Perceptions of and barriers to equitable healthcare access for undocumented populations in Belize: a qualitative study

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Mackey This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7502686/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Feb, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted 13 You are reading this latest preprint version Abstract Background Belize is primarily a destination country for migrants transiting through Central America. The impact of legal status on health access in Belize is under-researched. In October 2023, the Belize government removed medical fees in public hospitals to increase accessibility for all residents regardless of legal status. This study aims to qualitatively explore patterns of healthcare access for undocumented individuals compared to Belizean nationals in two historically under-resourced districts of Belize. Methods 60 semi-structured qualitative interviews were conducted exploring healthcare utilization, access, and barriers to care for undocumented populations between September to October 2024. Key informants, including health administrators, health providers, and public health workers were recruited through purposive snowball sampling. Undocumented participants and Belizean nationals were recruited through respondent-driven sampling via public health workers. Interviews were audio recorded, transcribed and translated as applicable. Transcripts were deductively and inductively coded for qualitative content analysis by two independent coders using Dedoose. Results 17 public health workers, 5 health providers, 4 health administrators, 19 undocumented and 15 documented individuals were interviewed across 14 rural villages and 3 towns in Southern Belize. Irrespective of documentation status, long wait times, staffing and medication shortages, limited and expensive transport to health facilities, and language barriers for Spanish and Kek’chi speaking individuals were significant obstacles. For undocumented participants, these existing challenges were compounded by lack of formal employment and resultant impoverishment, misinformation regarding healthcare access, marginalization by clinic staff, fear of deportation, and subsequent reluctance to seek government-provided health services and preference for free, NGO provided care. Conclusions Understanding how undocumented individuals in Belize access health services is crucial for enhancing their health outcomes and accurately assessing healthcare utilization and costs, especially amid government efforts to expand healthcare access. Study findings will enable more strategic resource allocation and ensure undocumented populations are included in national healthcare improvement plans. migrant health health equity healthcare access global health Figures Figure 1 Figure 2 Background The World Health Organization (WHO) global initiative for Action on Social Determinants of Health Equity recommends actions for ensuring that health equity is integrated into the development of social and economic policies to improve social determinants of health for disadvantaged populations 1 . A prerequisite to this, however, is the documentation and identification requirements to access many essential services, such as healthcare, education, and employment. These requirements include but are not limited to social security identification, birth registration, and passports. Pilot studies exploring the experiences of undocumented individuals accessing healthcare in multiple regions have identified significant health access barriers. At the patient-provider level, experiences of discrimination, stigmatization, and fear of deportation serve as significant deterrents to seeking health services. At the patient-facility level, drug shortages, understaffing, and long wait times were additional deterrents to care. At the systems level, non-nationals were often unable to access health services in the manner available to nationals, whether due to health services being offered to nationals only or being unable to purchase health insurance without proper identification documents. Furthermore, there were oftentimes discrepancies between knowledge and perception of available health services for undocumented individuals versus what services were available. Although there were sometimes informal mechanisms for accessing health services without legal identification and legal mechanisms for appealing health costs individually, these were not long-term solutions. Given this context, understanding how undocumented individuals access health services is essential not only to improve their health outcomes but also to assess systems-level drivers of healthcare utilization and associated costs. Existing literature in multiple regions already shows that upstream investments in civil registration and vitals statistics systems provide essential information for implementing focused public health policies that are ultimately more cost-effective long term despite potentially lacking obvious, immediate outcomes 2 . As for the Belize context, according to the Marco Integral Regional para la Protección y Soluciones (MIRPS), a Central America regional cooperation framework between countries of origin, transit, and destination, Belize is primarily a country of destination for migrants transiting through Central America 3 . In 2022, the Amnesty Program was implemented as a nationwide initiative to regularize an estimated 40,000 undocumented people living in Belize; however, by March 2023, only 13,540 applications had been received 4 . Notably, stateless individuals were largely excluded from this initiative, as they cannot provide any form of legal identification required for regularization in Belize. In addition, the lengthy application process meant that many are in various stages of the approval process and may continue to have difficulty accessing health services. Furthermore, in October 2023, the Belize government removed medical fees in public hospitals to increase accessibility for all inhabitants, regardless of legal status 5 . Prior qualitative studies on health access in Belize have also alluded to a tiered health system with gaps in coverage even for nationals, more difficult access in areas without public clinics, and healthcare accessibility stratified by differences in socioeconomic status 6 . Although efforts to expand asylum case processing capacity and grant a third national amnesty for asylum seekers in Belize have improved in recent years, the impact of legal status on health access in Belize is under-researched. Methods Objectives This study aims to qualitatively explore whether there are different patterns of access to care for undocumented individuals in Belize compared to Belizean nationals in two historically under-resourced districts of southern Belize. We aimed to identify differences in healthcare utilization, access, experiences, and other barriers to health access and care seeking. Study setting Belize is divided into six administrative districts. We focused on the Stann Creek and Toledo districts in Southern Belize due to the higher population of undocumented individuals and under-resourced settings of these two districts. In Southern Belize, public healthcare is typically accessed in a resource-tiered manner, ranging from village-based community health workers (CHWs) to regional referral hospitals. Patients can access care at any tier, but for most rural residents, this typically begins with community health workers or mobile outreach clinics in villages. Community health workers are typically residents of the rural village that they serve, work on a volunteer basis with a limited stipend for programming, and function as a liaison between residents of that village and the healthcare system. Responsibilities include conducting home visits, assisting with mobile outreach clinics, hosting community events, and provision of limited medical testing and care. Health educators supervise and provide ancillary support for all of the community health workers within that district. CHWs will refer individuals to government health clinics or polyclinics, if their needs exceed basic first aid. Mobile outreach clinics occur on a semi-regular basis (e.g. once every week a healthcare team from the regional hospital will visit a rural area). Mobile clinics typically offer limited medical services, vaccinations, maternal and pediatric care and also will refer to local clinics if additional services are needed. In turn, local clinics refer to the community hospital (Toledo district) or regional hospital (Stann Creek district) for emergencies or serious conditions that may require inpatient or specialist care. The regional referral hospital also serves as a community hospital for Dangriga Town and surrounding villages due to proximity. There are also private clinics available in the region but these costs are not subsidized by the Belizean government and patients are responsible for any fees incurred. Ambulance services are limited and typically only available from the hospital setting, so most patients need to charter transportation or navigate limited public transportation to access care outside of the village/town they reside in. For the purposes of this study, “undocumented” refers to individuals without a valid Belizean Social Security Identification (SSI), which is generally required to access healthcare, education, and other government services. In Bella Vista, the largest population center in Stann Creek, undocumented patients account for approximately 31.9% of clinic visits, while in Independence/Mango Creek, the district’s second largest population center, they represent about 17.2% of visits. Table 1 Percentage of total clinic visits within Stann Creek District by SSI. Of note, Bella Vista is geographically located in the Toledo District but is administratively and operationally included in Stann Creek-Independence Catchment. Data on the percentage of patients without SSI presenting to Toledo District clinics was not available. This table should appear at the end of the study setting section just prior to study design Stann Creek District Clinic Visits Jan - Sept 2024 Clinic Total Visits SSI No valid SSI Bella Vista 8,005 68.2% 31.8% Independence 12,247 84.8% 15.2% Study design The study was approved by the Baylor College of Medicine Institutional Review Board (IRB Protocol H-54879) and the Belize Ministry of Health and Wellness research committee. Study objectives were identified as areas of particular interest for the Belize Ministry of Health and Wellness, who provided ancillary staffing support for the study. Study methodology is reported below as per COREQ reporting guidelines for qualitative research. 7 Semi-structured qualitative interview questions were designed to explore participants’ knowledge of what health services are available to undocumented individuals, as well as barriers at the patient-provider, patient-facility, and patient-society levels. They also aimed to elucidate patterns of healthcare utilization, access, and barriers to care for undocumented populations. There was no predetermined order of questioning, and not all questions were asked to every participant. Interview questions were designed based on pilot studies exploring this topic as well as literature review of qualitative studies on health access for vulnerable populations in other contexts 8 – 12 . Interview questions are included in the supplemental material. All interviews were conducted in person by a single researcher between September to October 2024. Undocumented participants and Belizean nationals were recruited through respondent-driven sampling with the assistance of community health workers, health educators, and a local non-governmental organization, Humana People to People Belize (HPPBZ). HPPBZ empowers historically disenfranchised groups living in rural communities in Belize through capacity building and provides undocumented individuals with legal assistance, community programming, and additional resources. Interviews were conducted in participant homes, community centers and health posts located within rural villages, and public clinics located in larger villages and cities. Interviews with documented and undocumented individuals were arranged by a local community health worker who was present for the interview and provided language translation assistance if necessary. This recruitment approach allowed us to reach both individuals who were actively seeking formal medical care, as well as those who were unable to or wary of utilizing such services. Additionally, because undocumented individuals often lived in village outskirts, traveling to identified participant homes with trusted community leaders allowed us to reach this difficult to access population and engage in candid conversations regarding their lived experiences. Key informants, including administrative officials (Ministry of Health and Wellness officials and hospital administrators), healthcare providers (physicians and nurses), health educators, and community health workers were recruited through purposive snowball sampling. Community health workers and the villages they served were selected based on villages known to have a sizable population of undocumented individuals and health worker availability. Key informants were subsequently asked to recommend individuals within their professional networks who could speak to issues affecting undocumented patients. This combination of sampling approaches allowed us to identify a diverse array of perspectives at the patient, provider, and systems levels. Data collection 60 interviews were conducted in total. 