A Story about Optimism and Access to Healthcare Services Among Crisis Migrant Venezuelan Women Living in Peru

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Since 2016, approximately 1.8 million Venezuelans have migrated to Peru, resulting in significant challenges for both the migrants and the host country. Objectives This study, conducted in 2020–2021, investigates the interrelation between discrimination, mental health, and access to healthcare services among Venezuelan women residing in Peru. Specifically, it aims to elucidate how perceived cultural stressors (discrimination and negative context of reception) influence healthcare access, with a focus on the mediating roles of anxiety, depressive symptoms, optimism, and life satisfaction. Methods Data were collected in 2021 from 100 Venezuelan women ( M age: 34 years) living in Peru through surveys that assessed cultural stressors, mental health indicators, well-being, and healthcare access. Using structural equation modeling, we explored the associations of cultural stressors with healthcare access. We also examined the mediating effects of anxiety, depressive symptoms, optimism, and life satisfaction. Results The analyses revealed that perceived discrimination was negatively associated with optimism and life satisfaction, and directly correlated with decreased access to healthcare. Furthermore, negative context of reception was positively associated with greater anxiety and depressive symptoms, which in turn indirectly reduced healthcare access by reducing levels of optimism. Conclusion The findings highlight the profound impact of social and psychological factors on healthcare access among Venezuelan women in Peru. The study underscores the critical need for fostering supportive environments to enhance the well-being of this population. Additionally, it emphasizes the role of optimism and life satisfaction in mitigating the adverse effects of discrimination and negative context of reception. Venezuelan migration humanitarian crisis discrimination mental health healthcare access optimism life satisfaction Peru structural equation modeling immigrant well-being Figures Figure 1 Figure 2 Background Venezuela and the Humanitarian Crisis The Venezuelan exodus represents one of the largest migratory crises in Latin American history, with over 7 million Venezuelans fleeing their country due to economic, political, and humanitarian crises (Mcmanus & Irazábal, 2023 ; Tapia et al., 2022 ). Venezuela’s economy has experienced a severe collapse characterized by hyperinflation, devaluation of the local currency, and shortages of basic goods and services (Mijares, 2022 ). These shortages have led to malnutrition and inadequate healthcare, contributing to the decline in public health in the country (Compare et al., 2021 ; Datincorp, 2016 ; IHME, 2021; Pew Research Center, 2016 ; Paez, 2015). This turmoil, accompanied by human rights violations, a breakdown of social structures, political instability, violence, and crime, have resulted in a significant outflow of Venezuelans, creating one of the largest migration crises in the Western Hemisphere (Datincorp, 2016 ; Pew Research Center, 2016 ; Paez, 2015). The surge in migration has had a significant impact on Latin America and the Caribbean (LAC), with Venezuelan migrants becoming key protagonists in these unprecedented trends (Zambrano-Barragan et al., 2021). As of 2023, the estimated number of Venezuelan immigrants living outside their home country reached a staggering 7.32 million (Center for Operational and Strategic Analysis [CDP], 2023). Venezuelans in Peru Among the LAC countries, Peru has emerged as the second most-common destination (Mejia-Mantilla Et. al, 2014 ;USAID, 2021 ) for Venezuelan refugees and migrants only after Colombia, with approximately 1.52 million Venezuelans seeking refuge within its borders (United Nations High Commissioner for Refugees [UNHCR], 2022). This new wave of migration has contributed to an increase in Peru's population by 117% percent since 2018 (Groeger et al., 2023; Mejia-Mantilla et al., 2024 ). Due to its geographical proximity and relatively open migration policies, Peru has been appealing to many Venezuelans fleeing their home country. The influx of Venezuelan migrants has not only reshaped the demographic landscape of Peru but has also precipitated unique challenges, particularly in urban areas. The concentration of migrants in Peruvian cities has implications for public health, as densely populated regions are more susceptible to issues related to overcrowding, limited access to basic services, and inadequate housing conditions. Prior to the COVID-19 pandemic, it was estimated that up to 30% of Venezuelan households in Peru lived in precarious conditions (dangerous and unsanitary), hindering their ability to adhere to basic public health guidelines (CDP, 2023). Following the pandemic, these figures may have increased. Apart from challenges in meeting basic needs, the social challenges faced by Venezuelans in Peru also have significant psychological implications. For instance, experiences of xenophobic discrimination during and after the leadership of President Pedro Pablo Kuczynski (July 2016- March 2018) further exacerbate the mental health burden of Venezuelans (United States Department of State, 2016 ). Although there was positive movement towards the protection of Venezuelans, facilitating their legal access to and in Peru (Freier & Perez, 2021 ), Peruvian administrations since Kuczynski have restricted the aid given to Venezuelans (Dupraz-Dobias, 2024). These restrictions have coincided with increasingly negative opinions towards Venezuelan immigration among Peruvian citizens (Amnesty International, 2020). The change in public attitudes also accompanied restrictive immigration policies, that impeded the legal migration of Venezuelans into Peru. Experiences of discrimination and negative reception can lead to increased levels of stress, anxiety, and depression among Venezuelan migrants (XXXX). The psychological toll of facing prejudice and hostility can be profound. Discrimination can erode an individual’s self-esteem and sense of identity and poorer health outcomes across various populations (XXXX). For instance, among Hispanic emerging adults, higher ethnic discrimination was linked to lower self-rated health (XXXX). Similarly, for Muslim ethnic minority adolescents, perceived ethno-religious discrimination was related to more depressive symptoms (Marie et al., 2023; Wenzing et al., 2023). Venezuelan migrants who experience discrimination and a negative context of reception may feel isolated and marginalized (XXXX). They may withdraw from social interactions and communities to avoid further mistreatment, leading to feelings of loneliness and despair. Moreover, the emotional and psychological impacts of these social challenges are significant. Recent studies, such as that conducted by Mougenot et al. ( 2021 ), have found higher prevalence and increased probability of mental health symptoms (depression, anxiety, stress) among Venezuelans who perceive, or experience discrimination compared to those who do not. Additionally, research (Meyer et al., 2017 ; Urzua et al., 2019) suggests that social support and self-esteem may mediate the predictive effects of perceived discrimination on depressive symptoms, anxiety, and overall psychological well-being among Venezuelan migrants. Many Venezuelans may face challenges accessing healthcare services in Peru due to discrimination, xenophobia, and perceived negative contexts of reception, thereby hindering access to primary care as well as treatment. Furthermore, because Peru has not traditionally experienced large-scale immigration, the nation has faced challenges in adapting its healthcare system to meet the needs of the rapidly growing population of Venezuelan immigrants. Although Peru has taken steps to integrate Venezuelan migrants, migrants often are required to register and provide identification documents to obtain these services. This may limit healthcare access for the large number of Venezuelans who are undocumented in Peru (Hernández-Vásquez et al., 2023 ). Venezuelan Women in Peru Venezuelan women face greater challenges than their male counterparts in accessing basic health care, education, employment, and in experiencing xenophobia and discrimination (Freier & Perez, 2021 ). Particularly relevant to women, access to sexual and reproductive healthcare and other services have become difficult for Venezuelan migrants in Peru (Irons, 2022 ). Migrant Venezuelan women are accused of “importing” HIV and STIs, which contribute to concerns on physical and structural violence and inability to integrate (Irons, 2022 ) and experience gender-based violence in many different areas of their lives, including physical and psychological abuse and harassment in the workplace (Risquez, 2021). Poverty, insecurity, homelessness, and risk of violence represent additional barriers to Venezuelan women’s ability to successfully acculturate to their new living environments. Regarding gender differences, common mental health symptoms such as depressive symptoms and anxiety are generally higher among women than men (Whiteford et. al, 2013 ), and this trend is also reflected amongst migrant populations (Hou et al., 2020 ; Hiott et al., 2006 ). Cultural Stress Theory Cultural Stress theory posits that