PHYSICAL AND MENTAL HEALTH DISPARITIES BETWEEN MIGRANT AND NON-MIGRANT FAMILIES: THE CASE OF DEARBORN, MICHIGAN By Marah Maaita A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Urban and Regional Planning -- Master of Urban and Regional Planning 2021 ABSTRACT PHYSICAL AND MENTAL HEALTH DISPARITIES BETWEEN MIGRANT AND NON-MIGRANT FAMILIES: THE CASE OF DEARBORN, MICHIGAN By Marah Maaita Studies have shown that cultural changes can positively or negatively affect psychological, behavioral, and physical outcomes when different cultures come into continuous contact (Amer, 2007; Berry, 2992; Leopoldo, 2003). Most of the changes occur in the non-dominant group (migrants) due to the settlement in the dominant sub-group society (Berry, 1992). The majority of research done in the United States and North America has focused on these changes for larger immigrant and minority groups such as Hispanics/Latinos and Asians (Amer, 2007; Gerber, 2011). However, in the United States, there is sub-group that is largely understudied, resulting in misunderstood data in mental and physical health: Arab Americans (Abuelezam, 2018; Amer, 2007) In fact, in the U.S. census, Arab American’s in the U.S. are categorized as “Caucasians or Whites”. This discrepancy leads to an oversight of a minority sub-group’s health problems and omits them from receiving proper social services and healthcare (Amer, 2007; Bertran, 2017). Using an online survey instrument, this study assessed mental health disparities and behavioral habits before, and since COVID-19 restrictions, and physical health disparities for 3xx residents in Dearborn, MI. Through inferential statistics and logistic regressions, results indicate that Middle Easterners experience higher mental health problems, are less likely to have healthcare coverage, have lower annual incomes, and lower educational attainment than non-Middle Easterners. TABLE OF CONTENTS LIST OF FIGURES ....................................................................................................................... vi 1. INTRODUCTION ...................................................................................................................... 1 2. LITERATURE REVIEW ........................................................................................................... 4 2.1 What We Know about Migrant Health ................................................................................. 5 2.1.1 Physical Health .............................................................................................................. 5 2.1.2 Mental Health................................................................................................................. 8 2.1.3 Access to Social Services............................................................................................. 12 2.1.4 Policies and COVID-19 Impact ................................................................................... 14 3. METHODOLOGY ................................................................................................................... 18 3.1 Study Area .......................................................................................................................... 18 3.2 Data Collection ................................................................................................................... 21 3.3 Questionnaire ...................................................................................................................... 22 4. RESULTS ................................................................................................................................. 25 4.1 Mental Health Disparities ................................................................................................... 30 4.2 Food Consumption .............................................................................................................. 35 4.3 Physical Health ................................................................................................................... 36 4.4 Healthcare and Doctor Visits .............................................................................................. 37 4.5 Behavioral Habits................................................................................................................ 38 4.6 Socioeconomics .................................................................................................................. 39 5. DISCUSSION ........................................................................................................................... 40 CONCLUSION ............................................................................................................................. 48 APPENDICES .............................................................................................................................. 49 APPENDIX A: Survey Results ................................................................................................. 50 APPENDIX B: Survey Questionnaire ...................................................................................... 56 BIBLIOGRAPHY ......................................................................................................................... 71 iii LIST OF TABLES Table 1: Questionnaire Variables and Types ................................................................................ 23 Table 2: Descriptive Statistics for Continuous Variables ............................................................. 26 Table 3: Descriptive Statistics for Categorical Socio-Economics Variables ................................ 27 Table 4: Descriptive Statistics for Categorical Health Variables ................................................. 29 Table 5: Mental Health Scale ........................................................................................................ 30 Table 6: T-test Mental Health Between Middle Eastern and non-Middle Eastern (Since COVID- 19) ................................................................................................................................................. 32 Table 7: T-test Mental Health Differences Before and Since COVID-19 Pandemic (Before-Since COVID)......................................................................................................................................... 34 Table 8: Food Consumption Scale ................................................................................................ 35 Table 9: Food Consumption T-test Results .................................................................................. 35 Table 10: Logistic Regression for Physical Health....................................................................... 36 Table 11: Logistic Regression for Health Care and Doctor Visit ................................................. 37 Table 12: Logistic Regression for Behavioral Habits ................................................................... 38 Table 13: Alcohol Consumption Difference (Before COVID-since COVID) ............................. 39 Table 14: Logistic Regression for Household Income and Highest Educational Attainment ...... 39 Table 15: Been Able to Concentrate on Whatever You’re Doing Before COVID ...................... 50 Table 16: Been So Restless That It Was Hard to Sit Still Before COVID ................................... 50 Table 17: Lost Sleep Over Worry About Something Before COVID .......................................... 50 Table 18: Felt You Could Not Over Come Difficulties Before COVID ...................................... 50 Table 19: Been Feeling Reasonably Happy Before COVID ........................................................ 51 Table 20: Felt Afraid As If Something Awful Might Happen Before COVID ............................ 51 iv Table 21: Been Able to Concentrate on Whatever You’re Doing Since COVID ........................ 51 Table 22: Been So Restless That It Was Hard to Sit Still Since COVID ..................................... 51 Table 23: Lost Sleep Over Worry About Something Since COVID ............................................ 51 Table 24: Felt You Could Not Over Come Difficulties Since COVID ........................................ 52 Table 25: Been Feeling Reasonably Happy Since COVID .......................................................... 52 Table 26: Felt Afraid as If Something Awful Might Happen Since COVID ............................... 52 Table 27: Consume Beans ............................................................................................................ 52 Table 28: Consume Green Vegetables .......................................................................................... 53 Table 29: Consume Fruit .............................................................................................................. 53 Table 30: Consume Eggs .............................................................................................................. 53 Table 31: Consume Meats ............................................................................................................ 53 Table 32: Consume Fried Foods ................................................................................................... 54 Table 33: Smoke Cigarettes .......................................................................................................... 54 Table 34: Cigarette Consumption Change Since COVID ............................................................ 54 Table 35: Other Forms of Tobacco Use ........................................................................................ 54 Table 36: Tobacco Consumption Change Since COVID ............................................................. 54 Table 37: Drinks Alcoholic Beverages ......................................................................................... 54 Table 38: Worry of Worsening of Chronic Illness Since COVID ................................................ 55 v LIST OF FIGURES Figure 1. Produced in ArcGIS: Michigan, Dearborn, and Surrounding Cities ............................. 18 Figure 2. "Arab Market, Dearborn Michigan" by sharghzadeh is licensed under CC BY-NC 2.0 ....................................................................................................................................................... 19 Figure 3. "Arab Book Store, Dearborn Michigan" by sharghzadeh is licensed under CC BY-NC 2.0.................................................................................................................................................. 