14 community health workers, 3 health educators, 5 health providers, 2 hospital administrators, 19 undocumented and 15 documented individuals were interviewed across 14 rural villages and 2 towns in Southern Belize. An additional 2 interviews were conducted with public health officials at the Ministry of Health and Wellness in Belmopan. 56 participants were recruited in person during field visits to rural villages and health facilities. 4 key informants were recruited via Whatsapp and email for interview scheduling. All participants that were approached agreed to participate in the study. One interview with a health provider was conducted remotely via Zoom due to scheduling constraints. Interviews were conducted until thematic saturation was achieved, defined as the point at which no new insights were elicited during subsequent interviews. Due to the higher population of undocumented individuals in Stann Creek District and reportedly heightened disparities in health access, 36 interviews were conducted in Stann Creek District, while 22 were conducted in Toledo District. Locations where interviews were conducted are depicted in Fig. 1 . Data analysis Interviews were translated as applicable, audio recorded, transcribed with Otter.ai and manually verified for transcription accuracy against the original recordings. There were nine interviews in which the participant declined to be recorded, and instead notes were taken in real time by the interviewer. 18 (28.3%) interviews required translation assistance. Languages that required translation assistance included Spanish, Kek’chi Maya, Mopan Maya, and Garifuna. For interviews in which translation was required, only the interviewer questions and the translated participant responses were transcribed. Interview transcripts were deductively and inductively coded for thematic content analysis by three independent coders using Dedoose software (version 10.0.25; SocioCultural Research Consultants, Los Angeles, CA). We used a grounded theory approach to develop an initial codebook highlighting salient themes based on code frequency 13 . Relational analysis was then performed to identify relationships between identified themes and to ultimately derive a thematic framework illustrating the multitude of factors influencing patterns of healthcare access for undocumented individuals 11 . Results Table 2 . Participant characteristics. Key informants include doctors, nurses, hospital administrative officials, and Ministry of Health officials. Many participants spoke multiple languages as depicted in the above chart. The reason(s) for migration was applicable only to those who were born outside of Belize. This figure should appear at the beginning of results section. Participant Characteristics CHWs and Health Educators Key Informants Documented Undocumented Gender Male Female 1 (5.9%) 16 (94.1%) 5 (55.6%) 4 (44.4%) 2 (13.3%) 13 (86.7%) 3 (15.7%) 16 (84.2%) Country of origin Belize Guatemala Honduras El Salvador Other 16 (94.1%) 1 (5.9%) N/A N/A N/A 7 (77.8%) N/A N/A N/A 2 (22.2%) 11 (73.33%) 2 (13.33%) 1 (6.66%) 1 (6.66%) N/A 2 (10.5%) 12 (63%) 4 (21%) 1 (5%) N/A Ethnicity Creole Mestizo Maya Garifuna Other 1 (5.9%) 5 (29.4%) 10 (58.8%) 1 (5.9%) N/A 4 (44.4%) 4 (44.4%) N/A N/A 1 (11.1%) 2 (13%) 5 (33%) 8 (53%) N/A N/A N/A 10 (66.66%) 6 (40%) 3 (20%) N/A Languages spoken English Creole Spanish Mopan Mayan Kek’chi Mayan Mam Mayan Garifuna 16 (94.1%) 4 (23.5%) 7 (41.2%) 4 (23.5%) 9 (52.9%) N/A 1 (5.9%) 9 (100%) 5 (55.6%) 8 (88.9%) N/A N/A N/A N/A 13 (86.7%) 4 (26.7%) 6 (40%) 2 (13.3%) 5 (33.3%) 1 (6.7%) N/A 5 (26.3%) N/A 14 (73.7%) 1 (5.3%) 5 (26.3%) N/A 3 (15.8%) Reason for migration Political instability, gang violence Domestic violence Marriage Visiting family and friends Economic opportunity Childbirth in Belize N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 2 (50%) N/A N/A 1 (25%) 2 (50%) N/A 1 (5.9%) 2 (11.8%) 2 (11.8%) 10 (58.8%) 10 (58.8%) 1 (5.9%) District Stann Creek Toledo 8 (47.1%) 9 (52.9%) 6 (85.7%) 1 (14.3%) 9 (60%) 6 (40%) 13 (68.4%) 6 (31.6%) Interview duration (min) Mean Median 25 24 34 32 14 15 19 17 Table 3. Additional characteristics of undocumented participants. Reasons for ineligibility or rejection from the Amnesty program included statelessness, lack of birth registration in Belize or other country of origin, as provision of identification documents are required for the application. This figure should appear at the beginning of results section after Table 2. Additional Characteristics of Undocumented Participants Reason for undocumented status: Expired SSI Nationality in different country Eligible but can’t afford regularization fees Lack of birth registration (stateless) Legal documents left in home country 4 (22.2%) 7 (38.9%) 1 (5.3%) 4 (22.2%) 2 (11.1%) Amnesty program applicant Yes No Ineligible/Rejected 12 (66.7%) 3 (16.7%) 3 (16.7%) Motives for migration Reasons for migration to Belize among documented and undocumented participants were multifold. Overall, the most common reasons for migration were economic opportunity and visiting friends and family. Other cited motives included escaping political instability and gang violence, escaping domestic violence, marriage, and childbirth. Participants noted a longstanding history of both transient and permanent labor migration from neighboring Central American countries to agricultural regions of Southern Belize. This was particularly common in Stann Creek District, where large farms (i.e. banana farms) were known to provide economic migrants with temporary work permits and SSI attached to that specific employer. Though many returned to their home country after completion of their work contract, many aim to stay permanently in Belize due to better job opportunities compared to where they came from. The transient nature of the farm labor population was cited as a challenge for community health workers in developing trust and lasting relationships with the community. One health educator in Stann Creek District stated: “It's kind of challenging with that specific community, because the migration happens a lot, so there's always movement of people, so there are seasonal jobs, so you find an individual living in a specific home, and she's there for five months, and then she leaves, then another person would come, and that's how it goes. So to get the trust of those individuals is challenging, because it's like two community health workers in that specific community working with maybe 3,000 people every three, four months. So that's a challenge.” Although key informants alluded to a significant transient labor migrant population, all documented and undocumented participants who cited farm labor opportunities as a primary reason for migration in this study intended to stay in Belize long term. Reasons for undocumented status Reasons for undocumented legal status were multifold. Participants explained that many individuals initially entered Belize with a legal work permit tied to the farm employer. However, if they chose to leave that job, the work permit eventually expired or became invalid and the individual became undocumented. Some chose to work informal jobs for higher wages, which further reinforced their undocumented status. Others entered the country irregularly for such work and have since remained without a clear path to regularization. In addition to the above, several other factors contributed to individuals becoming undocumented. Some were nationals of other countries and could not afford the fees required for regularization in Belize despite being eligible. Others were effectively stateless, lacking key civil documents like birth certificates, which prevented them from obtaining a Social Security card or establishing legal identity in Belize. This was especially the case for those who were brought to Belize at a young age and had lived most of their lives there. A hospital administrator stated: “A lot of times people come in, want their social security card or want to work, and then they can't work because they don't have a social security card, and they can't get a social security card because they don't even have a birth certificate. So it's like, where are you from? Where is your identity? And that was a big problem because they could not get a birth certificate from where they came from. Some people didn’t even know where they were born and their parents passed, but they've been here since they were very young. Now they're in their 30s, 40s, and they've had children.” In some cases, individuals had left essential legal documents in their country of origin and faced financial or logistical constraints preventing their retrieval. Many participants described the registration process as complex and unclear, citing confusion over required documents and negative interactions with registration office staff. Language barriers further compounded these challenges, leaving many without a clear understanding of the legal processes required to obtain legal status. Barriers to health access Financial difficulties Although both documented and undocumented individuals cited financial constraints as a major barrier to accessing healthcare, undocumented individuals were particularly disadvantaged due to difficulties securing stable employment. Due to lack of documentation typically required for formal job positions, undocumented individuals were typically limited to informal work in sectors such as farming, construction, housekeeping, and other short-term work. This had significant downstream implications for their ability to afford transportation to clinics, medical services, and medications. Increased costs at public clinics In Stann Creek District specifically, participants noted significant discrepancies in healthcare costs between members and non-members. While all patients were required to pay a $2 clinic visit fee (this fee is waived for all patients in Toledo District), non-members faced substantially higher charges for laboratory tests and imaging. Although some participants reported that costs could be appealed informally through petitioning to clinic administrative officials, this was not viewed as a reliable or sustainable solution. Language barriers Language barriers were a common challenge for both documented and undocumented participants, particularly among Spanish and Mayan speakers. Difficulties in communication were most frequently reported during interactions with registration staff and, to a lesser extent, nurses. These challenges were especially pronounced in Dangriga, where fewer clinic staff spoke Spanish. An undocumented participant in Stann Creek stated: “Sometimes I go to the clinic, and since I only speak Spanish, and they are trying to explain something to me but in English and I do not understand, then they get mad because I do not understand.” A documented participant in Stann Creek stated: “Maybe just treat people who don't have papers with the same rights as a Belizean. All of us need to have the same rights. If they don't speak Spanish