immigrants face significant stress when adapting to host societies that differ culturally, socially, and linguistically from their country of origin (XXXX). This stress can stem from navigating unfamiliar norms, discrimination, and systemic barriers, all of which impact their ability to integrate and access essential services, such as healthcare. While it might be expected that immigrants settling in culturally similar environments experience less stress, intragroup variations—such as economic competition, social stratification, and subtle cultural differences—can still create stress and barriers. For Venezuelan women in Peru, despite a shared Hispanic heritage, differences in national identity, socio-political contexts, and migration experiences contribute to cultural stress and complicate their integration, particularly regarding healthcare access. Intragroup variations refer to the distinctions within ethnic or cultural groups that can lead to exclusion or discrimination, despite shared cultural or linguistic backgrounds. Venezuelan women in Peru may face unique challenges in navigating healthcare systems where their status as immigrants often renders them outsiders, even in a country with similar cultural roots. Optimism Drivers of migration are generally divided into two broad categories: push factors and pull factors (Olson & Olson, 2021 ). Common push factors include lack of employment, lack of economic opportunity, violence, and personal insecurity. Common pull factors include prospects for employment, family reunification, and greater security. Optimism has been recognized as a critical psychological resource that can buffer the negative effects of cultural stress on immigrant populations (Garcini et al., 2020). Migration is often driven by a desire for a better life (Ivlevs, 2014 ; Castelli, 2018 ). Optimism and life satisfaction represents integral components of assessing how well these aspirations are being met. Life satisfaction is a key indicator of the quality of life experienced by Venezuelan migrant women in Peru. High life satisfaction suggests that migrants are successfully adapting to their new environment and finding a sense of fulfillment. Higher life satisfaction is also associated with lower levels of anxiety and depression (Saldivia et al., 2023 ; Diener et al., 2003 ) Optimism can serve as a powerful psychological resource, even in the most difficult circumstances, motivating individuals to persevere through adversity. For many migrants, optimism is a driving force behind their decision to leave their home countries, fueling the hope of finding better opportunities elsewhere (the “pull factor”). Despite facing significant challenges, Venezuelan women in Peru may still hold onto optimism as a crucial element of their resilience. In this context, optimism not only represents their expectations for a brighter future but also acts as a coping mechanism that helps them navigate the difficulties of migration. Even amid discrimination and a negative reception, optimism can foster community building, encouraging them to form supportive networks that bolster their strength and adaptability in the face of adversity. The Current Study The present study was designed to understand the associations among cultural stressors (discrimination and negative context of reception), mental health (depressive and anxiety symptoms), and access to healthcare among Venezuelan women living in Peru, as well as the indirect effects of life satisfaction and optimism. We used structural equation modeling to investigate the associations among these factors. The following research questions were addressed in the present study: What are the associations of discrimination and context of reception with access to healthcare among Venezuelan women? To what extent do mental health symptoms (depression and anxiety) and well-being (optimism and life satisfaction) mediate these associations? Methodology Participants and Procedures The current study was cross-sectional study and was conducted online in 2021. The sample was collected using convenience sampling through Pasos Firmes, a community organization in Peru that provides support and services to Venezuelan migrants. This organization distributed the survey link to Venezuelan immigrant women aged 18 and older. We conducted a cross-sectional study using an online survey in 2020–2021. The study was approved by the Institutional Review Boards at the University of Miami and Universidad Peruana Cayetano Heredia. After the research protocol received IRB approval, the project coordinator contacted Pasos Firmes, a community organization in Peru that works to provide aid and services to Venezuelan migrants. This organization then distributed the survey link to Venezuelan immigrant women ages 18 and older. Participants provided email addresses so that they could receive payment, but no identifying information was linked with the data. Pasos Firmes agreed to provide the study information to their members and send a list of participants that met criteria markers. Those who decided to participate in this study had to meet the following criteria: 1) Female, 2) 18 years and older, and 3) a Venezuelan migrant living in Peru, migrating in the last 4 years. The survey, conducted in Spanish, had a total of 75 questions and was expected to take 15 to 20 minutes to complete. Each potential participant was contacted via telephone or WhatsApp by our research assistant in Peru. Those who consented to participate were given a brief overview of the study, potential harms and risks, and provided verbal consent to participate. They then were given the link to the anonymous online survey. The project coordinator and the first author worked together to confirm when a survey was completed. Because the survey was anonymous, each participant provided a screen shot of the last page of their completed survey via WhatsApp to the project coordinator as a proof that they had completed the survey. A total sample of 100 participants were collected. Participants completed an electronic survey consisting of demographic questions, along with open-ended questions on life in Venezuela, health care access, and use of health care services. The survey also included validated self-report measures for depression, anxiety, discrimination, life satisfaction, and optimism. All measures were previously available in Spanish (XXXX) and were administered in that language. All Spanish versions were reviewed by the Peruvian team prior to administration. All participants were provided a list of resources for mental health counseling and organizations that could provide further resources for meeting basic needs. Participants were paid an equivalent of 10 U.S. dollars via a payment application (i.e., YAPE app). This payment method application is popular amongst Venezuelan and Peruvian citizens in Peru. The payment was sent wirelessly and consistent with IRB and HIPPA protocols. Participant phone numbers for the Yape payment were not matched to their survey, to protect confidentiality and anonymity. The most common age ranges for women completing our survey were 25–34 (47%) and 35–44 (38%). Of the 101 women surveyed, 85.1% reported having a partner. In terms of educational levels, 23% completed grade 9 or less, 18% completed high school or its equivalent, and 43% completed, or were completing, a technical or university degree. Measures Perceived Discrimination Scale . The Perceived Discrimination Scale (Williams et. al, 1997 ) is a 7-item scale that measures how often people feel that others treat them badly or unfairly based on their race, ethnicity, gender, age, religion, physical appearance or other characteristics. The response options were on a likert-type scale from 1 (never) to 5 (always). Sample items include “Do people you do not know treat you unfairly or negatively because you are Venezuelan?” The Cronbach alpha for our sample was 0.90. Negative context of reception. The Negative Context of Reception Scale (XXXX) was used to assess perceived negative context of reception – a feeling of being excluded or marginalized from Peruvian society. This 6-item scale assesses how Venezuelans perceive differences in opportunities and reception in the Peruvian context compared to other migrant groups (e.g., People in this country often criticize people from Venezuela ). Items were rated using a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Cronbach’s alpha in the present sample was .83. Center for Epidemiologic Studies Depression Scale (CESD-R10) (Miller et al., 2008 ).. The Center for Epidemiologic Studies of Depression Scale is a 10-item self-report scale assessing depressive symptomatology during the week prior to assessment. Sample items include “I felt as though no one liked me.” Scores of 8 or above are indicative of elevated symptoms likely to meet criteria for a depressive disorder. Two of the scale questions were positively worded (items 4 and 7): “I was happy” and “I enjoy life”. The Cronbach alpha in our sample was .81. Generalized Anxiety Disorder (GAD-7) . The Generalized Anxiety Disorder Scale is a 7-item scale that screens for anxiety symptoms during the 2-weeks prior to assessment. Items were rated using a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Sample items include “Feeling nervous, anxious,, or on edge.” Scores of 8 or higher are regarded as indicative of a likely