20 vi Studies have shown that cultural changes can positively or negatively affect psychological, 1. INTRODUCTION behavioral, and physical outcomes when different cultures come into continuous contact (Amer, 2007; Berry, 2992; Leopoldo, 2003). Most of the changes occur in the non-dominant group (migrants) due to the settlement in the dominant sub-group society (Berry, 1992). These changes have been attributed to the acculturation process, socioeconomic status such as low literacy, low educational attainment, and poverty that affect mental, physical health, and behavioral habits. Acculturation differs between different ethnic communities as each process of accustoming to the new host is individualized. Migrants can face six different acculturations: physical, biological, political, economic, cultural, and social change that attribute to psychological, stress, and physical health changes (Berry, 1992; Ward ,2020). Economic, social, and cultural changes contribute to biological changes as access to social services stem from low-income, lower levels of education, racial discrimination, and language barriers to get the appropriate health care and food accessibility. Political changes also contribute to biological changes as immigration policies, especially in the United States, disadvantage immigrants from receiving proper health care and social benefits. Physiological changes such as negative mental health stressors rise from social and cultural acculturation as many migrants first and second-generation can face multiple pathways of discrimination (Amer, 2007; Berry, 1992; Phinney, 2001; Ward, 2020) Although there has been research done on migrants’ (internal and external) physical and mental health, simultaneously, there are still very few studies confirming the magnitude of health risks. The bulk of research in the United States and North America has concentrated on broader immigrant and minority groups including Hispanics/Latinos, African-Americans, and Asians. (Amer, 2007; Gerber, 2012). In the United States, Arab Americans are largely understudied, 1 resulting misleading data for mental and physical health research (Abuelezam, 2018; Amer 2007). In the U.S. census, Arab American and Middle Easterners are grouped within a different sub-category that results in a lack of visibility in public healthcare data on the relationship between health and social inequalities. Arab American’s in the U.S. are categorized as “Caucasians or whites,” misleading the use of data for both sub-groups, “whites'' and Middle Easterners. This discrepancy leads to misidentification, identity crisis, and an overlook on a minority subgroup that is facing critical health problems that omits them from receiving proper social services and the appropriate healthcare services (Abuelezam, 2018; El-Sayed, 2009). This study examines the health disparities between Middle Eastern migrants’ that are often recognized to be associated with the living and working conditions, socioeconomic status, and social environment and how the pandemic, COVID-19, has affected these health outcomes. In this study participants are asked if they are Middle Easterners rather than Arab-American to capture their geological origins from Lebanon, Jordan, Saudi Arabia, Yemen, Palestine, Syria, Iraq and other countries since the U.S. census uses the term Middle Eastern to define Arab- American as Caucasians or whites. The implications of the research point towards recommendations for policies that can be enforced to improve the environments that surround Arab-American migrant families and understand the intensity of the stresses they face. These policies can be implemented if there is awareness of the structural barriers and difficulties migrants face when they are not recognized and have not been accounted for in earlier migration health related articles (Amer & Hovey, 2007). Further, this research examines the experiences of immigrant families with the effects of the recent Covid-19 pandemic. For years, the government has lacked preparation towards emergency planning and focused their energy towards illegal migration, transnational organized crimes like terrorism, and human trafficking. Although those 2 are all important and need preparation, COVID-19 is a reminder that immigration policies towards migration health also deserves attention (Igoye, 2020). The social and economic impact of the COVID-19 pandemic has sparked institutional and economic instability, including a potential change in opinion against migrants, as many serve as front-line critical workers, raising their risk of contracting the virus or losing their jobs with no alternative source of income (Fernández-Reino et al., 2020). Through inferential statistics and logistic regressions, results indicate that Middle Easterners experience higher mental health problems such as greater feeling of restlessness, fear of physical health of ones or loved ones, less feeling of happiness, and other indicators of stressors before and since the COVID-19 pandemic. This study also found that Middle Easterners are less likely to have healthcare coverage than non-Middle Easterners coinciding with the findings of less likelihood to visit a doctor or health facility. Further, Middle Easterners earn much less in annual income and have much less educational attainment than non-Middle Easterners. However, the sample showed that Middle Easterners are less likely to be obese and have chronic illnesses than non-Middle Easterners, although there were no significant differences in eating habits or accessibility to foods. Applicable future policy and research implications and recommendations are given in hopes to benefit both subgroups through the acculturation process, destigmatizing negative mental health, and through immigration policies that advantage immigrants during the pandemic crises. 3 The process of acculturation; “culture change that results from continuous, first-hand contact 2. LITERATURE REVIEW between two cultural groups” (Mägi, 2018; Redfield, 1936), is not a new phenomenon as it has been part of the migration process study for over half a century (Berry, 1992). The cultural changes can have positive or negative psychological, behavioral, and attitudinal outcomes when different cultures come into continuous contact (Amer, 2007; Berry, 1992; Cabassa, 2003). Both sub-groups from the different cultures can experience changes but it is important to note that most of the changes occur in the non-dominant group (migrants) as a result from the settlement in a new host country (Berry, 1992). The “healthy immigrant effect” is a known phenomenon that states the health of immigrants is better than their native-born counterparts upon arrival (Aplipay, 2012; Mcdonald 2004). Multiple literatures include the idea that the immigrants with better physical and mental health deteriorate over time in the new host. When immigrants arrive in a new society, they encounter distinct cultural changes that cause behavioral shifts and acculturative stress (Aplipay, et al., 2012). To be more specific, there are six changes, in theory (Berry, 1980 & 1992), that migrants face in acculturation and produce group level results: i) physical changes, including a new place to live, housing, population density, urbanization, and environmental changes such as pollution; ii) biological changes: nutritional status and exposure to new diseases; iii) political changes and having some loss of autonomy; iv) economic changes and new forms of employment; v) cultural changes such as alteration of original linguistics, religion, and education; and vi) social, wherein social relations become altered. Each of the six have numerous psychological changes and are referred to acculturative stress (Berry, 1980) or a psychological culture shock (Ward & Furnham 2020). 4 There are four strategies migrants can experience settling into a new society; integration, assimilation, separation, and marginalization which determine the adaptive outcomes for different individuals and sub-groups (Amer, 2007; Berry, 1997; Ward, 2010). According to research, marginalization is linked to the highest levels of acculturation stress, which is caused by factors such as foreign languages, traditions, practices, bias, and discrimination. (Amer; 2007, Berry, 1997; Phinney, 2001). These stressors tend to lead to mental health problems, identity confusion, alienation, anxiety, and depression (Phinney, 2001; Ward, 2020). 2.1 What We Know about Migrant Health 2.1.1 Physical Health Several researchers argue that of acculturation has adverse effects on healthy behaviors and can potentially impact physical and mental health outcomes (Gerber, 2011; McKay, 2003; Unger, 2004). After settlement, migrants’ morbidity and mortality rates either stay the same, increase, or decrease (McKay, et al., 2003).These patterns may be influenced by a combination of certain risk factors, such as migrants’ diet, weight, and Body Mass Index (BMI) changes, smoking behavior and alcohol consumption in the duration of being in the new host country (McKay, et al., 2003). Having a background of ethnic minority status does not establish health risks alone; there are several hypotheses that present a linkage between migration and health risks: i) migrants might choose to emigrate with predisposed health problems such as coming from a poor country or running away from traumatic experiences, ii) the stress that comes after coping with migrating or acculturation in the new host, iii) The “healthy immigrant effect” holds that people who migrate have better health than those who do not migrate, iv) immigrants have better health than non- immigrants, and this better health deteriorates with time (a lengthy period of residency, language use, or increased status in generation) (Amer, 2011; Sam, 2006; Gerber, 2011). Empirical 5 evidence supports these four hypotheses because the circumstances under which migration an individual takes is different across different ethnic groups (Gerber, et al., 2011). Acculturation and health behaviors have been shown to have a detrimental relationship in studies conducted in the United States (Amer, 2011; Gerber, 2011; Unger, 2004). Hispanic and Asian- American immigrants in the U.S. have implicated acculturation risks of unhealthy behaviors (Gerber, et al., 2011). For instance, among Mexican immigrants in the U.S., there are trends in substance misuse, tobacco use, eating disorders and unhealthy dietary activity among who are more acculturated (Amer, 2011; Gerber, 2011; Unger, 2004). The new environment serves dietary and lifestyle habits to the dominant group, which are not beneficial to maintaining the norm of the healthy lifestyle as back home (Mckay, 2003). One adapts to the western dietary habits that could lead to increased risk of obesity, diabetes, heart disease, and cardiovascular diseases (Creatore, 2010; Ebrahim, 2011; Gerber, 2011; Goel, 2004; Kaplan 2004). Physical activity among migrant groups in high-income countries is hampered by cultural and religious factors, social relationships, socioeconomic factors, and environmental factors (Caperchione, 2009; Weiland, 2015). Migrating to a new host does not offer cultural standards that encourage physical activity leisure (Weiland, 2015; Singh, 2008). Social support is associated with physical activity and, as immigrants are poorly supported by a new host, physical activity is negligible (Weiland, 2015; Singh, 2008). It has been shown that in order to motivate people to lose weight and consider their diabetes risk, people are more likely to succeed if they have cultural and family social support and are well informed on the benefits of physical activity. (Marquez, 2006; Pinelli, 2011; Wolin, 2006). For example, Latina women in North Carolina who know positive physical activity role models in their community and see them to be more active were more likely to be physically active themselves (Weiland, 2015; Evenson, 2004). 6 Socioeconomic status such as low literacy, low educational attainment, and poverty are also associated with physical activity barriers (Evenson, et al., 2004). Poverty in a new country renders the economic barriers that contribute to environmental barriers for less physical activity (Lui, et al., 2009). Reasons for inactivity levels in youth may include poor neighborhood safety in low-income neighborhoods, lack of physical activity equipment, and low enrollment in organized sports (Gordon-Larsen, 2006; Hanson, 2006; Molnar, 2004; Weiland, 2015). These factors could explain why immigrant households, regardless of generational status, have low levels of physical activity. Food insecurity is often linked to a variety of acculturation and sociodemographic factors. Food insecurity is specified as “a household-level economic and social situation characterized by inadequate or uncertain access to sufficient food” (US Department of Agriculture, Economic Research Service, 2018). Financial issues such as low-income occupations are common for migrants, and disposable income typically gets allocated in the family budget towards satisfying children’s necessities (Hadley 2007, Hersey 2001). Food insecurity risk are also attributed to poor economic conditions such as below poverty level income and low education attainment (Dharod, 2013; Hadley, 2007; Hersey, 200; Murthy, 2016; Vu 2020). Immigrant and refugee families face financial constraints that limit food shopping decisions (Dharod, 2013; Hadley, 2007). They may seek out food products that are widely consumed in their home country, but the prices may be out of reach given their current financial condition (Jetter, 2006; Hadley, 2007). For example, since a meal without meat is not considered an appropriate dietary meal in their culture, in the U.S., Somali women refugees may prefer to reduce their fruit