maybe they could try their best to understand them. Sometimes if it's an emergency and people need to be seen but they can't, because they don't have papers and they can't explain what is wrong.” These sentiments were corroborated by community health workers, who noted: “Undocumented individuals think that because they don't have a social security card, they can't even go to the emergency room. But that is not true. There's attention for everyone. What they don't understand also is, and I think because of the language barrier on either side, they get the impression that they won't get attention.” Notably, language was generally not a reported barrier when interacting with physicians, as many Belizean physicians underwent medical training in Spanish-speaking countries, and Belize recruits a significant number of foreign physicians from Cuba through the Cuban Medical Brigade. Marginalization by clinic staff Most reports of marginalization and discrimination arose during interactions with clinic registration staff, who were primarily English-speaking and responsible for entering patients into the electronic medical record system. Spanish and Mayan speaking participants in particular reported substantial communication barriers during this process. Additionally, undocumented individuals often expressed discomfort with what they perceived as extended questioning about their documentation status and inferior treatment during the registration process. One community health worker in Stann Creek District stated: “I have heard some complaints that sometimes they go and clinic staff don't want to attend to them because they don't speak English and they don't have any documents to identify them. Sometimes they just put these patients on the side, and I feel bad because I refer them there, but I cannot do as much as I want to.” Another remarked: “Some undocumented people refuse to go to the hospital because the data entry personnel don't understand Spanish. And sometimes they are afraid to go because they never know how they will be treated because they don't have papers.” While discriminatory treatment by physicians was rarely reported, some participants described negative interactions with nurses, particularly toward Spanish-speaking patients. Healthcare workers who were interviewed, however, uniformly denied any differential treatment based on documentation status. They did generally acknowledge, however, a longstanding history of discrimination against Mestizo individuals, particularly those of Guatemalan descent. Reluctance to use public clinics due to questioning about documentation status Many undocumented individuals were reluctant to be seen at public clinics due to what they perceived as prolonged questioning regarding their documentation status during prior visits. At the administrative level however, participants cited that the purpose of this questioning was to solicit any legal identification document (regardless of whether these documents were from Belize or not) in order for the patient’s demographic information to be registered accurately into the Belize Health Information System (BHIS), which is the electronic medical record system for all public health facilities in Belize. As one administrative official stated: “So everyone who accesses the health system needs to be registered through the BHIS. It doesn't matter where you're from. They usually ask for a valid ID, because they want to make sure that whatever data is in the BHIS is correct. If you're saying that this is your first time accessing BHIS in this particular health system, but maybe you previously went to a clinic in Belize City and you were already entered into the BHIS. When you come and access the health system here, if you don't have a valid social security card, they will open a new encounter.” They cited instances of misspelled names, birthdates, and other demographic information that resulted in the creation of duplicate patient charts and inability for healthcare providers to access prior visit records when legal identification was not provided. Fear of deportation Multiple undocumented participants stated that they were fearful of seeking care at public facilities due to fear of deportation, although administrative officials, health workers, and public health workers all affirmed that this was not common practice. One health educator in Toledo District stated: “And as much as we try to encourage them to come to the hospital, we'll facilitate them with whatever they need, but they still refuse because of their immigration status. So we explained to them that your immigration status has nothing to do with the Ministry of Health, and we will help you. And still, they don’t go.” Rejected from public clinics due to undocumented status Although most undocumented participants were ultimately able to be seen by a physician when presenting to public clinics, there were occasional reports of participants without valid SSI being turned away in Stann Creek in particular. Notably, some documented participants also recounted witnessing denial of care to undocumented individuals due to lack of documentation. One documented participant in Stann Creek District noted: “The last time I went to the clinic I saw a woman who was trying to be seen because she was having pain in her armpit and she wasn’t seen because she didn’t have papers. They told her to come back next week or go to a private clinic. Just because she didn’t have papers.” These experiences likely reinforced misinformation surrounding healthcare access in the district, particularly among undocumented individuals who had recently migrated to Belize. A few undocumented participants expressed the belief that they were not entitled to the same level of access to health services as nationals. When asked about access to health services, one undocumented individual in Stann Creek stated: “I don’t feel like I have access like that because I have no social security. I can only go to private clinics.” Preference for private and NGO clinics A strong preference for private and NGO clinics was expressed by undocumented participants compared to documented participants. Undocumented individuals often preferred to wait for NGO clinics to visit their area due to transportation difficulties and fear of seeking care at public facilities. Private clinics were also preferred by undocumented participants for their perceived better treatment, shorter wait times, fewer documentation requirements, and more reliable medication availability. While private clinics were more expensive, some participants reported saving money specifically to access these services. As a community health worker in Toledo District stated: “I have seen that a lot of undocumented people will prefer to be seen at a private clinic, because there are fewer questions about their documentation status and better treatment and things like that, as long as they can pay. Even though the income they receive is very low, they prefer to sacrifice and pay a private doctor because the treatment would be better, and their legal status is not important at all.” Preference for self-medication and traditional medicine Individuals who did not seek formal medical care often relied on alternative strategies, including self-medication, the use of “bush medicine” (traditional herbal remedies), and consultation with traditional healers. This pattern was particularly pronounced among undocumented individuals, who reported higher rates of self-medication. A common practice involved purchasing medications from cobaneros, who are unlicensed vendors selling pharmaceuticals illegally, often traveling between rural communities on bicycles. These transactions typically occur without prescriptions or formal medical guidance. Limitations This study had several limitations. Firstly, home visits for interviews were conducted during weekday working hours, which resulted in an overrepresentation of women, who typically were homemakers, and subsequent underrepresentation of men who were typically not at home during these hours. Additionally, not all individuals selected for interviews were available at the time of home visits, introducing potential sampling bias. Although the number of individuals utilizing Belize as a transit country is unknown, this study did not include any undocumented transient migrants whose end destination was outside of Belize. These individuals may experience health barriers distinct from those of migrants intending to settle in Belize. Additionally, because undocumented individuals were identified by community health workers, we could not capture the perspectives of those who are not known to community leaders. Such individuals are less likely to be integrated with the local community and may experience even greater barriers to healthcare access. Third, remote villages inaccessible by road, such as Machakil Ha and Graham Creek, were not included. These communities likely have increased difficulties accessing healthcare due to transportation constraints and geographic isolation. Finally, although unfair treatment by registration staff was a prominent theme in these interviews, no registration staff were interviewed. Understanding their perspectives is likely essential for designing targeted interventions to improve undocumented patient experiences within public healthcare facilities. Conclusions Ultimately, undocumented individuals in Belize face a multitude of interconnected barriers to accessing healthcare, many of which stem from the lack of SSI. These findings are depicted in a thematic flowchart in Fig. 2 . Lack of SSI often results from expired work permits, being a national of another country, inability to afford regularization despite eligibility, lack of birth registration (rendering individuals effectively stateless), or the inability to retrieve legal documents left in their country of origin. Without SSI, individuals are ineligible for formal employment, leading to financial hardship that limits their ability to afford and access necessary health services. While some obstacles to care, such as long wait times, staffing and medication shortages, high transportation costs, and language barriers, were reported across all participants regardless of documentation status, these challenges were exacerbated for undocumented individuals. In particular, language barriers for undocumented Spanish and Mayan speakers contributed to misinformation about healthcare access and experiences of marginalization by clinic staff. These issues were especially pronounced in Stann Creek District, where fewer healthcare workers speak Spanish. Furthermore, there were occasional reports of undocumented patients being denied services in Stann Creek, although this was uncommon. Additionally, fear of deportation further discouraged undocumented individuals from seeking care at public health facilities. This was further compounded by increased costs for undocumented individuals at public clinics in Stann Creek. As a result, there was a general reluctance to seek care at public clinics and resultant preference for private facilities and NGO-provided care, which typically have more lenient documentation requirements. Those who did not seek formal medical care relied on self medication and traditional healers. Community health workers played an essential role in both districts as facilitators who bridge the gap between patients and the healthcare system. These patterns reflect a complex web of systemic and structural barriers that disproportionately affect undocumented populations, particularly in Stann Creek. Ultimately, understanding how undocumented individuals in Belize access health services is essential not only to improve their health outcomes but also to more accurately assess drivers of healthcare utilization and associated costs in Belize, particularly in the setting of public healthcare being made free. Results of this study will allow for more deliberate considerations and effective resource allocation to ensure that undocumented populations are included in national healthcare improvement plans. These findings are similar to other qualitative studies exploring barriers to healthcare access for undocumented populations in other countries. 