generalized anxiety disorder diagnosis. Cronbach alpha in our sample was .86. Optimism . The 10-item Life Orientation Test (revised) (Scheier et al., 1994 ) assesses dispositional optimism/pessimism. A Likert type scale is used to respond to each item, ranging from strongly agree (0) to strongly agree (4). This measure taps into the extent to which participants feel positive and hopeful about their future. Sample items include “In uncertain times, I usually expect the best.” Two items negatively phrased and coded inversely: “if something could go wrong for me, it will” and “rarely do good things happen to me”. Cronbach alpha for our sample was .90. Satisfaction with Life. The Satisfaction with Life Scale (Diener et al., 1985 ) is a 5-item scale designed to measure global cognitive judgements vis-à-vis overall happiness and contentment. Participants indicate how much they agree or disagree with each of the 5 items using a 7-point scale ranging from strongly disagree (1) to strongly agree (7). Cronbach’s alpha in our sample was .76. Access to Healthcare. We designed a 4-item access to healthcare measure for the present study. Items capture various facets and dimensions of healthcare access (ability to visit a doctor but did not go, last medical visit, discontinued medication due to lack of access to doctor, and health insurance status). Items were rated using “yes” or “no”. Cronbach’s alpha in our sample was .60. Data Analysis Sociodemographic information including age, ethnicity, marital status, education, household living, and partner information was collected for 101 Venezuelan women. We used M plus version 8.1 to estimate a path model. We explored the associations among discrimination and negative context of reception (predictors) and access to healthcare (outcomes). We also examined the potential mediating effects of anxiety, depressive symptoms, optimism, and life satisfaction in these associations (see Fig. 1 ). Results Descriptive Information For the CES-D-R10, scores of 10 or greater represent clinically elevated depressive symptoms(Andresen et al., 1994 ). The mean CES-D score in the present sample was 22, suggesting that the majority of participants were reported elevated depressive symptoms. Indeed, 86% of our sample met criteria for elevated depressive symptoms. On the GAD, a score of 8 or higher represents an established cut-off point for identifying probable cases of generalized anxiety disorder. The mean score among the Venezuelan women surveyed was 13, indicating elevated anxiety symptomatology among our sample. Further, 71% of participants met criteria for moderate to severe anxiety. For satisfaction with life in our sample, the average mean score was 20, indicating moderate levels of satisfaction with life. Based on item mean responses, 45% of our sample expressed feeling satisfied or slightly satisfied with lives, and 48% reported being slightly dissatisfied, dissatisfied, or extremely dissatisfied with life. The remaining 7% scored at the scale midpoint (4 on a 1–7 scale). In terms of optimism, 83% of participants expressed high optimism (item mean responses between 3 and 4 on a 0–4 scale), 13% expressed moderate optimism (item means between 2 and 3), and 4% expressed low optimism (item means below 2). In terms of access to health care, 80.2% reported they had gone to a medical establishment at least once since arriving to Peru. When asked if they had stopped taking medication due to not being able to afford it, 78% reported yes. Lastly, only 30% of the women reported they had medical insurance in Peru. In terms of whether participants’ medical insurance covered mental health services, 10.9% of participants reported they did not have adequate coverage, 4.1% reported they had adequate coverage, 25% did not know, and 60% reported they did not have health insurance. Model Fit and Path Estimates The path model indicated acceptable fit to the data, c 2 (df) = 224.162 ( p < .001), CFI = .992, RMSEA = .087. Path estimates yielded several significant associations related to healthcare access among Venezuelan women in Peru. Discrimination was found to have a significant and negative association with optimism (β = − .405, p < .001), and life satisfaction (β = − .248, p = .041). Whereas negative context of reception was significantly associated with anxiety (β = .251, p = .021), depressive symptoms (β = .282, p = .009) and optimism (β = .246, p = .039). Discrimination was significantly and directly associated with access to healthcare, (β = − .393, p = .001), but negative context of reception was not. Two mediated pathways emerged – one linking negative context of reception with access to healthcare through optimism (β = − .283, p = .049) and another linking discrimination with access to healthcare through optimism ( β = − .408, p = .001). Anxiety, depressive symptoms, and life satisfaction did not play any significant roles in the present results. See Fig. 2 . Discussion The present study was designed to examine the direct and indirect associations of cultural stressors (discrimination and negative context of reception) with access to health care among Venezuelan migrant women in Peru. Given the important roles of mental health and well-being in facilitating health care seeking, and given the deleterious associations of cultural stressors with mental health and well-being among Venezuelan migrants (XXXX; XXXX), we examined the intervening roles of depressive symptoms, anxiety, life satisfaction, and optimism in these associations. We also examined participants’ reported levels of cultural stress, mental health, well-being, and health care access. In their pursuit of a better life, Venezuelan migrant women frequently encounter discrimination and a sometimes-unwelcoming reception in their new homelands. Indeed, XXXX et al. (XX) found relatively high levels of discrimination and negative context of reception among Venezuelan migrants in Colombia. It is important to generalize these findings to other South American countries that receive large numbers of Venezuelan migrants, as well as to examine the extent to which these cultural stressors can compromise health care access both directly and indirectly through mental health and well-being. Our results suggest that both discrimination and negative context of reception may be negatively related to health care access through reduced levels of optimism, and that discrimination is directly related to reduced health care access above and beyond its indirect association through lowered optimism. These results suggest that cultural stressors interfere with Venezuelan immigrant women’s hopes for the future – and that these reduced hopes are linked with barriers to accessing health care. Of course, given the legal hurdles that Venezuelans have faced in Peru (Freier & Perez, 2021 ), it is also possible that reduced access to health care (as a structural impediment to migrant integration) may reduce Venezuelan women’s optimism vis-à-vis their lives in Peru. Future longitudinal work will be needed to examine the directionality of these effects. Our results also highlight the importance of addressing discriminatory practices and improving social contexts to ensure equitable access to healthcare for vulnerable populations such as crisis migrants. Women’s access to healthcare is significantly impacted by perceived discrimination on the part of healthcare workers, clinic organizations, and the destination community in general. Indeed, recent work has begun to address regarding the criminalization of mass migration and the extent to which threat perceptions among host nationals are associated with hostile policies toward migrant groups (Freier, 2021 ). This “crimmigration” narrative, the intersection of criminal and immigration law, (Menjívar et al., 2018 ) may compromise migrants’ daily lives and integration by increasing hostile attitudes and obstructing access to important types of health care, including mental health services. Our results suggest that individuals who experience discrimination may be hesitant to seek healthcare services due to fear of mistreatment, harassment, or biased treatment by healthcare providers (Togioka et al., 2024 ) Systemic barriers, such as limited availability of affordable health services in certain neighborhoods, specifically Venezuelan neighborhoods in Peru, can have serious negative impacts on migrants’ health and well-being. We also found that experiences of discrimination are associated with symptoms of depression and anxiety, as well as with levels of optimism and overall life satisfaction, among Venezuelan women. Interestingly, among these well-being and mental health variables, only optimism was associated with health care access. This finding suggests that crisis migrant women with lower levels of optimism may be less likely to seek medical attention when needed. Larger samples should be used to further explore these associations. Additionally, the significant associations of negative context of reception with anxiety and depressive symptoms emphasize the need for more supportive environments, especially for migrant women who have experienced trauma and stress during their migration journey. It is important to mention that these data were collected during the height of the COVID-19 pandemic – such that health care access rates might have been higher at other times. Nonetheless, findings for links