and vegetable consumption rather than meat (Dharod et al., 2013). The severity of food insecurity are also often related to acculturation actions such as shopping difficulty, 7 social insulating and language difficulty (Hadley, 2007; Himmelgreen, 2000; Kaiser, 2002; Vu, 2020). Food insecurity is a great indicator for health and well-being because of its association with poverty (Alaimo, 2002; Hadley, 2007; Himmelgreen, 2000), linking it to its effect on dietary intake patterns, obesity, physical inactivity, elevated depressive symptoms, and negative behavioral habits (Gucciardi, 2009; Fitzgerald, 2011; Kaiser, 2002; Lee, 2001). In 2016, a Michigans health risk studies for Arab-Chaldean revealed that a psychiatrist stated that 12.4 percent of Arab adults in Michigan have diabetes (Neumayer et al., 2017). In addition, Southeast Michigan has a large and increasing Arab-American population, whose risk of cardiovascular disease is increasing (Hatahet, 2002; Jamil, 2007). However, the inconsistency of Arab’s within Michigan reporting to have diabetes and cardiovascular diseases in this study also report to rarely or never have difficulties purchasing quality fresh fruits and vegetables (Neumayer et al., 2017). Although, Arab’s in this report are both native and non-native, there is a disparity among Arab-Americans regarding the relationship to physical health and food accessibility. This suggests that there needs to be further investigation between native and non- native Arabs in the United States, and what other factors could lead to the increased prevalence of diabetes, obesity, and cardiovascular diseases for both sub-groups of Arab-Americans. Often, due to limited data on Arab-American communities, the knowledge of country-specific immigration groups is blurred, which results in limited knowledge of health determinants within ethnic groups (Amer & Hovey, 2007). 2.1.2 Mental Health Migration can be a source of stress in many types of change. Migrants face social, political, and economic adversity upon migrating to the United State which are also the push-factors of leaving 8 their origin country (Torres & Wallace, 2003). Stressors related to these conditions can be from social and structural inequalities upon coming to the U.S., thus it is hard to determine if new norms are affecting mental health. Migrants face discrimination from language barriers, legal status discrimination, engendering to feel cross-border separation; having no one close-by for social support (Hunt, 2002; Torres, 2013; Viruell-Fuentes, 2012). Migrants who move from one location to another face a rapid shift in living and working conditions (Lu, 2010; Nauman, 2015). If migrants are committed to sending significant remittances to family members back home, or if there is a difference between commitment and achievement in new working environments, the stress level rises (Lu, 2010; Hashemi, 2019; Torres, 2013) Older Hispanic and Asian migrants have a higher risk of depression and anxiety compared to nonimmigrants and those that remained in their native countries. (Du & Xu, 2016). The induced depressive symptoms can result from not having social support due to being away from family or discrimination (Du & Xu, 2016). The fact of being away from primary support addresses an issue that social support groups should be provided and accessible in areas of high migrant population. The lack of social support causes feelings of loss and isolation, and it can also exacerbate the negative effects of stress (Philbin, et al. 2018). Many Middle Eastern immigrants who move to the United States and Europe come from war and conflict zones, exposing them to trauma and traumatic experiences (Abuelezam, et al., 2018). Iranian and Afghanistan refugees in Australia showed growing psychological disturbance over two-years (Steel, et al., 2011). Stress-related study found that migration and post-immigration experience examined for Arab immigrant women were positively correlated with depression and PTSD (Norris, et al., 2011). Arab Americans experienced more psychological distress in the years following September 11th, according to studies (Amer, 2012; Khawaja, 2016). Over the 9 last two decades, discrimination and stigmatization have risen in the United States (Abuelezam et al., 2018). In Arab American populations, anti-Arab feelings were correlated with negative results in mental wellbeing, such as depression and stress(Abuelezam, 2018; Amer, 2012; Khawaja, 2016). The tragedy of the 9/11 terrorist attacks was another trigger for Islamophobia and discrimination towards Arab Americans for being associated with terrorism and radicalization (Amer, 2013; Khawaja, 2016). The option of acculturation strategy did not occur in isolation, as Muslim and Arab-American individuals faced alienation from culture, socio-cultural adaptation, and larger society discrimination (Khawaja, 2016; Kunst, 2013). People from the west have perceived Muslims with fear and suspicion for a long time (Khawaja, 2016). Subsequently, Muslims and Arab-Americans then perceive this as a “us versus them” situation (Blackwood, 2015; Bux, 2007; Khawaja, 2016), staying close within their Muslim communities. These cause various levels of vulnerability within different communities in the West versus Arab American/Muslims as to who is more accepting and not. Many who use the separation technique by strengthening relations with their own ethnic group have higher rates of depression and anxiety (Fassaert, 2009; Khawaja, 2016; Ünlü Ince, 2014). Though there have been studies that show significant results of mental health inequalities, it becomes limited because results differ in different regions and ethnic groups. As a result, they are unable to speak for all Muslims in the West (Khawaja, 2016). Depending on a person's cultural group, the ties between acculturation, family acculturation, and mental health can differ (Asvat, 2008; Khawaja, 2016,). Arab Americans have recently identified 14% of Arab Americans with depression (Jaber et al., 2014) while another Arab-American survey showed that 50% of the people surveyed meet the depression criterion (Amer & Hovey, 2011).Depression has 10 been found to be more prevalent among older Muslim immigrants (Abu-Bader, et al. 2011). Discrimination has been identified against Muslim youths in the United States, and they tend to be the most vulnerable (Sirin & Fine, 2007). Stress expresses itself in a variety of ways, including psychiatric disorders, cardiovascular disease, a compromised immune system, and dysfunctional behavioral responses (Lu, 2010; Torres, 2013). Within the stress of also being a migrant and moving, stress is linked to physical well-being and unhealthy habits (Borrell, 2010; Du, 2016). Distress increases unhealthy habits like smoking and substance abuse that is detrimental to physical health (Borrell, 2010; Du, 2016). The less assimilated Arab Americans have been shown to have greater dependence on nicotine and cigarette products. (Abuelezam, 2018; Arfken ,2009). Prevalence of cardiovascular disease in the Arab Americans could be attributed in part to lifestyles of tobacco use and stress- induced behavioral habits. Evidence suggests that Arab-Americans are hesitant to seek psychotherapy and treatment (Kira, et al. 2015). In Arab, Muslim, and many refugee/immigrant cultures, mental illness is often stigmatized (Kira, 2015; Nasser-McMillan, 2003). Individuals internalize that family biases prevent them from finding support because it would be embarrassing for them and their family (Kira, 2015; Soheilian, 2009). Self-esteem, self-efficacy, and functioning are all affected by stigmatization (Corrigan, 2004; Kira, 2015). Public stigma of minorities' mental health is already problematic, as it vexes internal stigma towards mental health treatment (Kira, et al., 2014). When immigrants looked for treatment, clinicians documented a lot of intergenerational tensions and problems adapting to new hosts' cultural norms (Martin, 2012). 11 2.1.3 Access to Social Services Foreign-born people have lower levels of schooling and are less likely to have healthcare coverage than native-born people (U.S. Census, 2007; Edward, 2015). These inequalities have been linked to immigrant status, which makes people less likely to use health and social services (Chen, 2011; Derose, 2007; Edward, 2015). Migrants face multiple pathways that produce stress when accessing beneficial social services such as racism, education, health-related accessibility (health-care), the consequences of inequality, income, and geographical disbursement (De Santis, 1990; Fowler, 1998; Winn, 2018). Pathway of structural racism could plausibly reduce access to healthcare and detrimentally affect the conditions of peoples’ lives (Simich 2005, Pinelli, 2011). This causes confusion between state and federal policies and immigrants on eligibility for services, and even leads to a spillover towards second generation immigrants (Arbona, 2010; Edward, 2015; Simich, 2005). For racial and ethnic inequalities in insurance coverage and access to treatment, immigration status and length of residency are critical factors. Uninsured immigrants account for almost half of all immigrants, which is about three times the rate of native-born people (Ku, 2017). Since recent federal and state policies have limited some immigrants' access to health care, meeting the health care needs of immigrant communities is difficult. These initiatives have intensified already existing access disparities. When too many immigrants do not have health care, they face medical policy challenges and are likely to have to pay from pockets (Simich 2005, Ku 2017). Other obstacles to immigrants' access to and standard of medical care include language barriers, cultural beliefs toward accessing mental health treatment, and high levels of mistrust in physicians (Jimenez, 2012; Kim, 2011). Immigrants and refugees can avoid seeking treatment at public health care facilities that ask about immigration status and receipt of social benefits 12 because such inquiries can result in problems with immigration policies and officials (Ku 2017). As a result, immigrants are much less likely than natives to use medical facilities, hospitals, emergency medical services, and dental care (Du, 2016; Fowler, 1998; Ku, 2017; Jimenez, 2012). Due to the lack of social support and network connections, immigrants’ sense of identity may be corresponding to the level of acculturation, trust, and education sources to support immigrants over time, reducing inclinations for outreach. There has been little research reported on Middle Eastern immigrant parents’ social networks and help in seeking related health care for families (Abuelezam, 2018; May, 1992). In 2016, an estimated 18.8% of adults in Michigan said that, because of financial limitations, they had not seen a doctor during the past 12 months (Neumayer et al., 2017). In Michigan, an estimated 29.2 percent of Arab American adults said they delayed treatment for reasons other than cost (Neumayer et al., 2017). According to studies, using social services to gain social support is critical to reducing tension, preserving wellness, and ultimately achieving self-sufficiency and well-being (Anderson, 1991; Simich, 2005). For Arab-Americans, misunderstandings between healthcare professionals and clients could be caused by differences in culture, language, attitudes, and social behavior (De Santis, 1990; Simich, 2005; Stewartm 2008). Barriers to Arab Americans' breast cancer screening included immigration barriers, anxiety, lack of information and access problems (Abuelezam et al., 2018). The obstacles to Arab Americans' screening and recovery are lack of education, religious convictions or societal beliefs about illness, anxiety, humiliation of language differences, lack of cultural sensitivity from healthcare providers, lack of access to healthcare, and the desire to protect sickness or disease confidentiality (Abuelezam et al., 2018). Often, Arab immigrants do not meet their health care needs due to these misunderstandings (Amer, 2011; Laffrey, 1989). 