9 – 12 Abbreviations BHIS Belize Health Information System CHW community health workers COREQ Consolidated criteria for reporting qualitative research HPPBZ Humana People to People Belize MIRPS Marco Integral Regional para la Protección y Soluciones NGO non-governmental organization SSI social security identification WHO World Health Organization Declarations Ethics approval and consent to participate : The study was approved by the Baylor College of Medicine Institutional Review Board (IRB Protocol H-54879) and the Belize Ministry of Health and Wellness research committee. The need for written signed consent was waived as per the above IRB protocol. Participants verbally consented to participation in the study. Consent for publication : Not applicable Availability of data and materials : The datasets generated and/or analysed during the current study are not publicly available due to concern for participant confidentiality. The dataset contains information that can be traced back to the original participant. Data is available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests Funding : N/A Authors' contributions : RY designed the research study, collected data, transcribed and coded interview transcripts, and was the primary writer of the manuscript. GO provided on the ground logistical support regarding data collection, study design and data analysis. CW coded interview transcripts and assisted with data analysis. HM contributed to study design and data analysis. JM supervised the research study, coded interview transcripts and assisted with data analysis, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript. Acknowledgements : Melissa Diaz-Musa Authors' information (optional) : N/A References World Health Organization. Action on social determinants of health equity [Internet]. Geneva: World Health Organization; [cited 2022 Apr 17]. Available from: https://www.who.int/initiatives/action-on-the-social-determinants-of-health-for-advancing-equity Phillips DE, AbouZahr C, Lopez AD, Mikkelsen L, de Savigny D, Lozano R, et al. Are well functioning civil registration and vital statistics systems associated with better health outcomes? Lancet. 2015;386(10001):1386–94. 10.1016/S0140-6736(15)60172-6 . Comprehensive Regional Protection and Solutions Framework (MIRPS). Explainers 2022 [Internet]. [place unknown]: MIRPS; 2022 Oct [cited 2025 Aug 31]. Available from: https://mirps-platform.org/wp-content/uploads/2022/10/Explainers-2022-merged.pdf International Organization for Migration (IOM). Mechanisms for accessing legal identity for migrants in Belize [Internet]. San José (CR): IOM; 2023 [cited 2025 Aug 31]. Available from: https://programamesocaribe.iom.int/sites/default/files/il_belize_final.pdf Government of Belize. Government of Belize removes fees in public hospitals, promoting universal healthcare access [Internet]. Belmopan, Belize: Government of Belize. 2023 Oct 31 [cited 2025 Aug 31]. Available from: https://www.pressoffice.gov.bz/wp-content/uploads/2023/10/Oct-31-PR237-23-Government-of-Belize-Removes-Fees-in-Public-Hospitals-Promoting-Universal-Healthcare-Access.pdf Allen LP, Ellis L, Engleton C, Valerio VL, Hatala AR. Voices of those living with type 2 diabetes in Belize: barriers to care before and during the COVID-19 pandemic. Int J Equity Health. 2023;22(1):163. 10.1186/s12939-023-01987-3 . Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10463824/ Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. 10.1093/intqhc/mzm042 . Available from: https://academic.oup.com/intqhc/article/19/6/349/1791966 González-Rábago Y, Sánchez-Montalvá A, García-Basteiro AL et al. Perspectives on Spain's legislative experience providing access to healthcare for migrants: a qualitative study. BMJ Open. 2021;11(8):e050204. 10.1136/bmjopen-2021-050204 . Available from: https://bmjopen.bmj.com/content/11/8/e050204 Higginbottom GMA, Evans C, Morgan M, Bharj KK, Eldridge J, Hussain B. Interventions that improve maternity care for immigrant women in England: a narrative synthesis systematic review. Health Serv Deliv Res. 2020;8(14):1–152. 10.3310/hsdr08140 . Available from: https://www.journalslibrary.nihr.ac.uk/hsdr/hsdr08140 El Arab RA, Urbanavice R, Jakavonyte-Akstiniene A, Skvarcevskaja M, Austys D, Briones-Vozmediano E, Rubinat-Arnaldo E, Istomina N. We want our freedom back, that’s our only need: a qualitative study of health and social needs among asylum seekers and undocumented migrants crossing the borders from Belarus to Lithuania. Front Public Health. 2024;12:1371119. 10.3389/fpubh.2024.1371119 . Available from: https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2024.1371119/full Funge JK, Boye MC, Johnsen H, Nørredam M. No Papers. No Doctor: A qualitative study of access to maternity care services for undocumented immigrant women in Denmark. Int J Environ Res Public Health. 2020;17(18):6503. 10.3390/ijerph17186503 . Available from: https://www.mdpi.com/1660-4601/17/18/6503 McGibbon E, McPherson C, McKinnon S et al. Barriers to maternal healthcare for undocumented immigrants: a scoping review. BMC Pregnancy Childbirth. 2021;21(1):1–11. 10.1186/s12884-021-03842-1 . Available from: https://link.springer.com/article/10.1186/s12884-021-03842-1 Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88. 10.1177/1049732305276687 . Available from: https://journals.sagepub.com/doi/10.1177/1049732305276687 Robinson O. Relational Analysis: An Add-On Technique for Aiding Data Integration in Qualitative Research. Int J Qual Health Care. 2011;23(6):349–57. 10.1080/14780887.2011.572745 . Available from: https://www.tandfonline.com/doi/abs/10.1080/14780887.2011.572745 Additional Declarations No competing interests reported. Supplementary Files BelizeManuscriptSupplementaryMaterial.docx Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted Editorial decision: Revision requested 01 Oct, 2025 Reviews received at journal 30 Sep, 2025 Reviews received at journal 30 Sep, 2025 Reviews received at journal 26 Sep, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 05 Sep, 2025 Reviewers invited by journal 05 Sep, 2025 Editor assigned by journal 05 Sep, 2025 Submission checks completed at journal 03 Sep, 2025 First submitted to journal 31 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7502686","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":513252598,"identity":"b9d317df-505d-48c3-aca1-e919a8953de0","order_by":0,"name":"Rebecca Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYBAC+wYeJN7HBjBlgFeLwQEkLYwzSdbCzEuUluO9Bx/8qLEDMs4efm27wy6agb15mwQ+LfY955INe44lMxicyUuzzj2TnNvAc6wMrxY7iRwzacYGZqALc8yMc9sO5DYARfBqMZZ/Y/6bsaGeweD8GzNjS5AW+Tf4tRjO4DFjZmw4zGBwI8f4MSPYFh78WoBeSJbsOXacR/LGGzPGXqBf2njSii3wajl+9uCHHzXVcnznc4w//Nxhl9vPfnjjDXxaYIBH4QADG9g9bMQoBwP5BgbmD0SrHgWjYBSMghEFAMV4TQZJzL22AAAAAElFTkSuQmCC","orcid":"","institution":"Baylor College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Rebecca","middleName":"","lastName":"Yang","suffix":""},{"id":513252599,"identity":"26cfd41d-c674-44bd-9309-c238826d529e","order_by":1,"name":"Gino Orellana","email":"","orcid":"","institution":"Southern Regional Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gino","middleName":"","lastName":"Orellana","suffix":""},{"id":513252600,"identity":"fd1b595b-8b2d-4f22-9a83-536191d2b000","order_by":2,"name":"Curtis Wentz","email":"","orcid":"","institution":"Baylor College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Curtis","middleName":"","lastName":"Wentz","suffix":""},{"id":513252601,"identity":"b19be9ef-9df1-41d5-a6d2-7cbe4293c6c0","order_by":3,"name":"Heba Mesbah","email":"","orcid":"","institution":"Baylor College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Heba","middleName":"","lastName":"Mesbah","suffix":""},{"id":513252602,"identity":"4464f6cc-5ebe-4aa4-944f-bc0a3dfe93e4","order_by":4,"name":"Joy M. Mackey","email":"","orcid":"","institution":"Baylor College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Joy","middleName":"M.","lastName":"Mackey","suffix":""}],"badges":[],"createdAt":"2025-08-31 20:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7502686/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7502686/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12939-025-02741-7","type":"published","date":"2026-02-12T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91194322,"identity":"d789c55f-6c2f-41e0-bcdf-1119d02027bf","added_by":"auto","created_at":"2025-09-12 14:51:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":180345,"visible":true,"origin":"","legend":"\u003cp\u003eLocations where interviews were conducted. Red denotes villages in Toledo District, while blue denotes villages in Stann Creek District. Orange denotes the Belize Ministry of Health and Wellness where interviews with administrative officials were conducted. \u003cstrong\u003eThis table should appear at the end of the study design section just prior to data analysis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7502686/v1/791fd17a5635b6d58719ac96.png"},{"id":91192927,"identity":"8378623e-0ea2-4f42-bab6-ab59af1a2dbd","added_by":"auto","created_at":"2025-09-12 14:43:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":182841,"visible":true,"origin":"","legend":"\u003cp\u003eThematic flowchart depicting factors influencing access to care for undocumented individuals in Belize. \u003cstrong\u003eThis figure should appear at beginning of conclusions section.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7502686/v1/3725f25c95134130a108576c.png"},{"id":102531604,"identity":"1c92c974-ef81-4daf-9541-d81f361b4b3b","added_by":"auto","created_at":"2026-02-12 16:28:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1610619,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7502686/v1/8f17c725-26e9-4f17-9dd6-83a14bd01089.pdf"},{"id":91190479,"identity":"a64663e5-fc0d-4802-a22f-1dabeef9b2e0","added_by":"auto","created_at":"2025-09-12 14:35:35","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":21463,"visible":true,"origin":"","legend":"","description":"","filename":"BelizeManuscriptSupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7502686/v1/f84c207dd3b5c3e88264bf87.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perceptions of and barriers to equitable healthcare access for undocumented populations in Belize: a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe World Health Organization (WHO) global initiative for Action on Social Determinants of Health Equity recommends actions for ensuring that health equity is integrated into the development of social and economic policies to improve social determinants of health for disadvantaged populations\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. A prerequisite to this, however, is the documentation and identification requirements to access many essential services, such as healthcare, education, and employment. These requirements include but are not limited to social security identification, birth registration, and passports.