between cultural stress and mental health suggest that, given the embeddedness of cultural stressors within structural dynamics between majority and minority groups, government initiatives can play a pivotal role in addressing the mental health of Venezuelan women in Peru. Implementing accessible and culturally sensitive mental health services, raising awareness about the importance of mental well-being, and offering support for social integration and community engagement can significantly contribute to the overall mental health and acculturation process of this population. Limitations The present findings should be interpreted in light of at several important limitations. First, the sample was small, suggesting that future studies are necessary with larger samples. We should note that the use of convenience sampling may limit the representativeness of our sample regarding broader Venezuelan immigrant population in Peru. Second, the cross-sectional design we used does not permit predictive or causal conclusions to be drawn. Third, the exclusive reliance on self-reports is subject to recall and other biases. Longitudinal and observational research can help to address these limitations. Next, the absence f a pregnancy variable may influence the likelihood of depression. Lastly, we lack information on the number of children, which is an important demographic factor that could impact the mental health of Venezuelan immigrant women. Future Directions Given the findings of this study, several avenues for future research can be identified. First, longitudinal studies are needed to explore the directionality of the associations between cultural stressors, optimism, and healthcare access among Venezuelan migrant women. Such research would allow for a deeper understanding of how changes in discrimination and context of reception over time impact mental health and access to healthcare. Additionally, future studies should include larger and more diverse samples to enhance the generalizability of the results to broader populations of Venezuelan immigrants in Peru and other host countries. Lastly, future research should further examine the role of optimism in health outcomes for migrant populations. The finding that optimism, rather than other mental health variables, was associated with healthcare access suggests that promoting optimism through interventions could potentially improve healthcare-seeking behaviors. Exploring how targeted interventions—such as cognitive behavioral therapy (CBT) or community-based resilience programs—can enhance optimism and its protective effects on mental health and healthcare access among migrant women would provide practical implications for improving migrant health outcomes. Conclusion Despite these and other limitations, our findings suggest some important conclusions. Our findings underscore the importance of creating supportive environments for migrants, particularly those who have experienced trauma and stress during their migration journey. They also highlight the importance of cultural stressors as barriers to health care access for Venezuelan women in Peru, as well as the role of reduced optimism in these associations. It is therefore possible that, even if it is not immediately possible to reduce cultural stressors, programs to increase optimism may help to improve health care access among at least those women who have insurance but may not actively seek out care. We hope that the present results will inspire further work in this direction. Declarations Author Contribution Mentors Dr. Behar-Zusman and Dr. Schwartz contributed to the editing and making of this manuscript. 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Hopelessness and Corruption: Overlooked Drivers of Migration from the Northern Triangle of Central America. Jack Gordon Inst Res Publications 36. https://digitalcommons.fiu.edu/jgi_research/36 Páez T. La voz de la diáspora venezolana [The voice of the Venezuelan diaspora]. Caracas, Venezuela: La Catarata; 2015. Pavot W, Diener E. The Satisfaction With Life Scale and the emerging construct of life satisfaction. J Posit Psychol. 2008;3:137–52. Pew Research Center. (2016). Origins and destinations of the world’s migrants. Retrieved August 23, 2016 athttp://www.pewglobal.org/2016/05/17/global-migrantstocks/ Salas-Wright CP, Maldonado-Molina MM, Brown EC, Bates M, Rodríguez J, García MF, Schwartz SJ. Cultural Stress Theory in the Context of Family Crisis Migration: Implications for Behavioral Health with Illustrations from the Adelante Boricua Study. Am J criminal justice: AJCJ. 2021;46(4):586–608. https://doi.org/10.1007/s12103-021-09626-9 . Salas-Wright C, Oh S, Vaugh MG, Perez-Gomez A, Mejia-Trujillo J, Montero-Zamora P, Andrade P, Cohen M, Scaramutti C, Rodriguez J, Schwartz SJ. A Validation of the Perceived Negative Context of Reception Scale with recently-arrived Venezuelan immigrants in Colombia and the United States. Cultur Divers Ethnic Minor Psychl. 2021;27(4):649–58. Saldivia S, Aslan J, Cova F, Bustos C, Inostroza C, Castillo-Carreño A. Life satisfaction, positive affect, depression and anxiety symptoms, and their relationship with sociodemographic, psychosocial, and clinical variables in a general elderly population sample from Chile. Front Psychiatry. 2023;14:1203590. https://doi.org/10.3389/fpsyt.2023.1203590 . Scheier MF, Carver CS, Bridges MW. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A re-evaluation of the Life Orientation Test. J Personal Soc Psychol. 1994;67:1063–78. Schwartz SJ, Salas-Wright CP, Perez-Gomez A, Mejia-Trujillo J, Brown EC, Montero-Zamora P, Dickson-Gomez J. Cultural stress and psychological symptoms in recent Venezuelan immigrants to the United States and Colombia. Int J Intercultural Relations. 2018;67:25–34. Togioka BM, Duvivier D, Young E. (2024). Diversity and discrimination in health care. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK568721/ United States Department of State. (2016). Country Reports on Human Rights Practices. Retrieved, https://www.refworld.org/reference/annualreport/usdos/2017/en/116339 Urzúa A, Leiva-Gutiérrez J, Caqueo-Urízar A, Vera-Villarroel P. Rooting mediates the effect of stress by acculturation on the psychological well-being of immigrants living in Chile. PLoS ONE. 2019;14(8). https://doi.org/10.1371/journal.pone.0219485 . Article e0219485. USAID. 2021. Venezuela migration crisis Peru: Second largest destination for Venezuelan Migrants. US Aid. Retrieved from https://www.usaid.gov/sites/default/files/2023-08/FS%20Venezuela%20EnglishDecember2021.pdf Tapia MS, Gutiérrez S, Candela A, Y., Machado-Allison C. Some effects of convulsive political scenarios on food systems. The Venezuelan case. Innovative Food Sci Emerg Technol. 2022;82:103191. https://doi.org/10.1016/j.ifset.2022.103191 . Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE. Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575–86. Williams DR, Yu Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: Socio-economic status, stress and discrimination. J Health Psychol. 1997;2(3):335–51. Additional Declarations No competing interests reported. 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Brown","email":"","orcid":"","institution":"University of Miami","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"C.","lastName":"Brown","suffix":""},{"id":376406335,"identity":"125ba666-24a1-4c1d-af7c-c95f48fe3f5b","order_by":10,"name":"Victoria Behar-Zusman","email":"","orcid":"","institution":"University of Miami","correspondingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"","lastName":"Behar-Zusman","suffix":""},{"id":376406336,"identity":"9d0d854c-3080-4e4f-9dc7-d64891afc304","order_by":11,"name":"Seth J. Schwartz","email":"","orcid":"","institution":"The University of Texas at Austin","correspondingAuthor":false,"prefix":"","firstName":"Seth","middleName":"J.","lastName":"Schwartz","suffix":""}],"badges":[],"createdAt":"2024-11-06 22:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5405518/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5405518/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":70080824,"identity":"65dd2978-c118-4147-b972-7d53ac43d717","added_by":"auto","created_at":"2024-11-28 07:12:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":290791,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePredicted Structural Path of Mediation\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5405518/v1/2886e78a98cceba65d1b1859.png"},{"id":70080825,"identity":"2fba6c76-c3a8-4118-8869-e84654c1cf53","added_by":"auto","created_at":"2024-11-28 07:12:48","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":172150,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eStructural Mediation Path\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5405518/v1/ad94099793dc8b08e1cf23de.jpeg"},{"id":71823827,"identity":"34dfef74-59b5-4fda-bce8-818e906926b5","added_by":"auto","created_at":"2024-12-19 00:31:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":686996,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5405518/v1/65f19eb0-2821-43a0-990b-ba43f6bd6686.