13 2.1.4 Policies and COVID-19 Impact This paper further explores how Arab-American families in Dearborn, Michigan have adjusted through a recent global pandemic: the coronavirus. COVID19, a newly identified virus, was first confirmed in late 2019 in Wuhan, China, and “thought to have originated from snakes, bats, and pangolins at the Wuhan wet markets” (Ji, et al. 2020). The virus has quickly spread around the world, infecting a large number of people and resulting in many deaths (Centers for Disease Control and Prevention, 2020; Ji, 2020; Usher, 2020; Wang, 2020). The COVID-19 first case in the U.S. was roughly confirmed in late January of 2020 (World Health Organization, 2020). However, quickly after, human to human transmission escalated the spread of COVID in the U.S. and state after state announced emergencies including Michigan; declaring stay-at-home orders, shutting down of restaurants, gyms, restricting grocery store hours, and all nonessential workers had to either be laid-off or work remotely from home (Executive Order No. 2020-4, 2020). On March 13, President Donald Trump declared a national emergency and initiated a travel ban for any non-American who visited any European country within the past 14-days to not be allowed back in the U.S (World Health Organization, 2020). The everyday impacts of COVID-19 include our public health systems preparation, how families spend time together, friends, our entertainment activities, losses of jobs, and family. As a mass quarantine was imposed, social isolation, increased anxiety and fear of becoming trapped, a sense of lack of control, and fear of being ill all increased rapidly (Usher, 2020; Rubin, 2020). The pandemic's implications are both real and anticipated, namely fear and isolation of those who are sick, disruptions in the social support networks, disruptions to everyday life and mental health effects on healthcare workers (Usher, et al., 2020). 14 Regardless of the shut-down, many people were still traveling in other areas of the world, since travel restrictions differed in every country every day. Immigration policies have shifted during the pandemic as it was unclear which migrants would be let in from abroad during the pandemic (Moroz, et al., 2020). Immigration policy facilities typically determine which migrant workers are allowed in based on skill-level and education attainment and what type of labor force is needed in the nation (Leighton, 2015). With immigration restrictions in the United States becoming more restrictive over time, immigration programs tend to choose applicants who have a higher level of education or who are more likely to earn higher wages on a daily basis. Because of government and immigration policies that give them work permits for longer periods of time, higher-skilled or higher-paid immigrants experience less stress (Leighton, 2015). COVID-19, on the other hand, has raised public consciousness of the economy's daily reliance on low-wage jobs. Many of the lower wage workers listed as essential during an emergency rely on migrant work (Fernández-Reino et al., 2020). In some ways, migrants should not only be considered for short-term measures to satisfy peak labor demand, but immigration policies should also adjust for evolving demands for low- skilled migrant workers in the long run to provide vital goods and services when an emergency arises (Fernández-Reino, 2020; Moroz, 2020). In February 2020, the federal government extended visa refusal or green cards implementations to immigrants who are expected to become financially reliant on welfare (Cholera et al., 2020). The changes expanded the program's consideration of being a “public charge” in social service determinations, including Medicaid for adult immigrants (Cholera, 2020; Raphael, 2020). If any individual is receiving one or more benefits from the government, they are considered to be a public charge. If an individual becomes a public charge, the denial of visas or green cards is 15 plausible (Raphael, et al., 2020). Furthermore, by March 2020, in reaction to the economic consequences of this pandemic, the Government passed the Coronavirus, Relief and Economic Security Act of about $2 billion. However, everyone in a household that uses a taxpayer ID number, common in immigrant families, were not allowed to get additional capital benefits (Cholera, et al., 2020). The pandemic exacerbates current inequities while creating new ones for immigrant families that lack health care and do not receive other social services such as unemployment insurance. This "chilling effects" will discourage immigrant families from applying for Medicaid and other services, including WIC and SNAP, exacerbated by the ongoing immigration policies (Raphael, et al., 2020). In abstaining for evaluation or treatment from these policies, immigrant families may also risk virus transmission and receive inadequate access to healthcare (Cholera, et al., 2020). With the economic hardships of COVID-19 among all demographic groups, food and housing insecurity rose and studies have shown immigrant families faced higher risks because of prejudiced policies broadening inequalities (Cholera, 2020; Endale, 2020; Tai, 2020). Researchers discovered that many parents in the Kovler Center Child Trauma Program (KCCTP), which serves immigrant children and families, were laid off and had a hard time obtaining services like unemployment insurance, resulting in food and housing insecurity (Endale, et al., 2020). Ethnic minority groups are already facing mental health inequalities before the pandemic and have only increased since the pandemic (Smith, et al., 2020). In terms of psychological effects, clinical staff observed an increase in worry and anxiety among families (Endale, et al., 2020). Social distancing measures, the closing of schools, and places of work also meant increased boredom, isolation, loss of social support, as well as reduced daily structure, negatively affecting overall functioning (Endale, 2020; Smith, 2020; Tai, 2020). 16 There is evidence of Arab-American immigrants encountering numerous mental health problems in the United States but disparities among this group stays obscured as there is no clear inferences of linkage between Middle Easterner sub-groups and their relation to socioeconomic statuses, barriers to social services, and physical health. Studies have shown that Arab- Americans have an increasing prevalence of cardiovascular disease, diabetes, signs of depression and anxiety, but contradict the correlation between food accessibility’s attribution to physical and mental well-being. Between these studies, they have yet to discover correlations or links for these adverse explanations. This study hypothesizes that Middle Easterners/Arab-American in Dearborn, Michigan face higher risk of mental and physical health than their counter-parts, non- Middle Easterners. Further, this study’s data collection period occurs during a world-wide pandemic, COVID-19. COVID-19 does not discriminate from foreign-born or native individuals nor does it improve any measures for immigrants' lifestyles. It is expected that during these times, immigrant families will face further physical and mental health hardships as they are already included in public health data, but the impact is uncertain as policies and political agendas change receiving adequate health care and social services benefits. This study recognizes a second hypothesis that COVID-19 impacts Middle Easterners mental health than their counterpart, non-Middle Easterners. 17 3. METHODOLOGY 3.1 Study Area Known as the “birthplace of Henry Ford”, the City of Dearborn is the headquarters of research, engineering, and manufacturing of the Ford Motor Company (Britannica, 2013). The territory of Dearborn is 24.5 sq mi, of which 25.4 sq mi (99.6%) is land, and 01. sq mi (0.4%) is water (U.S. Census, 2019). The city is stationed in Wayne County, southeast of Michigan, adjacent to the city of Detroit. It holds the second largest population in Wayne County and 9th largest in Michigan with a population of 93,927. Since 2015, the population of Dearborn has decreased by a slight 1.3%, following a similar population decline as Wayne County which is projected to decline 3% by 2023 (SEMCOG, 2018). Figure 1. Produced in ArcGIS: Michigan, Dearborn, and Surrounding Cities 18 Dearborn has had a long history of the greatest concentration of population of Arab descent in the United States (Abdallah-Hijazi et al., 2019). Many of them immigrated during the World Wars to work in the Ford factory. Dearborn has done considerable work to cultivate the Arab descent culture within the city with street and shop signs posted with both English and Arabic language. It is self-conscious in cultural representation by providing cultural prominence through businesses, mosques, churches, and other forms of social clubs (Abraham & Shryock, 2000). Dearborn hosts over 50 grocery stores that are recognized as “Arabic grocery stores” and generic stores such as Kroger and Save-a-Lot supply groceries that are suitable for Arab-Americans like halal meats (Yellow Pages, 2021). Around 10 Muslim religious organizations, including mosques, two Islamic Schools, four advocacy groups for Arab-Americans, and 30 Christian religious organizations, including churches occupy particular regions in Dearborn (Yellow Pages, 2021; Shryock, 2014). Figure 2. "Arab Market, Dearborn Michigan" by sharghzadeh is licensed under CC BY-NC 2.0 19 Figure 3. "Arab Book Store, Dearborn Michigan" by sharghzadeh is licensed under CC BY-NC 2.0 Although, on foot there is cultural representation and inclusion, there is no acceptance of Arab- Americans through census data, making it difficult to track Arab immigrant trends. Dearborn is characterized as being 90% white (U.S. Census, 2010). In actuality, about 30% of the residents were Arab in Dearborn in the U.S. Census 2000 briefing; in which the briefing suggested further research should be done in order to identify Arab-American’s for future censuses (U.S. Census, 2003). Although there have been multiple confrontations and pushes to include Middle Eastern as a race option, in the Census 2020, the questions still exclude Middle Eastern and are left to be part of the "White" category (U.S. Census, 2020). 20 3.2 Data Collection The original plan was to do a random sampling of households that were of Middle Eastern ethnicities (Arab - immigrant households) and non-immigrant households so as to get a representative sample for the quantitative analyses. A commercial mailing list firm was contracted to provide addresses for all households in the city of Dearborn. There are about 31,440 households out of which 25% are Arab-origin and 75% are non-Arab. In order to get a representative sample, households would have to be selected randomly based on this population split, however, knowing that Arab participation would be lacking in the study, Arab and non- Arab households were sampled equally. Typically, a 20% response rate is considered normal for surveys, however, knowing that online survey participation in minority population groups is much lower (closer to 10%), it was decided to pick a random sample of 4,000 households (1,000 Arab and 3,000 non-Arab ethnicities) to aim for a 10% response rate and get about 400 participants in the study. Based on a sample calculator, in order to get a confidence level of 5% and an interval of 5, it was determined that a sample size of 380 was needed (Survey System - Sample Size Calculator) and in hopes for a rounded figure of 400 participants, and at a 10% response rate, 4,000 households were selected at random to get invitations to participate in the study. Once the random sample was chosen (representing Arab and non-Arab households), a postcard was sent out to all the households informing them of the study and encouraging participation in the study. As an incentive, those that participated in the study and completed the survey were offered to be entered into a random drawing to win one of two gift cards for $50. The survey instrument was developed on the Qualtrics survey platform, and included questions on socio-demographic characteristics and both sub-groups’ physical and mental health before and after the COVID-19 pandemic, allowing for a comparative study (before and after) with the 21 pandemic restrictions as the event. The aim of the study was to assess whether a crisis, such as the pandemic, has disproportionate effects on a marginalized population. The study was approved by the Michigan State University Institutional Review Board (IRB) as exempt (STUDY00004367). With the data collection using the above methods underway in April 2020, it was apparent that the responses and participation rates were laboriously low. There was about a 1.2% response rate by June 2020. Understanding that there needed to be a change in the approach for the project to be successfully completed, it was decided that contracting with and purchasing responses through Qualtrics would be attempted to get more participants. This was successful as the study ended up with a total of about 398 survey responses by September 2020. All statistical analysis was conducted through Stata/IC software for descriptive, t-tests, and regression analyses. 