\u003c/p\u003e\u003cp\u003ePilot studies exploring the experiences of undocumented individuals accessing healthcare in multiple regions have identified significant health access barriers. At the patient-provider level, experiences of discrimination, stigmatization, and fear of deportation serve as significant deterrents to seeking health services. At the patient-facility level, drug shortages, understaffing, and long wait times were additional deterrents to care. At the systems level, non-nationals were often unable to access health services in the manner available to nationals, whether due to health services being offered to nationals only or being unable to purchase health insurance without proper identification documents. Furthermore, there were oftentimes discrepancies between knowledge and perception of available health services for undocumented individuals versus what services were available. Although there were sometimes informal mechanisms for accessing health services without legal identification and legal mechanisms for appealing health costs individually, these were not long-term solutions. Given this context, understanding how undocumented individuals access health services is essential not only to improve their health outcomes but also to assess systems-level drivers of healthcare utilization and associated costs. Existing literature in multiple regions already shows that upstream investments in civil registration and vitals statistics systems provide essential information for implementing focused public health policies that are ultimately more cost-effective long term despite potentially lacking obvious, immediate outcomes\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAs for the Belize context, according to the \u003cem\u003eMarco Integral Regional para la Protección y Soluciones\u003c/em\u003e (MIRPS), a Central America regional cooperation framework between countries of origin, transit, and destination, Belize is primarily a country of destination for migrants transiting through Central America\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In 2022, the Amnesty Program was implemented as a nationwide initiative to regularize an estimated 40,000 undocumented people living in Belize; however, by March 2023, only 13,540 applications had been received\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Notably, stateless individuals were largely excluded from this initiative, as they cannot provide any form of legal identification required for regularization in Belize. In addition, the lengthy application process meant that many are in various stages of the approval process and may continue to have difficulty accessing health services. Furthermore, in October 2023, the Belize government removed medical fees in public hospitals to increase accessibility for all inhabitants, regardless of legal status\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Prior qualitative studies on health access in Belize have also alluded to a tiered health system with gaps in coverage even for nationals, more difficult access in areas without public clinics, and healthcare accessibility stratified by differences in socioeconomic status\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Although efforts to expand asylum case processing capacity and grant a third national amnesty for asylum seekers in Belize have improved in recent years, the impact of legal status on health access in Belize is under-researched.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eObjectives\u003c/p\u003e\u003cp\u003eThis study aims to qualitatively explore whether there are different patterns of access to care for undocumented individuals in Belize compared to Belizean nationals in two historically under-resourced districts of southern Belize. We aimed to identify differences in healthcare utilization, access, experiences, and other barriers to health access and care seeking.\u003c/p\u003e\u003ch3\u003eStudy setting\u003c/h3\u003e\u003cp\u003eBelize is divided into six administrative districts. We focused on the Stann Creek and Toledo districts in Southern Belize due to the higher population of undocumented individuals and under-resourced settings of these two districts. In Southern Belize, public healthcare is typically accessed in a resource-tiered manner, ranging from village-based community health workers (CHWs) to regional referral hospitals. Patients can access care at any tier, but for most rural residents, this typically begins with community health workers or mobile outreach clinics in villages.\u003c/p\u003e\u003cp\u003eCommunity health workers are typically residents of the rural village that they serve, work on a volunteer basis with a limited stipend for programming, and function as a liaison between residents of that village and the healthcare system. Responsibilities include conducting home visits, assisting with mobile outreach clinics, hosting community events, and provision of limited medical testing and care. Health educators supervise and provide ancillary support for all of the community health workers within that district. CHWs will refer individuals to government health clinics or polyclinics, if their needs exceed basic first aid. Mobile outreach clinics occur on a semi-regular basis (e.g. once every week a healthcare team from the regional hospital will visit a rural area). Mobile clinics typically offer limited medical services, vaccinations, maternal and pediatric care and also will refer to local clinics if additional services are needed. In turn, local clinics refer to the community hospital (Toledo district) or regional hospital (Stann Creek district) for emergencies or serious conditions that may require inpatient or specialist care. The regional referral hospital also serves as a community hospital for Dangriga Town and surrounding villages due to proximity. There are also private clinics available in the region but these costs are not subsidized by the Belizean government and patients are responsible for any fees incurred. Ambulance services are limited and typically only available from the hospital setting, so most patients need to charter transportation or navigate limited public transportation to access care outside of the village/town they reside in.\u003c/p\u003e\u003cp\u003eFor the purposes of this study, “undocumented” refers to individuals without a valid Belizean Social Security Identification (SSI), which is generally required to access healthcare, education, and other government services. In Bella Vista, the largest population center in Stann Creek, undocumented patients account for approximately 31.9% of clinic visits, while in Independence/Mango Creek, the district’s second largest population center, they represent about 17.2% of visits.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePercentage of total clinic visits within Stann Creek District by SSI. Of note, Bella Vista is geographically located in the Toledo District but is administratively and operationally included in Stann Creek-Independence Catchment. Data on the percentage of patients without SSI presenting to Toledo District clinics was not available. \u003cb\u003eThis table should appear at the end of the study setting section just prior to study design\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eStann Creek District Clinic Visits Jan - Sept 2024\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal Visits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSSI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo valid SSI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBella Vista\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8,005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndependence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12,247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e84.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003e The study was approved by the Baylor College of Medicine Institutional Review Board (IRB Protocol H-54879) and the Belize Ministry of Health and Wellness research committee. Study objectives were identified as areas of particular interest for the Belize Ministry of Health and Wellness, who provided ancillary staffing support for the study. Study methodology is reported below as per COREQ reporting guidelines for qualitative research.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eSemi-structured qualitative interview questions were designed to explore participants’ knowledge of what health services are available to undocumented individuals, as well as barriers at the patient-provider, patient-facility, and patient-society levels. They also aimed to elucidate patterns of healthcare utilization, access, and barriers to care for undocumented populations. There was no predetermined order of questioning, and not all questions were asked to every participant. Interview questions were designed based on pilot studies exploring this topic as well as literature review of qualitative studies on health access for vulnerable populations in other contexts\u003csup\u003e\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Interview questions are included in the supplemental material. All interviews were conducted in person by a single researcher between September to October 2024.\u003c/p\u003e\u003cp\u003eUndocumented participants and Belizean nationals were recruited through respondent-driven sampling with the assistance of community health workers, health educators, and a local non-governmental organization, Humana People to People Belize (HPPBZ). HPPBZ empowers historically disenfranchised groups living in rural communities in Belize through capacity building and provides undocumented individuals with legal assistance, community programming, and additional resources. Interviews were conducted in participant homes, community centers and health posts located within rural villages, and public clinics located in larger villages and cities. Interviews with documented and undocumented individuals were arranged by a local community health worker who was present for the interview and provided language translation assistance if necessary. This recruitment approach allowed us to reach both individuals who were actively seeking formal medical care, as well as those who were unable to or wary of utilizing such services. Additionally, because undocumented individuals often lived in village outskirts, traveling to identified participant homes with trusted community leaders allowed us to reach this difficult to access population and engage in candid conversations regarding their lived experiences.\u003c/p\u003e\u003cp\u003eKey informants, including administrative officials (Ministry of Health and Wellness officials and hospital administrators), healthcare providers (physicians and nurses), health educators, and community health workers were recruited through purposive snowball sampling. Community health workers and the villages they served were selected based on villages known to have a sizable population of undocumented individuals and health worker availability. Key informants were subsequently asked to recommend individuals within their professional networks who could speak to issues affecting undocumented patients. This combination of sampling approaches allowed us to identify a diverse array of perspectives at the patient, provider, and systems levels.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003e60 interviews were conducted in total. 14 community health workers, 3 health educators, 5 health providers, 2 hospital administrators, 19 undocumented and 15 documented individuals were interviewed across 14 rural villages and 2 towns in Southern Belize. An additional 2 interviews were conducted with public health officials at the Ministry of Health and Wellness in Belmopan. 56 participants were recruited in person during field visits to rural villages and health facilities. 4 key informants were recruited via Whatsapp and email for interview scheduling. All participants that were approached agreed to participate in the study. One interview with a health provider was conducted remotely via Zoom due to scheduling constraints. Interviews were conducted until thematic saturation was achieved, defined as the point at which no new insights were elicited during subsequent interviews. Due to the higher population of undocumented individuals in Stann Creek District and reportedly heightened disparities in health access, 36 interviews were conducted in Stann Creek District, while 22 were conducted in Toledo District. Locations where interviews were conducted are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003e Interviews were translated as applicable, audio recorded, transcribed with Otter.ai and manually verified for transcription accuracy against the original recordings. There were nine interviews in which the participant declined to be recorded, and instead notes were taken in real time by the interviewer. 18 (28.3%) interviews required translation assistance. Languages that required translation assistance included Spanish, Kek’chi Maya, Mopan Maya, and Garifuna. For interviews in which translation was required, only the interviewer questions and the translated participant responses were transcribed.\u003c/p\u003e\u003cp\u003eInterview transcripts were deductively and inductively coded for thematic content analysis by three independent coders using Dedoose software (version 10.0.25; SocioCultural Research Consultants, Los Angeles, CA). We used a grounded theory approach to develop an initial codebook highlighting salient themes based on code frequency\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Relational analysis was then performed to identify relationships between identified themes and to ultimately derive a thematic framework illustrating the multitude of factors influencing patterns of healthcare access for undocumented individuals\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Participant characteristics. Key informants include doctors, nurses, hospital administrative officials, and Ministry of Health officials. Many participants spoke multiple languages as depicted in the above chart. The reason(s) for migration was applicable only to those who were born outside of Belize. \u003cstrong\u003eThis figure should appear at the beginning of results section.