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Story about Optimism and Access to Healthcare Services Among Crisis Migrant Venezuelan Women Living in Peru","fulltext":[{"header":"Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eVenezuela and the Humanitarian Crisis\u003c/h2\u003e \u003cp\u003eThe Venezuelan exodus represents one of the largest migratory crises in Latin American history, with over 7\u0026nbsp;million Venezuelans fleeing their country due to economic, political, and humanitarian crises (Mcmanus \u0026amp; Irazábal, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Tapia et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Venezuela’s economy has experienced a severe collapse characterized by hyperinflation, devaluation of the local currency, and shortages of basic goods and services (Mijares, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These shortages have led to malnutrition and inadequate healthcare, contributing to the decline in public health in the country (Compare et al., 2021 ; Datincorp, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; IHME, 2021; Pew Research Center, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Paez, 2015). This turmoil, accompanied by human rights violations, a breakdown of social structures, political instability, violence, and crime, have resulted in a significant outflow of Venezuelans, creating one of the largest migration crises in the Western Hemisphere (Datincorp, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Pew Research Center, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Paez, 2015). The surge in migration has had a significant impact on Latin America and the Caribbean (LAC), with Venezuelan migrants becoming key protagonists in these unprecedented trends (Zambrano-Barragan et al., 2021). As of 2023, the estimated number of Venezuelan immigrants living outside their home country reached a staggering 7.32\u0026nbsp;million (Center for Operational and Strategic Analysis [CDP], 2023).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eVenezuelans in Peru\u003c/h2\u003e \u003cp\u003eAmong the LAC countries, Peru has emerged as the second most-common destination (Mejia-Mantilla Et. al, 2014 ;USAID, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) for Venezuelan refugees and migrants only after Colombia, with approximately 1.52\u0026nbsp;million Venezuelans seeking refuge within its borders (United Nations High Commissioner for Refugees [UNHCR], 2022). This new wave of migration has contributed to an increase in Peru's population by 117% percent since 2018 (Groeger et al., 2023; Mejia-Mantilla et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Due to its geographical proximity and relatively open migration policies, Peru has been appealing to many Venezuelans fleeing their home country. The influx of Venezuelan migrants has not only reshaped the demographic landscape of Peru but has also precipitated unique challenges, particularly in urban areas. The concentration of migrants in Peruvian cities has implications for public health, as densely populated regions are more susceptible to issues related to overcrowding, limited access to basic services, and inadequate housing conditions. Prior to the COVID-19 pandemic, it was estimated that up to 30% of Venezuelan households in Peru lived in precarious conditions (dangerous and unsanitary), hindering their ability to adhere to basic public health guidelines (CDP, 2023). Following the pandemic, these figures may have increased.\u003c/p\u003e \u003cp\u003eApart from challenges in meeting basic needs, the social challenges faced by Venezuelans in Peru also have significant psychological implications. For instance, experiences of xenophobic discrimination during and after the leadership of President Pedro Pablo Kuczynski (July 2016- March 2018) further exacerbate the mental health burden of Venezuelans (United States Department of State, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Although there was positive movement towards the protection of Venezuelans, facilitating their legal access to and in Peru (Freier \u0026amp; Perez, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), Peruvian administrations since Kuczynski have restricted the aid given to Venezuelans (Dupraz-Dobias, 2024). These restrictions have coincided with increasingly negative opinions towards Venezuelan immigration among Peruvian citizens (Amnesty International, 2020). The change in public attitudes also accompanied restrictive immigration policies, that impeded the legal migration of Venezuelans into Peru.\u003c/p\u003e \u003cp\u003eExperiences of discrimination and negative reception can lead to increased levels of stress, anxiety, and depression among Venezuelan migrants (XXXX). The psychological toll of facing prejudice and hostility can be profound. Discrimination can erode an individual’s self-esteem and sense of identity and poorer health outcomes across various populations (XXXX). For instance, among Hispanic emerging adults, higher ethnic discrimination was linked to lower self-rated health (XXXX). Similarly, for Muslim ethnic minority adolescents, perceived ethno-religious discrimination was related to more depressive symptoms (Marie et al., 2023; Wenzing et al., 2023). Venezuelan migrants who experience discrimination and a negative context of reception may feel isolated and marginalized (XXXX). They may withdraw from social interactions and communities to avoid further mistreatment, leading to feelings of loneliness and despair.\u003c/p\u003e \u003cp\u003eMoreover, the emotional and psychological impacts of these social challenges are significant. Recent studies, such as that conducted by Mougenot et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), have found higher prevalence and increased probability of mental health symptoms (depression, anxiety, stress) among Venezuelans who perceive, or experience discrimination compared to those who do not. Additionally, research (Meyer et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Urzua et al., 2019) suggests that social support and self-esteem may mediate the predictive effects of perceived discrimination on depressive symptoms, anxiety, and overall psychological well-being among Venezuelan migrants.\u003c/p\u003e \u003cp\u003eMany Venezuelans may face challenges accessing healthcare services in Peru due to discrimination, xenophobia, and perceived negative contexts of reception, thereby hindering access to primary care as well as treatment. Furthermore, because Peru has not traditionally experienced large-scale immigration, the nation has faced challenges in adapting its healthcare system to meet the needs of the rapidly growing population of Venezuelan immigrants. Although Peru has taken steps to integrate Venezuelan migrants, migrants often are required to register and provide identification documents to obtain these services. This may limit healthcare access for the large number of Venezuelans who are undocumented in Peru (Hernández-Vásquez et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVenezuelan Women in Peru\u003c/h3\u003e\n\u003cp\u003eVenezuelan women face greater challenges than their male counterparts in accessing basic health care, education, employment, and in experiencing xenophobia and discrimination (Freier \u0026amp; Perez, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Particularly relevant to women, access to sexual and reproductive healthcare and other services have become difficult for Venezuelan migrants in Peru (Irons, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Migrant Venezuelan women are accused of “importing” HIV and STIs, which contribute to concerns on physical and structural violence and inability to integrate (Irons, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and experience gender-based violence in many different areas of their lives, including physical and psychological abuse and harassment in the workplace (Risquez, 2021). Poverty, insecurity, homelessness, and risk of violence represent additional barriers to Venezuelan women’s ability to successfully acculturate to their new living environments. Regarding gender differences, common mental health symptoms such as depressive symptoms and anxiety are generally higher among women than men (Whiteford et. al, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), and this trend is also reflected amongst migrant populations (Hou et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hiott et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eCultural Stress Theory\u003c/h3\u003e\n\u003cp\u003eCultural Stress theory posits that immigrants face significant stress when adapting to host societies that differ culturally, socially, and linguistically from their country of origin (XXXX). This stress can stem from navigating unfamiliar norms, discrimination, and systemic barriers, all of which impact their ability to integrate and access essential services, such as healthcare. While it might be expected that immigrants settling in culturally similar environments experience less stress, intragroup variations—such as economic competition, social stratification, and subtle cultural differences—can still create stress and barriers. For Venezuelan women in Peru, despite a shared Hispanic heritage, differences in national identity, socio-political contexts, and migration experiences contribute to cultural stress and complicate their integration, particularly regarding healthcare access.