of mexican descent in colonias in two texas counties

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