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"667\" style=\"margin-right: calc(3%); width: 97%;\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 667px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19.3403%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHWs and Health Educators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey Informants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDocumented\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.8921%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUndocumented\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19.3403%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003cp\u003e16 (94.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e5 (55.6%)\u003c/p\u003e\n \u003cp\u003e4 (44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003cp\u003e13 (86.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.8921%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e3 (15.7%)\u003c/p\u003e\n \u003cp\u003e16 (84.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry of origin\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBelize\u003c/p\u003e\n \u003cp\u003eGuatemala\u003c/p\u003e\n \u003cp\u003eHonduras\u003c/p\u003e\n \u003cp\u003eEl Salvador\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19.3403%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e16 (94.1%)\u003c/p\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e7 (77.8%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003e2 (22.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e11 (73.33%)\u003c/p\u003e\n \u003cp\u003e2 (13.33%)\u003c/p\u003e\n \u003cp\u003e1 (6.66%)\u003c/p\u003e\n \u003cp\u003e1 (6.66%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.8921%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2 (10.5%)\u003c/p\u003e\n \u003cp\u003e12 (63%)\u003c/p\u003e\n \u003cp\u003e4 (21%)\u003c/p\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCreole\u003c/p\u003e\n \u003cp\u003eMestizo\u003c/p\u003e\n \u003cp\u003eMaya\u003c/p\u003e\n \u003cp\u003eGarifuna\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19.3403%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003cp\u003e5 (29.4%)\u003c/p\u003e\n \u003cp\u003e10 (58.8%)\u003c/p\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e4 (44.4%)\u003c/p\u003e\n \u003cp\u003e4 (44.4%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003e1 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2 (13%)\u003c/p\u003e\n \u003cp\u003e5 (33%)\u003c/p\u003e\n \u003cp\u003e8 (53%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.8921%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003e10 (66.66%)\u003c/p\u003e\n \u003cp\u003e6 (40%)\u003c/p\u003e\n \u003cp\u003e3 (20%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLanguages spoken\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003cp\u003eCreole\u003c/p\u003e\n \u003cp\u003eSpanish\u003c/p\u003e\n \u003cp\u003eMopan Mayan\u003c/p\u003e\n \u003cp\u003eKek\u0026rsquo;chi Mayan\u003c/p\u003e\n \u003cp\u003eMam Mayan\u003c/p\u003e\n \u003cp\u003eGarifuna\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19.3403%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e16 (94.1%)\u003c/p\u003e\n \u003cp\u003e4 (23.5%)\u003c/p\u003e\n \u003cp\u003e7 (41.2%)\u003c/p\u003e\n \u003cp\u003e4 (23.5%)\u003c/p\u003e\n \u003cp\u003e9 (52.9%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e9 (100%)\u003c/p\u003e\n \u003cp\u003e5 (55.6%)\u003c/p\u003e\n \u003cp\u003e8 (88.9%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e13 (86.7%)\u003c/p\u003e\n \u003cp\u003e4 (26.7%)\u003c/p\u003e\n \u003cp\u003e6 (40%)\u003c/p\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003cp\u003e5 (33.3%)\u003c/p\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.8921%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e5 (26.3%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003e14 (73.7%)\u003c/p\u003e\n \u003cp\u003e1 (5.3%)\u003c/p\u003e\n \u003cp\u003e5 (26.3%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003e3 (15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReason for migration\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePolitical instability, gang violence\u003c/p\u003e\n \u003cp\u003eDomestic violence\u003c/p\u003e\n \u003cp\u003eMarriage\u003c/p\u003e\n \u003cp\u003eVisiting family and friends\u003c/p\u003e\n \u003cp\u003eEconomic opportunity\u003c/p\u003e\n \u003cp\u003eChildbirth in Belize\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19.3403%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2 (50%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003e1 (25%)\u003c/p\u003e\n \u003cp\u003e2 (50%)\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.8921%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003cp\u003e10 (58.8%)\u003c/p\u003e\n \u003cp\u003e10 (58.8%)\u003c/p\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistrict\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eStann Creek\u003c/p\u003e\n \u003cp\u003eToledo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19.3403%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e8 (47.1%)\u003c/p\u003e\n \u003cp\u003e9 (52.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e6 (85.7%)\u003c/p\u003e\n \u003cp\u003e1 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e9 (60%)\u003c/p\u003e\n \u003cp\u003e6 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.8921%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e13 (68.4%)\u003c/p\u003e\n \u003cp\u003e6 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview duration (min)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19.3403%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.8921%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eAdditional characteristics of undocumented participants. Reasons for ineligibility or rejection from the Amnesty program included statelessness, lack of birth registration in Belize or other country of origin, as provision of identification documents are required for the application.\u0026nbsp;\u003cstrong\u003eThis figure should appear at the beginning of results section after Table 2.\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"499\" style=\"margin-right: calc(18%); width: 82%;\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 499px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdditional Characteristics of Undocumented Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66.8301%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReason for undocumented status:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eExpired SSI\u003c/p\u003e\n \u003cp\u003eNationality in different country\u003c/p\u003e\n \u003cp\u003eEligible but can\u0026rsquo;t afford regularization fees\u003c/p\u003e\n \u003cp\u003eLack of birth registration (stateless)\u003c/p\u003e\n \u003cp\u003eLegal documents left in home country\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33.0065%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (22.2%)\u003c/p\u003e\n \u003cp\u003e7 (38.9%)\u003c/p\u003e\n \u003cp\u003e1 (5.3%)\u003c/p\u003e\n \u003cp\u003e4 (22.2%)\u003c/p\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66.8301%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmnesty program applicant\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eIneligible/Rejected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33.0065%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e12 (66.7%)\u003c/p\u003e\n \u003cp\u003e3 (16.7%)\u003c/p\u003e\n \u003cp\u003e3 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch4\u003eMotives for migration\u003c/h4\u003e\n\u003cp\u003eReasons for migration to Belize among documented and undocumented participants were multifold. Overall, the most common reasons for migration were economic opportunity and visiting friends and family. Other cited motives included escaping political instability and gang violence, escaping domestic violence, marriage, and childbirth.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants noted a longstanding history of both transient and permanent labor migration from neighboring Central American countries to agricultural regions of Southern Belize. This was particularly common in Stann Creek District, where large farms (i.e. banana farms) were known to provide economic migrants with temporary work permits and SSI attached to that specific employer. Though many returned to their home country after completion of their work contract, many aim to stay permanently in Belize due to better job opportunities compared to where they came from. The transient nature of the farm labor population was cited as a challenge for community health workers in developing trust and lasting relationships with the community.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne health educator in Stann Creek District stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026apos;s kind of challenging with that specific community, because the migration happens a lot, so there\u0026apos;s always movement of people, so there are seasonal jobs, so you find an individual living in a specific home, and she\u0026apos;s there for five months, and then she leaves, then another person would come, and that\u0026apos;s how it goes. So to get the trust of those individuals is challenging, because it\u0026apos;s like two community health workers in that specific community working with maybe 3,000 people every three, four months. So that\u0026apos;s a challenge.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlthough key informants alluded to a significant transient labor migrant population, all documented and undocumented participants who cited farm labor opportunities as a primary reason for migration in this study intended to stay in Belize long term.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eReasons for undocumented status\u003c/h4\u003e\n\u003cp\u003eReasons for undocumented legal status were multifold. Participants explained that many individuals initially entered Belize with a legal work permit tied to the farm employer. However, if they chose to leave that job, the work permit eventually expired or became invalid and the individual became undocumented. Some chose to work informal jobs for higher wages, which further reinforced their undocumented status. Others entered the country irregularly for such work and have since remained without a clear path to regularization.\u003c/p\u003e\n\u003cp\u003eIn addition to the above, several other factors contributed to individuals becoming undocumented. Some were nationals of other countries and could not afford the fees required for regularization in Belize despite being eligible. Others were effectively stateless, lacking key civil documents like birth certificates, which prevented them from obtaining a Social Security card or establishing legal identity in Belize. This was especially the case for those who were brought to Belize at a young age and had lived most of their lives there.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA hospital administrator stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of times people come in, want their social security card or want to work, and then they can\u0026apos;t work because they don\u0026apos;t have a social security card, and they can\u0026apos;t get a social security card because they don\u0026apos;t even have a birth certificate. So it\u0026apos;s like, where are you from? Where is your identity? And that was a big problem because they could not get a birth certificate from where they came from. Some people didn\u0026rsquo;t even know where they were born and their parents passed, but they\u0026apos;ve been here since they were very young. Now they\u0026apos;re in their 30s, 40s, and they\u0026apos;ve had children.