\u003c/p\u003e \u003cp\u003eIntragroup variations refer to the distinctions within ethnic or cultural groups that can lead to exclusion or discrimination, despite shared cultural or linguistic backgrounds. Venezuelan women in Peru may face unique challenges in navigating healthcare systems where their status as immigrants often renders them outsiders, even in a country with similar cultural roots.\u003c/p\u003e\n\u003ch3\u003eOptimism\u003c/h3\u003e\n\u003cp\u003eDrivers of migration are generally divided into two broad categories: push factors and pull factors (Olson \u0026amp; Olson, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Common push factors include lack of employment, lack of economic opportunity, violence, and personal insecurity. Common pull factors include prospects for employment, family reunification, and greater security. Optimism has been recognized as a critical psychological resource that can buffer the negative effects of cultural stress on immigrant populations (Garcini et al., 2020). Migration is often driven by a desire for a better life (Ivlevs, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Castelli, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Optimism and life satisfaction represents integral components of assessing how well these aspirations are being met. Life satisfaction is a key indicator of the quality of life experienced by Venezuelan migrant women in Peru. High life satisfaction suggests that migrants are successfully adapting to their new environment and finding a sense of fulfillment. Higher life satisfaction is also associated with lower levels of anxiety and depression (Saldivia et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Diener et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2003\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOptimism can serve as a powerful psychological resource, even in the most difficult circumstances, motivating individuals to persevere through adversity. For many migrants, optimism is a driving force behind their decision to leave their home countries, fueling the hope of finding better opportunities elsewhere (the “pull factor”). Despite facing significant challenges, Venezuelan women in Peru may still hold onto optimism as a crucial element of their resilience. In this context, optimism not only represents their expectations for a brighter future but also acts as a coping mechanism that helps them navigate the difficulties of migration. Even amid discrimination and a negative reception, optimism can foster community building, encouraging them to form supportive networks that bolster their strength and adaptability in the face of adversity.\u003c/p\u003e\n\u003ch3\u003eThe Current Study\u003c/h3\u003e\n\u003cp\u003eThe present study was designed to understand the associations among cultural stressors (discrimination and negative context of reception), mental health (depressive and anxiety symptoms), and access to healthcare among Venezuelan women living in Peru, as well as the indirect effects of life satisfaction and optimism. We used structural equation modeling to investigate the associations among these factors.\u003c/p\u003e \u003cp\u003eThe following research questions were addressed in the present study:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the associations of discrimination and context of reception with access to healthcare among Venezuelan women?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo what extent do mental health symptoms (depression and anxiety) and well-being (optimism and life satisfaction) mediate these associations?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003c/div\u003e "},{"header":"Methodology","content":"\u003ch2\u003eParticipants and Procedures\u003c/h2\u003e\u003cp\u003eThe current study was cross-sectional study and was conducted online in 2021. The sample was collected using convenience sampling through Pasos Firmes, a community organization in Peru that provides support and services to Venezuelan migrants. This organization distributed the survey link to Venezuelan immigrant women aged 18 and older. We conducted a cross-sectional study using an online survey in 2020–2021. The study was approved by the Institutional Review Boards at the University of Miami and Universidad Peruana Cayetano Heredia. After the research protocol received IRB approval, the project coordinator contacted Pasos Firmes, a community organization in Peru that works to provide aid and services to Venezuelan migrants. This organization then distributed the survey link to Venezuelan immigrant women ages 18 and older. Participants provided email addresses so that they could receive payment, but no identifying information was linked with the data.\u003c/p\u003e\u003cp\u003ePasos Firmes agreed to provide the study information to their members and send a list of participants that met criteria markers. Those who decided to participate in this study had to meet the following criteria: 1) Female, 2) 18 years and older, and 3) a Venezuelan migrant living in Peru, migrating in the last 4 years. The survey, conducted in Spanish, had a total of 75 questions and was expected to take 15 to 20 minutes to complete. Each potential participant was contacted via telephone or WhatsApp by our research assistant in Peru. Those who consented to participate were given a brief overview of the study, potential harms and risks, and provided verbal consent to participate. They then were given the link to the anonymous online survey. The project coordinator and the first author worked together to confirm when a survey was completed. Because the survey was anonymous, each participant provided a screen shot of the last page of their completed survey via WhatsApp to the project coordinator as a proof that they had completed the survey. A total sample of 100 participants were collected.\u003c/p\u003e\u003cp\u003eParticipants completed an electronic survey consisting of demographic questions, along with open-ended questions on life in Venezuela, health care access, and use of health care services. The survey also included validated self-report measures for depression, anxiety, discrimination, life satisfaction, and optimism. All measures were previously available in Spanish (XXXX) and were administered in that language. All Spanish versions were reviewed by the Peruvian team prior to administration. All participants were provided a list of resources for mental health counseling and organizations that could provide further resources for meeting basic needs. Participants were paid an equivalent of 10 U.S. dollars via a payment application (i.e., YAPE app). This payment method application is popular amongst Venezuelan and Peruvian citizens in Peru. The payment was sent wirelessly and consistent with IRB and HIPPA protocols. Participant phone numbers for the Yape payment were not matched to their survey, to protect confidentiality and anonymity. The most common age ranges for women completing our survey were 25–34 (47%) and 35–44 (38%). Of the 101 women surveyed, 85.1% reported having a partner. In terms of educational levels, 23% completed grade 9 or less, 18% completed high school or its equivalent, and 43% completed, or were completing, a technical or university degree.\u003c/p\u003e\u003ch3\u003eMeasures\u003c/h3\u003e\u003cp\u003e \u003cem\u003ePerceived Discrimination Scale\u003c/em\u003e. The Perceived Discrimination Scale (Williams et. al, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1997\u003c/span\u003e) is a 7-item scale that measures how often people feel that others treat them badly or unfairly based on their race, ethnicity, gender, age, religion, physical appearance or other characteristics. The response options were on a likert-type scale from 1 (never) to 5 (always). Sample items include “Do people you do not know treat you unfairly or negatively because you are Venezuelan?” The Cronbach alpha for our sample was 0.90.\u003c/p\u003e\u003cp\u003e \u003cem\u003eNegative context of reception.\u003c/em\u003e The Negative Context of Reception Scale (XXXX) was used to assess perceived negative context of reception – a feeling of being excluded or marginalized from Peruvian society. This 6-item scale assesses how Venezuelans perceive differences in opportunities and reception in the Peruvian context compared to other migrant groups (e.g., \u003cem\u003ePeople in this country often criticize people from Venezuela\u003c/em\u003e). Items were rated using a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Cronbach’s alpha in the present sample was .83.\u003c/p\u003e\u003cp\u003e \u003cem\u003eCenter for Epidemiologic Studies Depression Scale (CESD-R10)\u003c/em\u003e (Miller et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).. The Center for Epidemiologic Studies of Depression Scale is a 10-item self-report scale assessing depressive symptomatology during the week prior to assessment. Sample items include “I felt as though no one liked me.” Scores of 8 or above are indicative of elevated symptoms likely to meet criteria for a depressive disorder. Two of the scale questions were positively worded (items 4 and 7): “I was happy” and “I enjoy life”. The Cronbach alpha in our sample was .81.\u003c/p\u003e\u003cp\u003e \u003cem\u003eGeneralized Anxiety Disorder (GAD-7)\u003c/em\u003e. The Generalized Anxiety Disorder Scale is a 7-item scale that screens for anxiety symptoms during the 2-weeks prior to assessment. Items were rated using a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Sample items include “Feeling nervous, anxious,, or on edge.” Scores of 8 or higher are regarded as indicative of a likely generalized anxiety disorder diagnosis. Cronbach alpha in our sample was .86.