3.3 Questionnaire Before proceeding to send out the postcards attached with the survey, measures were taken to develop a questionnaire to focus specifically on physical and mental health disparities. The questionnaire contained general socioeconomic status, weight and height to measure BMI, food habits, and behavioral habits. The questions were broadly based on other general health-status measures found in other online questionnaires that have been widely distributed from The National Institute of Environmental Health Sciences (NIEHS) and The Demographic and Health Surveys Program (DHS) (DHS, n.d.; NIEHS, 2013) Our physical health questions centered around weight and height; whether the participant is under/overweight, food habits; whether they are eating fresh foods or eating more fried, and tobacco and alcohol consumptions. Food and alcohol consumption questions are on a 5-point Likert scale from daily to once a month. The 22 mental health questions focused on the feeling of lack of sleep, productivity, stress, and worry. These questions were on a scale of 0 to 100 for intensity based on perceptions of wellbeing to mental health concerns. Majority of the physical and mental health questions followed with the general feeling before COVID-19 and since COVID-19. Table1 displays the number of questions for each focus and number of responses. Table 1: Questionnaire Variables and Types Type # of Variable Socioeconomics Mental Health Physical Health questions 14 10 21 Age Ethnicity Middle Eastern Gender Religion Education Attainment Household Number Household Number Under 18 Years Old Marital Status Employment Status Owner/Rental Duration in House Duration in Dearborn Median Household Income Concentrate During Tasks Felt Restless Loss of Sleep Not Overcome Difficulties Reasonably Happy Felt Afraid General Bad Mental Health Poor Health – slowing you down Fear of Physical Health Fear of Access to Health Care Weight Height FT Height IN Doctor Visit Within !2 months 23 Numeric/Categorical Before-COVID-19 & since-COVID-19 change Numeric Categorical Categorical Categorical Categorical Ordinal Numeric Numeric Categorical Categorical Categorical Numeric Numeric Ordinal Likert scale Likert scale Likert scale Likert scale Likert scale Likert scale Numeric Numeric Numeric Numeric Numeric Numeric Numeric Categorical X X X X X X X X X X X X Table 1 (Cont’d) Type # of Variable questions Numeric/Categorical Before-COVID-19 & since-COVID-19 change Health Care Facility Visit Covered by Health Insurance Type of Health Insurance Weekly/Monthly Milk Intake Weekly/Monthly Beans Intake Weekly/Monthly Vegetables Intake Weekly/Monthly Fruits Intake Weekly/Monthly Eggs Intake Weekly/Monthly Meat Intake Weekly/Monthly Fried Foods Intake Cigarette User Cigarette Habits Change Other Tobacco Form Tobacco Habits Change Alcohol Consumer Drink per week Drink per month Categorical Categorical Categorical Ordinal Ordinal Ordinal Ordinal Ordinal Ordinal Ordinal Categorical Categorical Categorical Categorical Categorical Numeric Numeric X X Specific variables were chosen to understand the disparities, so questions that were not necessary were omitted before the posting of the survey. This was intended so the survey did not take longer than 5 to 10 minutes to complete. In general, the 10 minutes mark seemed to be the average amount to complete the survey online. Overall, 360 consented to continue taking the survey. 24 4. RESULTS A total of 360 participant’s responses were included in the analysis, however, not every participant answered every question as they were given the right to not answer any question if they choose not to. Questions that came later in the survey have the least response back than the questions that appeared earlier; these questions were the socio-economic related questions. In table 2, the descriptive statistics shown are for the continuous variables. These statistics helped identify any outliers before analysis. For example, as for age, there were five respondents that were below the age of 18 years old that could not be included for further analysis. As observed in Table 2, the mean age of all the respondents is approximately 36 years old. The mean age for Middle Easterners in our sample is 27 years old and for non-Middle Easterners is about 41 years old, a difference of 14 years. The mean household size in our sample is about 3 people, for Middle Easterners it is about 5 people in a household and for non-Middle Easterners it is about 3 people. The average duration that respondents have lived in Dearborn is about 11 years, for Middle Easterners the average is about 9 years while for non-Middle Easterners it is about 12 years. All other variables in Table 2 are best used to compare differences with T-tests to see statistical significance. 25 Table 2: Descriptive Statistics for Continuous Variables Variable Obs Mean Min Max Std. Dev. Age Household size Weight Height in Inches BMI Household Size Under 18 Duration Living in House Duration Living in Dearborn Not Good Mental Health Before COVID Poor Physical or Mental Health Keeping You from Doing Your Usual Activities Before COVID Fear About Your Own Physical Health or Love Ones Before COVID Fear That You Will Not Have Access to Health Facilities Before COVID Not Good Mental Health Since COVID Poor Physical or Mental Health Keeping You from Doing Your Usual Activities Since COVID Fear About You Own Physical Health or Love Ones Since COVID Fear That You Will Not Have Access to Health Facilities Since COVID Alcoholic Drinks Per Week Before COVID Alcoholic Drinks Per Month Before COVID Alcoholic Drinks Per Week Since COVID Alcoholic Drinks Per Month Since COVID 343 332 176 167 167 332 310 256 177 172 175 170 178 173 178 176 45 51 48 51 18 36.4 1 3.5 53 172.7 66.9 57 27.5 11.5 1 4.9 0 10.9 0 15.7 34.2 0 31.5 39.5 29.8 39.4 38.0 47.9 37.6 2.7 6.0 2.9 7.9 0 0 0 0 0 0 0 0 1 0 0 84 10 360 81 53.6 7 65 71 100 100 100 100 100 100 100 100 8 30 7 30 15.5 1.9 54.6 4.0 7.6 1.2 10.7 15.0 30.5 28.9 32.6 31.9 31.7 31.8 34.0 32.6 2.0 5.9 2.0 7.9 Table 3 shows the descriptive statistics for the categorical socio-economic variables. The sample (n=355) represents 34% of Middle Easterners and 66% non-Middle Easterners; similar to the representation of the city of Dearborn. 41% of the Middle Eastern sample (n=121) is from Lebanon, while 59% of the sample are from Iraq (14%), Yemen (13%), Palestine (8%), Saudi Arabia (4%), Jordan (2%), Syria, (2%), and other (15%). Majority of the sample (n=348) are women (63%), 36 % are men, and 1% preferred to not answer. 25% of the sample (n=333) is Muslim, and 47% is Christian, while the others made up smaller percentages of Jewish, Buddhism, Hindu, other, and no religion. Majority of the sample (n=332) have never been 26 married (50%), while 35% are currently married. Lastly, the majority of the sample (n=332) own their home (64%), while the others are renters (36%). Frequency Percentage/Proportion 234 121 3 17 5 49 3 10 16 18 124 220 4 155 94 84 4 4 16 137 53 73 45 65.92 34.08 2.48 14.05 4.13 40.50 2.48 8.26 13.22 14.88 35.63 63.22 1.15 46.55 28.23 25.22 1.20 1.20 4.82 41.27 15.96 21.99 13.55 Categories Table 3: Descriptive Statistics for Categorical Socio-Economics Variables Variable (N=sample size) Middle Eastern (N=355) Other Middle Eastern If Middle East, Specific Ethnicity (N=121) Gender (N=348) Religion (N=333) Highest Educational Attainment (N=332) Syria Iraq Saudi Arabia Lebanon Jordan Palestine Yemen Other Male Female Prefer not to answer Christian Muslim Other No schooling completed Nursery schooling to 8th grade Some high school, no diploma High school graduate, diploma, or the equivalent (ex. GED) Associate degree Bachelor's Degree Graduate degree or higher 27 Table 3 (Cont’d) Categories Renter Owner Currently Married Divorced Separated Widowed Never Married Other Employed for pay outside your home Self-employed Student Homemaker Unemployed Retired Other Variable (N=sample size) Marital Status (N=332) Employment Status Before COVID-19 (N=332) Employment Status Changed Since COVID-19 (N=332) Owner or Renter (N=332) Total Combined Annual Household Income (N=329) If Household Income Changed Due to COVID (N=332) Less than $5,000 $5000 to $9,999 $10,000 to $14,999 $15,000 to $19,999 $20,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $100,000 More than $100,000 No Employment Change Employment Change No Income Change Income Change 28 Frequency Percentage/Proportion 114 22 9 7 163 17 172 34 45 23 24 28 6 229 103 121 211 33 18 8 17 19 38 40 58 45 53 217 115 34.34 6.63 2.71 2.11 49.10 5.12 51.81 10.24 13.55 6.93 7.23 8.43 1.81 68.98 31.02 36.45 63.55 10.03 5.47 2.43 5.17 5.78 11.55 12.16 17.63 13.68 16.11 65.36 34.64 Table 4 shows descriptive statistics for the health variables 94% of the sample (n=177) is covered by healthcare, while 6% are not covered by healthcare. From those that are covered, 53% are covered through employment, 25% from the state, and 17% from other forms such as from parents. Further, when asked if they have recently visited the doctors or other health care providers within the past 12 months, 82% (n=146) responded with yes, and 18% responded with no (n=31). Of those that responded yes to visiting the doctors or other health care providers, majority visited a doctor’s clinic (68%), while the 32% responded visited were small percentages of facilities such as telemedicine services (10%), pharmacy (9%), health facilities (6%), camp facilities (1%), and government facilities (1%). Of these visits, the majority of the reason was for a check-up (58%), and 28% for treatment for self. The other services for visit reason were small percentages of treatment for a child (3%), family planning (3%), immunization (2%), and other services (6%). Categories Frequency Percentage/Proportion Table 4: Descriptive Statistics for Categorical Health Variables Variable (N=sample size) Have You Visited Doctor or Other Health Care Provider within Last 12 Months (N=177) 17.51 82.49 Type of Health Facility Most Recently Visited (for yourself or your children) (N=146) Service Reason for Most Recent Visit (N=146) Doctor's clinic Government/Municipal Camp Health facility Pharmacy Used Telemedicine Other Family planning Health check-up Immunization 68.49 0.68 1.37 6.16 8.90 9.59 4.79 100 1 2 9 13 14 7 2.74 58.22 2.05 No Yes 31 146 4 85 3 29 Other Categories Table 4 (Cont’d) Variable (N=sample size) Covered by Healthcare (N=177) Healthcare Type (N=149) No, Healthcare Coverage Yes, Healthcare Coverage Employment State Health Insurance Medical reimbursement Other: Treatment for child Treatment for self Frequency Percentage/Proportion 8 10 167 79 38 6 26 5 41 5.48 5.65 94.35 53.02 25.50 4.03 17.45 3.42 28.08 4.1 Mental Health Disparities T-tests were conducted to compare mental health conditions between Middle Eastern and non- Middle Eastern respondents and comparisons before and since the COVID-19 restrictions were put in place. The first set of analyses is comparing the mean of mental health between the two sub-groups with 177 responses used for the analysis. These survey questions (Table 5) are on a 5-point Likert scale. Table 5: Mental Health Scale Questions ● Been able to concentrate on whatever you’re doing? ● Been so restless that it was hard to sit still? ● Lost sleep over worry about something? ● Felt you could not overcome difficulties? ● Been feeling reasonably happy, considering all things going on in life? ● Felt afraid as if something awful might happen? 