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn some cases, individuals had left essential legal documents in their country of origin and faced financial or logistical constraints preventing their retrieval. Many participants described the registration process as complex and unclear, citing confusion over required documents and negative interactions with registration office staff.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eLanguage barriers further compounded these challenges, leaving many without a clear understanding of the legal processes required to obtain legal status.\u003c/p\u003e\n\u003ch4\u003eBarriers to health access\u003c/h4\u003e\n\u003ch5\u003eFinancial difficulties\u003c/h5\u003e\n\u003cp\u003eAlthough both documented and undocumented individuals cited financial constraints as a major barrier to accessing healthcare, undocumented individuals were particularly disadvantaged due to difficulties securing stable employment. Due to lack of documentation typically required for formal job positions, undocumented individuals were typically limited to informal work in sectors such as farming, construction, housekeeping, and other short-term work. This had significant downstream implications for their ability to afford transportation to clinics, medical services, and medications.\u003c/p\u003e\n\u003ch6\u003eIncreased costs at public clinics\u003c/h6\u003e\n\u003cp\u003eIn Stann Creek District specifically, participants noted significant discrepancies in healthcare costs between members and non-members. While all patients were required to pay a $2 clinic visit fee (this fee is waived for all patients in Toledo District), non-members faced substantially higher charges for laboratory tests and imaging. Although some participants reported that costs could be appealed informally through petitioning to clinic administrative officials, this was not viewed as a reliable or sustainable solution.\u003c/p\u003e\n\u003ch5\u003eLanguage barriers\u003c/h5\u003e\n\u003cp\u003eLanguage barriers were a common challenge for both documented and undocumented participants, particularly among Spanish and Mayan speakers. Difficulties in communication were most frequently reported during interactions with registration staff and, to a lesser extent, nurses. These challenges were especially pronounced in Dangriga, where fewer clinic staff spoke Spanish.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn undocumented participant in Stann Creek stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes I go to the clinic, and since I only speak Spanish, and they are trying to explain something to me but in English and I do not understand, then they get mad because I do not understand.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA documented participant in Stann Creek stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe just treat people who don\u0026apos;t have papers with the same rights as a Belizean. All of us need to have the same rights. If they don\u0026apos;t speak Spanish maybe they could try their best to understand them. Sometimes if it\u0026apos;s an emergency and people need to be seen but they can\u0026apos;t, because they don\u0026apos;t have papers and they can\u0026apos;t explain what is wrong.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese sentiments were corroborated by community health workers, who noted:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Undocumented individuals think that because they don\u0026apos;t have a social security card, they can\u0026apos;t even go to the emergency room. But that is not true. There\u0026apos;s attention for everyone. What they don\u0026apos;t understand also is, and I think because of the language barrier on either side, they get the impression that they won\u0026apos;t get attention.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNotably, language was generally not a reported barrier when interacting with physicians, as many Belizean physicians underwent medical training in Spanish-speaking countries, and Belize recruits a significant number of foreign physicians from Cuba through the Cuban Medical Brigade.\u003c/p\u003e\n\u003ch5\u003eMarginalization by clinic staff\u003c/h5\u003e\n\u003cp\u003eMost reports of marginalization and discrimination arose during interactions with clinic registration staff, who were primarily English-speaking and responsible for entering patients into the electronic medical record system. Spanish and Mayan speaking participants in particular reported substantial communication barriers during this process. Additionally, undocumented individuals often expressed discomfort with what they perceived as extended questioning about their documentation status and inferior treatment during the registration process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne community health worker in Stann Creek District stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have heard some complaints that sometimes they go and clinic staff don\u0026apos;t want to attend to them because they don\u0026apos;t speak English and they don\u0026apos;t have any documents to identify them. Sometimes they just put these patients on the side, and I feel bad because I refer them there, but I cannot do as much as I want to.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother remarked:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some undocumented people refuse to go to the hospital because the data entry personnel don\u0026apos;t understand Spanish. And sometimes they are afraid to go because they never know how they will be treated because they don\u0026apos;t have papers.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile discriminatory treatment by physicians was rarely reported, some participants described negative interactions with nurses, particularly toward Spanish-speaking patients. Healthcare workers who were interviewed, however, uniformly denied any differential treatment based on documentation status. They did generally acknowledge, however, a longstanding history of discrimination against Mestizo individuals, particularly those of Guatemalan descent. \u0026nbsp;\u003c/p\u003e\n\u003ch5\u003eReluctance to use public clinics due to questioning about documentation status\u003c/h5\u003e\n\u003cp\u003eMany undocumented individuals were reluctant to be seen at public clinics due to what they perceived as prolonged questioning regarding their documentation status during prior visits. At the administrative level however, participants cited that the purpose of this questioning was to solicit any legal identification document (regardless of whether these documents were from Belize or not) in order for the patient\u0026rsquo;s demographic information to be registered accurately into the Belize Health Information System (BHIS), which is the electronic medical record system for all public health facilities in Belize.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs one administrative official stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So everyone who accesses the health system needs to be registered through the BHIS. It doesn\u0026apos;t matter where you\u0026apos;re from. They usually ask for a valid ID, because they want to make sure that whatever data is in the BHIS is correct. If you\u0026apos;re saying that this is your first time accessing BHIS in this particular health system, but maybe you previously went to a clinic in Belize City and you were already entered into the BHIS. When you come and access the health system here, if you don\u0026apos;t have a valid social security card, they will open a new encounter.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThey cited instances of misspelled names, birthdates, and other demographic information that resulted in the creation of duplicate patient charts and inability for healthcare providers to access prior visit records when legal identification was not provided.\u0026nbsp;\u003c/p\u003e\n\u003ch5\u003eFear of deportation\u003c/h5\u003e\n\u003cp\u003eMultiple undocumented participants stated that they were fearful of seeking care at public facilities due to fear of deportation, although administrative officials, health workers, and public health workers all affirmed that this was not common practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne health educator in Toledo District stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;And as much as we try to encourage them to come to the hospital, we\u0026apos;ll facilitate them with whatever they need, but they still refuse because of their immigration status. So we explained to them that your immigration status has nothing to do with the Ministry of Health, and we will help you. And still, they don\u0026rsquo;t go.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003ch5\u003eRejected from public clinics due to undocumented status\u003c/h5\u003e\n\u003cp\u003eAlthough most undocumented participants were ultimately able to be seen by a physician when presenting to public clinics, there were occasional reports of participants without valid SSI being turned away in Stann Creek in particular. Notably, some documented participants also recounted witnessing denial of care to undocumented individuals due to lack of documentation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne documented participant in Stann Creek District noted:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The last time I went to the clinic I saw a woman who was trying to be seen because she was having pain in her armpit and she wasn\u0026rsquo;t seen because she didn\u0026rsquo;t have papers. They told her to come back next week or go to a private clinic. Just because she didn\u0026rsquo;t have papers.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese experiences likely reinforced misinformation surrounding healthcare access in the district, particularly among undocumented individuals who had recently migrated to Belize. A few undocumented participants expressed the belief that they were not entitled to the same level of access to health services as nationals.\u003c/p\u003e\n\u003cp\u003eWhen asked about access to health services, one undocumented individual in Stann Creek stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t feel like I have access like that because I have no social security. I can only go to private clinics.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch5\u003ePreference for private and NGO clinics\u003c/h5\u003e\n\u003cp\u003eA strong preference for private and NGO clinics was expressed by undocumented participants compared to documented participants. Undocumented individuals often preferred to wait for NGO clinics to visit their area due to transportation difficulties and fear of seeking care at public facilities. Private clinics were also preferred by undocumented participants for their perceived better treatment, shorter wait times, fewer documentation requirements, and more reliable medication availability. While private clinics were more expensive, some participants reported saving money specifically to access these services.\u003c/p\u003e\n\u003cp\u003eAs a community health worker in Toledo District stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have seen that a lot of undocumented people will prefer to be seen at a private clinic, because there are fewer questions about their documentation status and better treatment and things like that, as long as they can pay. Even though the income they receive is very low, they prefer to sacrifice and pay a private doctor because the treatment would be better, and their legal status is not important at all.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch5\u003ePreference for self-medication and traditional medicine\u003c/h5\u003e\n\u003cp\u003eIndividuals who did not seek formal medical care often relied on alternative strategies, including self-medication, the use of \u0026ldquo;bush medicine\u0026rdquo; (traditional herbal remedies), and consultation with traditional healers. This pattern was particularly pronounced among undocumented individuals, who reported higher rates of self-medication. A common practice involved purchasing medications from \u003cem\u003ecobaneros,\u0026nbsp;\u003c/em\u003ewho are unlicensed vendors selling pharmaceuticals illegally, often traveling between rural communities on bicycles. These transactions typically occur without prescriptions or formal medical guidance.