\u003c/p\u003e\u003cp\u003e \u003cem\u003eOptimism\u003c/em\u003e. The 10-item Life Orientation Test (revised) (Scheier et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e1994\u003c/span\u003e) assesses dispositional optimism/pessimism. A Likert type scale is used to respond to each item, ranging from strongly agree (0) to strongly agree (4). This measure taps into the extent to which participants feel positive and hopeful about their future. Sample items include “In uncertain times, I usually expect the best.” Two items negatively phrased and coded inversely: “if something could go wrong for me, it will” and “rarely do good things happen to me”. Cronbach alpha for our sample was .90.\u003c/p\u003e\u003cp\u003e \u003cem\u003eSatisfaction with Life.\u003c/em\u003e The Satisfaction with Life Scale (Diener et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1985\u003c/span\u003e) is a 5-item scale designed to measure global cognitive judgements vis-à-vis overall happiness and contentment. Participants indicate how much they agree or disagree with each of the 5 items using a 7-point scale ranging from strongly disagree (1) to strongly agree (7). Cronbach’s alpha in our sample was .76.\u003c/p\u003e\u003cp\u003e \u003cem\u003eAccess to Healthcare.\u003c/em\u003e We designed a 4-item access to healthcare measure for the present study. Items capture various facets and dimensions of healthcare access (ability to visit a doctor but did not go, last medical visit, discontinued medication due to lack of access to doctor, and health insurance status). Items were rated using “yes” or “no”. Cronbach’s alpha in our sample was .60.\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eSociodemographic information including age, ethnicity, marital status, education, household living, and partner information was collected for 101 Venezuelan women. We used M\u003cem\u003eplus\u003c/em\u003e version 8.1 to estimate a path model. We explored the associations among discrimination and negative context of reception (predictors) and access to healthcare (outcomes). We also examined the potential mediating effects of anxiety, depressive symptoms, optimism, and life satisfaction in these associations (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive Information\u003c/h2\u003e \u003cp\u003eFor the CES-D-R10, scores of 10 or greater represent clinically elevated depressive symptoms(Andresen et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). The mean CES-D score in the present sample was 22, suggesting that the majority of participants were reported elevated depressive symptoms. Indeed, 86% of our sample met criteria for elevated depressive symptoms.\u003c/p\u003e \u003cp\u003eOn the GAD, a score of 8 or higher represents an established cut-off point for identifying probable cases of generalized anxiety disorder. The mean score among the Venezuelan women surveyed was 13, indicating elevated anxiety symptomatology among our sample. Further, 71% of participants met criteria for moderate to severe anxiety.\u003c/p\u003e \u003cp\u003eFor satisfaction with life in our sample, the average mean score was 20, indicating moderate levels of satisfaction with life. Based on item mean responses, 45% of our sample expressed feeling satisfied or slightly satisfied with lives, and 48% reported being slightly dissatisfied, dissatisfied, or extremely dissatisfied with life. The remaining 7% scored at the scale midpoint (4 on a 1\u0026ndash;7 scale). In terms of optimism, 83% of participants expressed high optimism (item mean responses between 3 and 4 on a 0\u0026ndash;4 scale), 13% expressed moderate optimism (item means between 2 and 3), and 4% expressed low optimism (item means below 2).\u003c/p\u003e \u003cp\u003eIn terms of access to health care, 80.2% reported they had gone to a medical establishment at least once since arriving to Peru. When asked if they had stopped taking medication due to not being able to afford it, 78% reported yes. Lastly, only 30% of the women reported they had medical insurance in Peru. In terms of whether participants\u0026rsquo; medical insurance covered mental health services, 10.9% of participants reported they did not have adequate coverage, 4.1% reported they had adequate coverage, 25% did not know, and 60% reported they did not have health insurance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eModel Fit and Path Estimates\u003c/h2\u003e \u003cp\u003eThe path model indicated acceptable fit to the data, c\u003csup\u003e2\u003c/sup\u003e(df)\u0026thinsp;=\u0026thinsp;224.162 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), CFI\u0026thinsp;=\u0026thinsp;.992, RMSEA\u0026thinsp;=\u0026thinsp;.087. Path estimates yielded several significant associations related to healthcare access among Venezuelan women in Peru. Discrimination was found to have a significant and negative association with optimism (β = \u0026minus;\u0026thinsp;.405, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and life satisfaction (β = \u0026minus;\u0026thinsp;.248, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.041). Whereas negative context of reception was significantly associated with anxiety (β\u0026thinsp;=\u0026thinsp;.251, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.021), depressive symptoms (β\u0026thinsp;=\u0026thinsp;.282, p\u0026thinsp;=\u0026thinsp;.009) and optimism (β\u0026thinsp;=\u0026thinsp;.246, p\u0026thinsp;=\u0026thinsp;.039).\u003c/p\u003e \u003cp\u003eDiscrimination was significantly and directly associated with access to healthcare, (β = \u0026minus;\u0026thinsp;.393, p\u0026thinsp;=\u0026thinsp;.001), but negative context of reception was not. Two mediated pathways emerged \u0026ndash; one linking negative context of reception with access to healthcare through optimism (β = \u0026minus;\u0026thinsp;.283, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.049) and another linking discrimination with access to healthcare through optimism (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;.408, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001). Anxiety, depressive symptoms, and life satisfaction did not play any significant roles in the present results. See Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e The present study was designed to examine the direct and indirect associations of cultural stressors (discrimination and negative context of reception) with access to health care among Venezuelan migrant women in Peru. Given the important roles of mental health and well-being in facilitating health care seeking, and given the deleterious associations of cultural stressors with mental health and well-being among Venezuelan migrants (XXXX; XXXX), we examined the intervening roles of depressive symptoms, anxiety, life satisfaction, and optimism in these associations. We also examined participants\u0026rsquo; reported levels of cultural stress, mental health, well-being, and health care access.\u003c/p\u003e \u003cp\u003eIn their pursuit of a better life, Venezuelan migrant women frequently encounter discrimination and a sometimes-unwelcoming reception in their new homelands. Indeed, XXXX et al. (XX) found relatively high levels of discrimination and negative context of reception among Venezuelan migrants in Colombia. It is important to generalize these findings to other South American countries that receive large numbers of Venezuelan migrants, as well as to examine the extent to which these cultural stressors can compromise health care access both directly and indirectly through mental health and well-being.\u003c/p\u003e \u003cp\u003e Our results suggest that both discrimination and negative context of reception may be negatively related to health care access through reduced levels of optimism, and that discrimination is directly related to reduced health care access above and beyond its indirect association through lowered optimism. These results suggest that cultural stressors interfere with Venezuelan immigrant women\u0026rsquo;s hopes for the future \u0026ndash; and that these reduced hopes are linked with barriers to accessing health care. Of course, given the legal hurdles that Venezuelans have faced in Peru (Freier \u0026amp; Perez, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), it is also possible that reduced access to health care (as a structural impediment to migrant integration) may reduce Venezuelan women\u0026rsquo;s optimism vis-\u0026agrave;-vis their lives in Peru. Future longitudinal work will be needed to examine the directionality of these effects.\u003c/p\u003e \u003cp\u003eOur results also highlight the importance of addressing discriminatory practices and improving social contexts to ensure equitable access to healthcare for vulnerable populations such as crisis migrants. Women\u0026rsquo;s access to healthcare is significantly impacted by perceived discrimination on the part of healthcare workers, clinic organizations, and the destination community in general. Indeed, recent work has begun to address regarding the criminalization of mass migration and the extent to which threat perceptions among host nationals are associated with hostile policies toward migrant groups (Freier, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This \u0026ldquo;crimmigration\u0026rdquo; narrative, the intersection of criminal and immigration law, (Menj\u0026iacute;var et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) may compromise migrants\u0026rsquo; daily lives and integration by increasing hostile attitudes and obstructing access to important types of health care, including mental health services.