5-Point Likert Scale 1. Always 2. Most of the time 3. About half the time 4. Sometimes 5. Never The first six variables shown in Table 6 are on a 5-pont Likert Scale from the questions in Table 5. Variables that are in a 5-point Likert Scale are marked with an (L) or (H) for guidance indicating that (L): lower mean value means better mental health condition and (H): higher mean 30 value means better mental health conditions. The latter four questions marked in ♦, are answers from a 0-100 continuous scale of feeling. Comparing the means of mental health conditions between Middle Eastern and non-Middle Eastern since COVID-19 (current mental health state of respondents when taking the survey) in Table 6, Middle Easterners display greater intensity/frequency for eight out of the ten variables: restlessness, feeling of not being able to overcome difficulties, lost sleep over worry, less feeling of being reasonably happy, afraid if something awful might happen, poor mental health, poor physical or mental health keeping you from doing usual activities, fear about your own physical health or love ones, and fearing that you will not have access to health. For the variables restlessness, feeling of not being able to overcome difficulties, afraid if something awful might happen, fear about your own physical health or loved ones, and fear that you will not have access to health facilities the means differences between the two sub-groups are statistically significantly, calling attention that the disparities in means between Middle Easterners and non- Middle Easterners are significant. 31 Table 6: T-test Mental Health Between Middle Eastern and non-Middle Eastern (Since COVID-19) Diff Both Middle Eastern Non-Middle Eastern Variables Been Able to Concentrate (L) Been So Restless (H) Lost Sleep Over Worry (H) Not Overcome Difficulties (H) Reasonably Happy (L) Afraid as If Something Awful Might Happen (H) Not Good Mental Health ♦ Poor Physical or Mental Health Keeping You from Doing Your Usual Activities ♦ Fear About Your Own Physical Health or Love Ones ♦ Fear That You Will Not Have Access to Health Facilities ♦ 2.49 3.54 3.42 3.52 2.83 3.28 39.12 37.83 48.00 37.33 2.389 3.31 3.28 3.32 2.90 2.94 40.96 40.12 53.68 41.37 Standard Errors in Parenthesis *** p<0.01, **p<0.05, * p<0.1 ♦ Continuous Variables from a scale 0-100 of feeling (L) Lower value= better condition (H) Higher value=better condition N=177 (NM-M) 0.18 0.39** 0.24 0.34* -.13 .57*** -3.70 2.57 3.69 3.52 3.66 2.780 3.52 37.86 36.18 -4.56 44.03 -9.62* 34.48 -7.25* Adding to the comparisons in table 6, analysis of mean differences between both sub-groups mental health before and since COVID-19 were conducted through t-tests. Table 7 suggests that the impact of COVID-19 on mental health were significant for both sub-groups combined for nine out of the ten indicators of mental health. For Middle Easterners, the impact of COVID-19 on their mental health was statistically significant for five indicators: been able to concentrate (0.32), afraid of as if something awful might happen (0.28) , poor physical health keeping you from doing your usual activities (7.82%), fear about your own physical health or loved one (9.03%), and fear that you will not have access to health facilities (6.64%). For non-Middle Easterners, the impact of COVID-19 on their mental was statistically significant for nine indicators: been able to concentrate (0.43), restlessness (0.23), feeling of not being able to overcome difficulties (0.17), less feeling of being reasonably happy (0.28), afraid if something awful might happen (0.28), not good mental health (6.99%), poor physical or mental health 32 keeping them from doing usual activities (4.94%), fear about your own physical health or love ones (8.05%), and fear that they will not have access to health (7.91%). Although, the impact of COVID-19 is statistically significant for four more variables for non- Middle Easterners, Table 6 suggests that Middle Easterners have higher intensity/feeling of negative mental health since COVID-19. In addition, Table 7 includes mental health indicators for both sub-groups before COVID-19. Table 7 illustrates that Middle Easterners’ mental health were worse before the pandemic than non-Middle Easterners during the pandemic. Middle Easterners face higher intensity of negative mental health for eight out of the ten indictors: restlessness, fear of not over coming difficulties, feeling reasonably happy, afraid something awful might happen, not good mental health, poor physical or mental health keeping you from doing your usually activities, fear about your own physical health or loved ones, and fear that you will not have access to health facilities. The difference of means of mental health before COVID-19 are statically significant for 6 indicators: restlessness (0.47), fear of not overcoming difficulties (0.42), afraid something awful might happen (0.55), not good mental health (0.35%), fear about your own physical health or loved ones (8.67%), and fear that you will not have access to health facilities (8.42%) suggesting that mental health is negatively statistically significant for Middle Easterners than non-Middle Easterners. 33 Table 7: T-test Mental Health Differences Before and Since COVID-19 Pandemic (Before-Since COVID) Variables Been Able to Concentrate (L) Been So Restless (H) Lost Sleep Over Worry (H) Not Overcome Difficulties (H) Reasonably Happy (L) Afraid as If Something Awful Might Happen (H) Not Good Mental Health ♦ Poor Physical or Mental Health Keeping You from Doing Your Usual Activities ♦ Fear About Your Own Physical Health or Love Ones ♦ Fear That You Will Not Have Access to Health Facilities ♦ Before COVID-19 Pandemic Difference (Before-Since) Both Middle Eastern Non-Middle Eastern Diff (NM-M) 2.113 3.737 3.511 3.657 2.563 3.563 2.069 3.458 3.347 3.417 2.653 3.222 2.143 3.932 2.625 3.825 2.500 3.798 34.672 40.222 30.867 0.07 0.47*** 0.17 0.42* -0.14 .55*** -9.35* Both -.38*** .20*** 0.09 0.14** -0.28*** 0.28*** -4.45** Middle Eastern Non-Middle Eastern -0.32** 0.15 0.07 0.10 -0.25 0.28* -0.74 -0.43*** 0.23** 0.10 0.17* -.28** 0.28*** -6.99*** 31.690 32.324 31.240 -1.39 -6.13*** -7.82*** -4.94** 39.549 44.653 35.981 -8.67* -8.45*** -9.03** -8.05** 29.947 34.729 26.566 -8.42* -7.39*** -6.64** -7.91*** Standard Errors in Parenthesis *** p<0.01, **p<0.05, * p<0.1 ♦ Continuous Variables from a scale 0-100 of feeling (L) Lower value= better condition (H) Higher value=better condition N=177 34 4.2 Food Consumption Table 8: Food Consumption Scale Question/Categories How often do you consume the following: 5-Point Likert Scale ● Milk ● Beans ● Vegetables ● Fruits ● Eggs ● Meats ● Fried Foods 1. Daily 2. 2-3 times a week 3. Once a week 4. Once a month 5. Never Table 9: Food Consumption T-test Results Milk Beans Vegetables Fruits Eggs Meats Fried Foods Non- Middle Eastern (N=102) Middle Eastern (N=72) Standard Errors in Parenthesis *** p<0.01, **p<0.05, * p<0.1 2.81 (.14) 2.49 (.15) 2.69 (.10) 2.83 (.12) 1.91 (.08) 2.06 (.11) 1.76 (.07) 1.69 (.10) 2.56 (.09) 2.38 (.12) 1.80 (.09) 1.97 (.14) 3.06 (.09) 2.95 (.12) For the food consumption variables, the categories (milk, beans, green vegetables, fruits, eggs, meats, and fried foods) were selected to understand nutrient content, reliable grocery or food stores nearby based on the practices of the household’s diet. Similar to the mental health analysis, the comparisons were conducted through a t-test comparing the different consumptions of each food category between Middle Easterners and Non-Middle Easterners. The higher the value of the means in Table 9, the less often the food is part of their diet indicated in scale in Table 8. There were no statistically significant differences between what Middle Eastern and non-Middle Eastern respondents consumed in the various food categories (table 8). The mean for both sub- groups are similar in each of the food groups. For milk, the intake is between 1-3 times a week. 35 For beans, the intake is around once a week. For green vegetables, the intake is around 2-3 times a week. For fruits, it’s approximately between daily to 2-3 times a week. For eggs, the intake is between 1-3 times a week. For meats, the intake is about 2-3 times a week. Finally, fried foods intake is about once a week. 4.3 Physical Health Table 10: Logistic Regression for Physical Health Variable Reference Category Wald Exp(B) Non-Middle Eastern BMI (Overweight/ Obese) (N=167) Diabetes (N=176) Heart Disease (N=176) Asthma (N=176) Other Chronic Illnesses (N=176) Standard Errors in Parenthesis *** p<0.01, **p<0.05, * p<0.1 3.05 0.12 0.18 3.28 5.39 0.547* (.183) 0.833 (.4503) 1.429 (1.187) 0.368* (.217) 0.293** (.169) For the physical health variables: weight, height, diabetes, heart disease, asthma, and other chronic illnesses, logistic regressions were used to make better comparison of likelihoods between both sub-groups. The physical health dependent variables were coded as binary variables; either the participant reported having or does not have the chronic illness. The only variables that needed appropriate calculations was weight and height in inches to calculate BMI; as BMI is an indicator for underweight, normal weight, overweigh, or obese. First, BMI was calculated by (703*weight(lb))/(height2(in)) with the given weights and heights from the respondents. BMI ranges are underweight <18.5, normal weight 18.5-24.9, overweight 25.0- 29.9, and obese >30.0 (Centers for Disease Control and Prevention, 2020). In Table 2, the mean BMI of the participants is 27.454, indicating the sample (n=167) mean is in the range of 36 overweight. After calculating the BMIs, participants’ BMI’s were coded into two categories; either underweight or normal and overweight or obese. Table 10 displays the logistic regression results for physical health comparisons between Middle Easterners and Non-Middle Easterners. Results show that Middle Easterners are statistically significant by 0.547 times less likely to be overweight or obese than non-Middle Easterners. For chronic illnesses, Middle Easterners were statistically significantly 0.367 times and 0.293 times less likely to have asthma or other chronic illnesses. These other chronic illnesses from the sample were given as lupus, fibrositis, arthritis, and hypertension. There were no significant differences in the likelihood of having diabetes or heart diseases, however, Middle Easterners were 1.429 times more likely to have heart disease than non-Middle Easterners. 4.4 Healthcare and Doctor Visits Similar to the physical health analysis, logistic regressions were conducted to predict likelihoods of Middle Easterners and non-Middle Easterners being covered by health insurance (Table 11). Through regression analysis, Middle Easterners are statistically significant 0.159 times less likely to be covered by health insurance than non-Middle Easterners. The analysis shows no significant likelihood of doctor visits within the past 12 months but Middle Eastern are 0.703 less likely to visit than non-Middle Easterners. Table 11: Logistic Regression for Health Care and Doctor Visit Variable Reference Category Wald Exp(B) Non-Middle Eastern Healthcare Insurance (N=177) Doctor Visit within past 12 Months (N=177) Standard Errors in Parenthesis *** p<0.01, **p<0.05, * p<0.1 6.66 0.78 0.159** (.128) 0.703 (.279) 37 4.5 Behavioral Habits The behavioral habits variables included the consumption of alcohol, cigarettes, and tobacco use (Table 12). Middle Easterners are statistically less likely to consume alcoholic beverages by 0.132 times than non-Middle Easterners. Although there was no significance in the results for cigarettes or tobacco use, logistic regression analysis estimated that Middle Easterners are also less likely to consume tobacco (0.432 times) and cigarettes (0.486 times). Table 12: Logistic Regression for Behavioral Habits Variable Reference Category Wald Exp(B) Non-Middle Eastern Alcohol (N=174) Cigarettes (N=174) Tobacco (N=174) Standard Errors in Parenthesis *** p<0.01, **p<0.05, * p<0.1 32.53 1.54 2.64 .132*** (.052) 0.486 (.294) .432 (.234) Table 13 displays the changes of consumption of alcoholic beverages before and since COVID. For analysis, comparisons for both subgroups consumption differences were conducted through t-tests to find significance. For both sub-groups, the increase of consumption of alcohol weekly was not significant. Middle Easterners consumption did not change weekly, but for non-Middle Easterners, their drink consumption increased by 0.0297 weekly. For monthly, both sub-groups monthly consumption of alcohol increases. Middle Easterners’ intake increased by 2.25 drinks and for non-Middle Easterners’, intake statistically increased by 1.317 drinks. 