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study had several limitations. Firstly, home visits for interviews were conducted during weekday working hours, which resulted in an overrepresentation of women, who typically were homemakers, and subsequent underrepresentation of men who were typically not at home during these hours. Additionally, not all individuals selected for interviews were available at the time of home visits, introducing potential sampling bias.\u003c/p\u003e\n\u003cp\u003eAlthough the number of individuals utilizing Belize as a transit country is unknown, this study did not include any undocumented transient migrants whose end destination was outside of Belize. These individuals may experience health barriers distinct from those of migrants intending to settle in Belize. Additionally, because undocumented individuals were identified by community health workers, we could not capture the perspectives of those who are not known to community leaders. Such individuals are less likely to be integrated with the local community and may experience even greater barriers to healthcare access.\u003c/p\u003e\n\u003cp\u003eThird, remote villages inaccessible by road, such as Machakil Ha and Graham Creek, were not included. These communities likely have increased difficulties accessing healthcare due to transportation constraints and geographic isolation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, although unfair treatment by registration staff was a prominent theme in these interviews, no registration staff were interviewed. Understanding their perspectives is likely essential for designing targeted interventions to improve undocumented patient experiences within public healthcare facilities.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e\u003c/p\u003e\u003cp\u003eUltimately, undocumented individuals in Belize face a multitude of interconnected barriers to accessing healthcare, many of which stem from the lack of SSI. These findings are depicted in a thematic flowchart in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Lack of SSI often results from expired work permits, being a national of another country, inability to afford regularization despite eligibility, lack of birth registration (rendering individuals effectively stateless), or the inability to retrieve legal documents left in their country of origin. Without SSI, individuals are ineligible for formal employment, leading to financial hardship that limits their ability to afford and access necessary health services.\u003c/p\u003e\u003cp\u003eWhile some obstacles to care, such as long wait times, staffing and medication shortages, high transportation costs, and language barriers, were reported across all participants regardless of documentation status, these challenges were exacerbated for undocumented individuals. In particular, language barriers for undocumented Spanish and Mayan speakers contributed to misinformation about healthcare access and experiences of marginalization by clinic staff. These issues were especially pronounced in Stann Creek District, where fewer healthcare workers speak Spanish. Furthermore, there were occasional reports of undocumented patients being denied services in Stann Creek, although this was uncommon. Additionally, fear of deportation further discouraged undocumented individuals from seeking care at public health facilities. This was further compounded by increased costs for undocumented individuals at public clinics in Stann Creek.\u003c/p\u003e\u003cp\u003eAs a result, there was a general reluctance to seek care at public clinics and resultant preference for private facilities and NGO-provided care, which typically have more lenient documentation requirements. Those who did not seek formal medical care relied on self medication and traditional healers. Community health workers played an essential role in both districts as facilitators who bridge the gap between patients and the healthcare system.\u003c/p\u003e\u003cp\u003eThese patterns reflect a complex web of systemic and structural barriers that disproportionately affect undocumented populations, particularly in Stann Creek. Ultimately, understanding how undocumented individuals in Belize access health services is essential not only to improve their health outcomes but also to more accurately assess drivers of healthcare utilization and associated costs in Belize, particularly in the setting of public healthcare being made free. Results of this study will allow for more deliberate considerations and effective resource allocation to ensure that undocumented populations are included in national healthcare improvement plans. These findings are similar to other qualitative studies exploring barriers to healthcare access for undocumented populations in other countries.\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBHIS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBelize Health Information System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecommunity health workers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOREQ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConsolidated criteria for reporting qualitative research\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHPPBZ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHumana People to People Belize\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMIRPS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMarco Integral Regional para la Protecci\u0026oacute;n y Soluciones\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNGO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003enon-governmental organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSSI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003esocial security identification\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: The study was approved by the Baylor College of Medicine Institutional Review Board (IRB Protocol H-54879) and the Belize Ministry of Health and Wellness research committee. The need for written signed consent was waived as per the above IRB protocol. Participants verbally consented to participation in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets generated and/or analysed during the current study are not publicly available due to concern for participant confidentiality. The dataset contains information that can be traced back to the original participant. Data is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: N/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: RY designed the research study, collected data, transcribed and coded interview transcripts, and was the primary writer of the manuscript. GO provided on the ground logistical support regarding data collection, study design and data analysis. CW coded interview transcripts and assisted with data analysis. HM contributed to study design and data analysis. JM supervised the research study, coded interview transcripts and assisted with data analysis, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Melissa Diaz-Musa\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e: N/A\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Action on social determinants of health equity [Internet]. Geneva: World Health Organization; [cited 2022 Apr 17]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.tandfonline.com/doi/abs/10.1080/14780887.2011.572745\u003c/span\u003e\u003cspan address=\"https://www.tandfonline.com/doi/abs/10.1080/14780887.2011.572745\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"migrant health, health equity, healthcare access, global health","lastPublishedDoi":"10.21203/rs.3.rs-7502686/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7502686/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eBelize is primarily a destination country for migrants transiting through Central America. The impact of legal status on health access in Belize is under-researched. In October 2023, the Belize government removed medical fees in public hospitals to increase accessibility for all residents regardless of legal status. This study aims to qualitatively explore patterns of healthcare access for undocumented individuals compared to Belizean nationals in two historically under-resourced districts of Belize.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e60 semi-structured qualitative interviews were conducted exploring healthcare utilization, access, and barriers to care for undocumented populations between September to October 2024. Key informants, including health administrators, health providers, and public health workers were recruited through purposive snowball sampling. Undocumented participants and Belizean nationals were recruited through respondent-driven sampling via public health workers. Interviews were audio recorded, transcribed and translated as applicable. Transcripts were deductively and inductively coded for qualitative content analysis by two independent coders using Dedoose.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e17 public health workers, 5 health providers, 4 health administrators, 19 undocumented and 15 documented individuals were interviewed across 14 rural villages and 3 towns in Southern Belize. Irrespective of documentation status, long wait times, staffing and medication shortages, limited and expensive transport to health facilities, and language barriers for Spanish and Kek\u0026rsquo;chi speaking individuals were significant obstacles. For undocumented participants, these existing challenges were compounded by lack of formal employment and resultant impoverishment, misinformation regarding healthcare access, marginalization by clinic staff, fear of deportation, and subsequent reluctance to seek government-provided health services and preference for free, NGO provided care.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eUnderstanding how undocumented individuals in Belize access health services is crucial for enhancing their health outcomes and accurately assessing healthcare utilization and costs, especially amid government efforts to expand healthcare access. Study findings will enable more strategic resource allocation and ensure undocumented populations are included in national healthcare improvement plans.\u003c/p\u003e","manuscriptTitle":"Perceptions of and barriers to equitable healthcare access for undocumented populations in Belize: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-12 14:35:30","doi":"10.21203/rs.3.rs-7502686/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-01T09:01:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-01T01:10:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-30T22:06:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-26T14:25:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212882538287297511068533302209079768599","date":"2025-09-12T02:32:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131681309856875116762417603483143221451","date":"2025-09-10T17:44:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275040911763831990875575612177389576455","date":"2025-09-10T13:52:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19811560873923755665867633223461265351","date":"2025-09-10T10:05:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119188285592359521584035053995289063087","date":"2025-09-05T10:13:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-05T09:59:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-05T09:55:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-03T09:24:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2025-08-31T20:20:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ebaebe61-a7ca-4267-8efb-e8754e7cef3e","owner":[],"postedDate":"September 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-12T16:28:17+00:00","versionOfRecord":{"articleIdentity":"rs-7502686","link":"https://doi.org/10.1186/s12939-025-02741-7","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2026-02-12 00:00:00","publishedOnDateReadable":"February 12th, 2026"},"versionCreatedAt":"2025-09-12 14:35:30","video":"","vorDoi":"10.1186/s12939-025-02741-7","vorDoiUrl":"https://doi.org/10.1186/s12939-025-02741-7","workflowStages":[]},"version":"v1","identity":"rs-7502686","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7502686","identity":"rs-7502686","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}