\u003c/p\u003e \u003cp\u003eOur results suggest that individuals who experience discrimination may be hesitant to seek healthcare services due to fear of mistreatment, harassment, or biased treatment by healthcare providers (Togioka et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) Systemic barriers, such as limited availability of affordable health services in certain neighborhoods, specifically Venezuelan neighborhoods in Peru, can have serious negative impacts on migrants\u0026rsquo; health and well-being.\u003c/p\u003e \u003cp\u003eWe also found that experiences of discrimination are associated with symptoms of depression and anxiety, as well as with levels of optimism and overall life satisfaction, among Venezuelan women. Interestingly, among these well-being and mental health variables, only optimism was associated with health care access. This finding suggests that crisis migrant women with lower levels of optimism may be less likely to seek medical attention when needed. Larger samples should be used to further explore these associations.\u003c/p\u003e \u003cp\u003eAdditionally, the significant associations of negative context of reception with anxiety and depressive symptoms emphasize the need for more supportive environments, especially for migrant women who have experienced trauma and stress during their migration journey. It is important to mention that these data were collected during the height of the COVID-19 pandemic \u0026ndash; such that health care access rates might have been higher at other times. Nonetheless, findings for links between cultural stress and mental health suggest that, given the embeddedness of cultural stressors within structural dynamics between majority and minority groups, government initiatives can play a pivotal role in addressing the mental health of Venezuelan women in Peru. Implementing accessible and culturally sensitive mental health services, raising awareness about the importance of mental well-being, and offering support for social integration and community engagement can significantly contribute to the overall mental health and acculturation process of this population.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe present findings should be interpreted in light of at several important limitations. First, the sample was small, suggesting that future studies are necessary with larger samples. We should note that the use of convenience sampling may limit the representativeness of our sample regarding broader Venezuelan immigrant population in Peru. Second, the cross-sectional design we used does not permit predictive or causal conclusions to be drawn. Third, the exclusive reliance on self-reports is subject to recall and other biases. Longitudinal and observational research can help to address these limitations. Next, the absence f a pregnancy variable may influence the likelihood of depression. Lastly, we lack information on the number of children, which is an important demographic factor that could impact the mental health of Venezuelan immigrant women.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFuture Directions\u003c/h2\u003e \u003cp\u003eGiven the findings of this study, several avenues for future research can be identified. First, longitudinal studies are needed to explore the directionality of the associations between cultural stressors, optimism, and healthcare access among Venezuelan migrant women. Such research would allow for a deeper understanding of how changes in discrimination and context of reception over time impact mental health and access to healthcare. Additionally, future studies should include larger and more diverse samples to enhance the generalizability of the results to broader populations of Venezuelan immigrants in Peru and other host countries.\u003c/p\u003e \u003cp\u003eLastly, future research should further examine the role of optimism in health outcomes for migrant populations. The finding that optimism, rather than other mental health variables, was associated with healthcare access suggests that promoting optimism through interventions could potentially improve healthcare-seeking behaviors. Exploring how targeted interventions\u0026mdash;such as cognitive behavioral therapy (CBT) or community-based resilience programs\u0026mdash;can enhance optimism and its protective effects on mental health and healthcare access among migrant women would provide practical implications for improving migrant health outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite these and other limitations, our findings suggest some important conclusions. Our findings underscore the importance of creating supportive environments for migrants, particularly those who have experienced trauma and stress during their migration journey. They also highlight the importance of cultural stressors as barriers to health care access for Venezuelan women in Peru, as well as the role of reduced optimism in these associations. It is therefore possible that, even if it is not immediately possible to reduce cultural stressors, programs to increase optimism may help to improve health care access among at least those women who have insurance but may not actively seek out care. We hope that the present results will inspire further work in this direction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMentors Dr. Behar-Zusman and Dr. Schwartz contributed to the editing and making of this manuscript. Colleagues Dr.'s Pesante, Montero-Zamora, Alpysbekova, PortoCarrero, Brown,Sahbaz, and Vo and Ms. Penna contributed to the editing, data analysis, drafting and final reviews of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAndresen EM, Malmgren JA, Carter WB, Patrick DL. 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J Health Psychol. 1997;2(3):335\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Venezuelan migration, humanitarian crisis, discrimination, mental health, healthcare access, optimism, life satisfaction, Peru, structural equation modeling, immigrant well-being","lastPublishedDoi":"10.21203/rs.3.rs-5405518/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5405518/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe ongoing humanitarian crisis in Venezuela has triggered a substantial migration exodus, with Peru emerging as a primary destination for Venezuelan refugees. Since 2016, approximately 1.8\u0026nbsp;million Venezuelans have migrated to Peru, resulting in significant challenges for both the migrants and the host country.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study, conducted in 2020\u0026ndash;2021, investigates the interrelation between discrimination, mental health, and access to healthcare services among Venezuelan women residing in Peru. Specifically, it aims to elucidate how perceived cultural stressors (discrimination and negative context of reception) influence healthcare access, with a focus on the mediating roles of anxiety, depressive symptoms, optimism, and life satisfaction.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData were collected in 2021 from 100 Venezuelan women (\u003cem\u003eM\u003c/em\u003e age: 34 years) living in Peru through surveys that assessed cultural stressors, mental health indicators, well-being, and healthcare access. Using structural equation modeling, we explored the associations of cultural stressors with healthcare access. We also examined the mediating effects of anxiety, depressive symptoms, optimism, and life satisfaction.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analyses revealed that perceived discrimination was negatively associated with optimism and life satisfaction, and directly correlated with decreased access to healthcare. Furthermore, negative context of reception was positively associated with greater anxiety and depressive symptoms, which in turn indirectly reduced healthcare access by reducing levels of optimism.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings highlight the profound impact of social and psychological factors on healthcare access among Venezuelan women in Peru. The study underscores the critical need for fostering supportive environments to enhance the well-being of this population. Additionally, it emphasizes the role of optimism and life satisfaction in mitigating the adverse effects of discrimination and negative context of reception.\u003c/p\u003e","manuscriptTitle":"A Story about Optimism and Access to Healthcare Services Among Crisis Migrant Venezuelan Women Living in Peru","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-28 07:12:43","doi":"10.21203/rs.3.rs-5405518/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"91445921-509a-4bf3-96ee-5d175bf03569","owner":[],"postedDate":"November 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-19T00:23:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-28 07:12:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5405518","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5405518","identity":"rs-5405518","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}