38 Table 13: Alcohol Consumption Difference (Before COVID-since COVID) Alcoholic Beverages (weekly) Alcoholic Beverages (monthly) Standard errors in parentheses * p<0.05, ** p<0.01, *** p<0.001 4.6 Socioeconomics Both -0.244 (0.251) -1.469 (0.512) Middle Eastern Non-Middle Eastern 0 (.926) -2.25 (1.497) -.0297 (0.239) -1.317* (0.543) In Table 14, for the variables combined annual household income and highest educational attainment, simple comparisons are not applicable by statistical comparisons through means but instead through ordinal categories by ranking. Table 3 displays the ranking series for annual household income and educational attainment. As 1 (less than $5,000) being the lowest household income and 10 (more than $100,000) for highest household income. For educational attainment, 1 (no schooling completed) for lowest educational attainment and 7 (graduate degree or higher). Table 14 models an ordered logistic regression analysis of the sample’s annual household income and educational attainment for Middle Easterners. Middle Easterners are statistically 0.435 times less likely to have a higher income threshold than non-Middle Easterners. Middle Easterners are also statistically 0.522 less likely to have a higher educational attainment level than non-Middle Easterners. Table 14: Logistic Regression for Household Income and Highest Educational Attainment Exp(B) Reference Category Variable Wald Non-Middle Eastern Household Income (N=329) Highest Educational Attainment (N=332) Standard Errors in Parenthesis *** p<0.01, **p<0.05, * p<0.1 16.04 2.64 .435*** (.091) .522*** (.112) 39 The sample size (n=360) closely mirrored the representation of Middle Easterners in Dearborn 5. DISCUSSION with 33% (n=121) of the respondents being Middle Eastern (U.S. Census 2003). It is important to highlight here that the mean age difference is 14 years, with the sample size for Middle Easterners being younger than non-Middle Easterners. However, the duration of living in Dearborn is only a three-year difference with Middle Easterners average at nine years and 12 years for non-Middle Easterners. Results of this study indicate that Middle Easterners in Dearborn are experiencing similar mental health stressors as other immigrants in the U.S. (Amer, 2007; Berry, 1992; Du, 2016; Torres, 2013). Although there is a large population in Dearborn that share the same heritage of being Middle Eastern, these stressors can be tied to separation from American culture, discrimination, lack of social support, financial status, and keeping up with work (Amer, 2007; Amer, 2012; Berry, 1997; Khawaja 2016, Phinney, 2001), Middle Eastern respondents showed intensified feelings of being restless, worrying about not overcoming difficulties, not being happy, and fear of access to healthcare and physical health than the non-Middle Easterners before COVID. When asked in an open-ended question on further information about the mental stress they were facing before COVID, 23% of Middle Eastern respondents' answers mentioned the general feeling of anxiety and stress. Some of the stress and anxiety was tied to school, work, finances, and social anxiety. Non-Middle Eastern respondents (13%) also indicated stress and anxiety with similar reasons; however, some non-Middle Eastern respondents indicated they are in treatment for their stress, anxiety, and depression, while none of the Middle Easterners mentioned any indication of being under treatment with medication or seeing a therapist. With internal stigma in the Arab community and minorities towards mental health issues, non-Middle Eastern are more open to 40 admitting having depression and already seeking treatment for it than Middle Easterners (Kira, 2014; Kira, 2015; Nasser-McMillan, 2003). Middle Eastern respondents continued to report greater intensities of restlessness, worry of not overcoming difficulties, losing sleep over worries, not feeling happy, and fear than non-Middle Easterners since the pandemic (Smith et al., 2020). However, for some of the mental health indicators, the intensity of mental health stress increased before- and since-COVID, was statistically greater for non-Middle Easterners (Endale, 2020; Smith, 2020; Tai, 2020). When asked what the reasons for these mental health stressors are since COVID, there were greater responses focused more on fear of loved ones getting sick, financial stresses, the anxiety of being in crowds, and social isolation, leading to increased depression, while Middle Eastern respondents added that the induced stress is from fear of loved ones being sick, increased anxiety, and depression. Although the results displayed more statistical significance to increased mental stressors on non-Middle Easterners, Middle Easterners had greater concerns of mental health before the pandemic disturbed the nation. When states and nations shutdown during the pandemic, people were forced to isolate and lose immediate social support (Rubin & Wessely, 2020). This means that non-Middle Easterners experienced greater mental stressors of anxiety, stress, worry, and fear of family and job loss after something disturbed their daily structure from increased social isolation, financial stress, and worry about a loved one's health (Usher, et al., 2020). Middle Easterners have been feeling this way before the pandemic and fear and worry are part of their daily structure. Unlike findings found for Somalian refugees and other immigrant populations, food insecurity for Arab-Americans in Michigan reported no difficulty in purchasing quality food (Neumayer et al., 2017). As expected, similar to non-Middle Easterners, the Middle Easterners in Dearborn do 41 not face significant challenges in accessing culturally appropriate foods. This could be because Dearborn has many grocery stores around the corners of Middle Easterners' homes that are accustomed to Middle Eastern shopping environment that accommodates to their food cultures, such as halal food, ingredients that are common in Middle Eastern dishes, and Arabic signs that translate ingredients and foods that remove language difficulty (Hadley, 2007; Himmelgreen, 2000; Kaiser, 2002;, Vu, 2020). Results of physical health relating to obesity and chronic illnesses did not show any significant signs that Middle Easterners have more physical health problems than non-Middle Easterners. The sample displayed a lower likelihood of Middle Easterners having a BMI greater than 25, indicating less likelihood of being overweight and obese than non-Middle Easterners. Likewise, there were not any significant likelihood of having chronic illnesses such as diabetes, heart disease, asthma, etc. This could be relating to the age difference of both groups as the mean for Middle Easterners was younger than non-Middle Easterners. Younger people are less likely to have developed chronic illnesses and can maintain a healthy weight. What is more is, although not significant in result but proven in studies, Middle Easterners were 0.703 less likely to visit the doctors or health facilities than non-Middle Easterners. This could mean lack of check-ups reduces adequate physical health data/reports. Fear of access to healthcare, lack of cultural sensitivity from healthcare providers, and embarrassment of language barriers lead to low knowledge of illnesses and social health services (Abuelezam et al., 2018). There were no statistical signs of detrimental behavioral habits for Middle Easterners for cigarette and tobacco consumption in conjunction with the physical health results. However, Middle Easterners are less likely to consume alcoholic beverages before and since COVID due to alcohol not being a great part of Arab and Muslim culture's social habits. Since non-Middle 42 Easterners showed to have higher likelihood of being overweight and chronic illnesses, some of this can be attributed to the likelihoods of consuming alcohol and cigarette use for longer durations as the non-Middle Eastern sample was older and more accustomed to western practices (Gerber, 2011; Unger, 2004). Healthcare and doctor visits did interact significantly with the Middle Easterner population by showing less likelihood of being covered by healthcare insurance and visiting the doctors within the past 12 months since COVID (Chen, 2011; Derose, 2007, Du, 2016; Edward 2015; Fowler, 1998; Jimenez, 2012; Neumayer, 2017). The Middle Eastern sample was younger, implying less frequency of needing to visit the doctor for check-ups and not obtaining healthcare insurance because they are unable to afford it. Obtaining affordable healthcare insurance could correspond with the results of less likelihood of earning a higher annual household income than non-Middle Easterners and higher education level (Edward 2015, Ku 2017; Simich,, 2005). Middle Easterners cannot afford essentials like healthcare with a lower-wage occupation or still attempting to receive a higher degree to earn more for the future as the younger Middle Eastern sample contribute their stress to college and schoolwork. Furthermore, Middle Easterners reported lower income but food accessibility was not an issue. This could mean that Dearborn, with a high concentration of Arab-Americans, groceries and food stores accommodate Middle Eastern cultural foods affordability. Studies that correlate food insecurity to negative mental and physical health (Fitzgerald, 2011; Gucciardi, 2009; Kaiser, 2002; Lee, 2001) could be excluded from the sample’s attribution to mental health. 43 Implications for Future Research This research is a significant step toward examining Arab-American mental health before and after COVID-19, as well as food accessibility and physical health. The study's results may extend to second-generation/early immigrant individuals due to the study's greater sample size of younger Middle Easterners. Further research with adolescents and adults who are second- generation/early immigrants is needed to recognize explanatory stressors and physical health disparities that may exist compared to first-generation immigrants. Research should assess the impact of additional socio-demographics like country of origin, length of duration since migrating, and religion for better understanding of the acculturation process for this group. Further, studies of Middle Eastern health should not be limited to Dearborn, but is open to areas across the U.S. with Middle Eastern populations that can bring forth comparative studies of geographical disbursements. New studies can reduce gaps in unidentified explanations to accessibility to health facilities, grocery/food stores, social services, and green spaces. These findings pose challenges to traditional immigration research based on food insecurity and physical health (Dharod, 2013; Hadley, 2007; Hersey, 2001; Murthy, 2016; Vu, 2020). For example, compared to non-Middle Easterners, Middle Easterners showed significant likelihood of earning less and obtaining a lower education but have no trouble obtaining food. Research is moreover needed to examine the built environment of areas with a concentrated immigration population and comparably conduct migrant physical health disparities with walkability, access to parks, and various connections to physical activity. More in-depth analyses of proximity to health facilities and social services that offer social support should be undertaken in addition to built environment comparative studies. These research implications can presumably be expanded to comparative studies with adult/senior first and second-generation/early immigrants for 44 identifying stressors, food insecurity, physical health, accessibility to health facilities, and shared spaces for physical activity (Neumayer et al., 2017). Policy Implications Consistent with the study (Kira, et al. 2015), Middle Easterners are less likely to report seeking treatment for psychotherapy. Refraining from seeking treatment could be attributed to internal cultural stigmatization surrounding mental health problems (Soheilian & Inman, 2009). Although research suggests that assimilation is linked to positive mental wellbeing, immigrants seeking counseling attributed to transgenerational conflicts and difficulties in adapting to Western cultural conditions their challenge (Martin, 2012). Clinics should intervene by educating Middle Eastern families into supporting one another when an individual is wanting to seek treatment for overcoming mental health problems as this strengthens their social support within family members first. Cooperation between psychiatrists and immigrant families can destigmatize seeking help and educate accessibility to health clinics. Particularly two groups can be targeted to help destigmatize mental health for immigrants: the native born sub-groups and children of immigrants. Exposing them to the field of psychology and mental health professions, as well as addressing the stigma associated with mental illness, can help them better manage with mental health issues. Therapists can work with their non- immigrant clients to explore the benefits of other cultures and shape a healthy space for bicultures. Children from immigrant families can benefit from destigmatizing mental health illnesses early on so intergenerational cultures can normalize therapy treatment and increase social support related to negative mental health. 45 Policies during national emergencies should not disadvantage immigrants giving them a dilemma between citizenship and benefits but rather ensure all immigrants are included to receiving health treatments or vaccines by focusing on areas with high vulnerability. Indication of healthcare and doctor visits suggest that Middle Easterners are disproportionately less likely to be covered by healthcare than non-Middle Easterners. A number of policies should be reviewed to end these disparities not only in Dearborn but regions with high immigrant and minority concentrations. There needs to be monitoring in these regions for families' wellness by assessing education, employment, and children of immigrants' health as the gap of inequality greatens with policies such as the federal policies shifting the definition of an immigrant being a “public charge” to limit accesses to benefits. In areas with high correlation of food insecurity and negative physical and mental health for immigrants and refugees, urban planners or policy makers should educate dominant sub-groups in host areas of incorporating cultural foods and needs in restaurants, grocery, and food stores and provide affordability services such as more restaurants or grocery stores accepting food related social services such as EBT, SNAP, and WIC. While the pandemic is still around, online interactions with immigrant and non-immigrant communities can educate and consult one another on dietary intakes, open willingness for language training, and provide social support as immigrants need to be reminded that they are thought of and not discriminated against. As Dearborn has formed a microcosm world with various representations of the Arab American culture, there is still a lack of social support for adult Arab American immigrants/refugees that prevent higher levels of educational attainment or income. Services like Arab Community Center for Economic and Social Services (ACCESS) in Dearborn offer training for skilled-level work and language courses for ex-criminals with records and children of immigrants but not directly 46 for adult immigrant or refugees. Social services like Bethany Christian Services Refugee & Immigrant Services in Grand Rapids, Michigan focus solely on ensuring immigrants and refugees get skilled-level training for careers that offer higher incomes and aim to get these jobs for them within 5-years. If there are services that attract adult Arab American immigrants and refugees to get the right training and successfully bring more adults immigrants to the labor force, healthcare facilities can be more access and decrease financial burdens. Limitations There were several limitations of this study pertaining to the data collection process. When the survey was first sent out as a postcard with a website linked, there was only a 1.2% return. The younger sample of Middle Easterners might have better access to the internet and frequently use it. Although the survey gave the option to be translated in Arabic, the survey online might have been presented first in English, decreasing the probability of older Middle Easterners immigrants who experience language difficulties or internet trust issues to take the survey. Moreover, although internet methods allow for greater sample sizes for comparatively, the sample size was still small. Obtaining random samples should be replicated to increase diversity in sample and statistical confidence. 47 Like other immigrant groups in the U.S., Arab-Americans in Dearborn, Michigan face countless CONCLUSION structural, social and economic challenges which impede their mental health and the coverage for healthcare. Further, these findings indicate that Arab-Americans in Dearborn, even with a younger sample size, still obtain lower educational levels and household income than their comparative groups, non-Arab American. Immigration policies engender these challenges by hindering accessibility to proper healthcare and receiving government benefits in times of crisis as immigrants are more vulnerable than non-immigrants. Immigrants are compelled to make difficult decisions that infringes on their earlier mental stressors; financial stress, policy confusion, discrimination, and receiving appropriate health services. Nonetheless, regions like Dearborn, Michigan that accommodate for food accessibility with grocery and food stores that embrace cultural dietary contribute to positive physical health and food security for immigrants and minorities. 48 APPENDICES 49 Table 15: Been Able to Concentrate on Whatever You’re Doing Before COVID APPENDIX A: Survey Results Freq. 54 79 21 20 4 178 Freq. 6 22 29 73 47 177 Freq. 14 28 24 74 37 177 Freq. 11 29 22 62 53 177 Percent 30.34 44.38 11.80 11.24 2.25 100.00 Percent 3.39 12.43 16.38 41.24 26.55 100.00 Percent 7.91 15.82 13.56 41.81 20.90 100.00 Percent 6.21 16.38 12.43 35.03 29.94 100.00 Always Most of the time About half the time Sometimes Never Total Table 16: Been So Restless That It Was Hard to Sit Still Before COVID Always Most of the time About half the time Sometimes Never Total Table 17: Lost Sleep Over Worry About Something Before COVID Always Most of the time About half the time Sometimes Never Total Table 18: Felt You Could Not Over Come Difficulties Before COVID Always Most of the time About half the time Sometimes Never Total 50 Table 19: Been Feeling Reasonably Happy Before COVID Always Most of the time About half the time Sometimes Never Total Table 20: Felt Afraid As If Something Awful Might Happen Before COVID Always Most of the time About half the time Sometimes Never Total Table 21: Been Able to Concentrate on Whatever You’re Doing Since COVID Always Most of the time About half the time Sometimes Never Total Table 22: Been So Restless That It Was Hard to Sit Still Since COVID Always Most of the time About half the time Sometimes Never Total Table 23: Lost Sleep Over Worry About Something Since COVID Always Most of the time About half the time Sometimes Never Total 51 Freq. 28 70 38 34 7 177 Freq. 13 25 26 74 39 177 Freq. 35 66 34 37 5 177 Freq. 10 27 37 61 40 175 Freq. 16 29 30 67 34 176 Percent 15.82 39.55 21.47 19.21 3.95 100.00 Percent 7.34 14.12 14.69 41.81 22.03 100.00 Percent 19.77 37.29 19.21 20.90 2.82 100.00 Percent 5.71 15.43 21.14 34.86 22.86 100.00 Percent 9.09 16.48 17.05 38.07 19.32 100.00 Freq. 8 35 35 52 45 175 Freq. 23 60 36 41 17 177 Freq. 19 34 32 60 31 176 Freq. 10 76 44 36 8 174 Percent 4.57 20.00 20.00 29.71 25.71 100.00 Percent 12.99 33.90 20.34 23.16 9.60 100.00 Percent 10.80 19.32 18.18 34.09 17.61 100.00 Percent 5.75 43.68 25.29 20.69 4.60 100.00 Table 24: Felt You Could Not Over Come Difficulties Since COVID Always Most of the time About half the time Sometimes Never Total Table 25: Been Feeling Reasonably Happy Since COVID Always Most of the time About half the time Sometimes Never Total Table 26: Felt Afraid as If Something Awful Might Happen Since COVID Always Most of the time About half the time Sometimes Never Total Table 27: Consume Beans Daily 2-3 times a week Once a week Once a month Never Total 52 Freq. 50 92 19 11 2 174 Freq. 75 77 16 5 1 174 Percent 15.52 39.66 30.46 9.77 4.60 100.00 Freq. 66 82 15 4 7 174 Percent 28.74 52.87 10.92 6.32 1.15 100.00 Percent 43.10 44.25 9.20 2.87 0.57 100.00 Cum. 15.52 55.17 85.63 95.40 100.00 Percent 37.93 47.13 8.62 2.30 4.02 100.00 Table 28: Consume Green Vegetables 1 2 3 4 5 Total Table 29: Consume Fruit Daily 2-3 times a week Once a week Once a month Never Total Table 30: Consume Eggs 1 2 3 4 5 Total Table 31: Consume Meats Daily 2-3 times a week Once a week Once a month Never Total Freq. 27 69 53 17 8 174 53 Table 32: Consume Fried Foods Daily 2-3 times a week Once a week Once a month Never Total Table 33: Smoke Cigarettes Does not Smoke Cigarettes Does Smokes Cigarettes Total Table 34: Cigarette Consumption Change Since COVID I smoke more than before I smoke the same amount as before I smoke less than before Total Table 35: Other Forms of Tobacco Use Cigar Hookah Other I don't use tobacco in any form Total Table 36: Tobacco Consumption Change Since COVID I use it more than before I use the same amount as before I use less than before Total Table 37: Drinks Alcoholic Beverages Don’t Drink Alcoholic Beverage Drink Alcoholic Beverages Total 54 Freq. 8 47 60 52 7 174 Freq. 159 15 174 Freq. 5 7 3 15 Percent 4.60 27.01 34.48 29.89 4.02 100.00 Percent 91.38 8.62 100.00 Percent 33.33 46.67 20.00 100.00 Freq. Percent 7 8 5 154 174 Freq. 6 8 6 20 Freq. 108 66 174 4.02 4.60 2.87 88.51 100.00 Percent 30.00 40.00 30.00 100.00 Percent 62.07 37.93 100.00 Table 38: Worry of Worsening of Chronic Illness Since COVID No fear Fear/worry of worsen chronic illness Total Freq. 28 13 41 Percent 68.29 31.71 100.00 55 APPENDIX B: Survey Questionnaire Introduction and Consent Physical and mental health disparities in Dearborn, Michigan: The role of the built environment and social support for immigrant/refugee and non-immigrant families Consent Form You are being asked to participate in a study to investigate the effects of your physical environment and social and economic conditions on mental and physical stress levels and overall health conditions. You are being asked to participate by filling out a survey that helps us understand these associations. You must be at least 18 years old and a resident of Michigan to participate in the survey. All information that you give us will be kept strictly confidential and only be evaluated in combination with other questionnaires received. Participation is voluntary and you have the right to refuse to participate in the survey or stop answering the survey at any time. The survey should take about 12 minutes to complete. Dr. Z. Kotval-K, assistant professor of Urban & Regional Planning at Michigan State University and Marah Maaita, graduate student in the same program, are available to answer any questions you may have about the survey and can be reached via email at kotvalze@msu.edu or maaitam1@msu.edu or via telephone at (517) 353-5460. Please indicate your consent to participate in this study and proceed to the survey. o I agree to participate - take me to the survey (1) o I do not agree to participate in the survey (2) 56 Demographic Questions: Is your ethnic origin Middle Eastern? o Yes (1) o No (2) Please specify your ethnicity: o Syria (1) o Iraq (2) o Saudi Arabia (3) o Lebanon (4) o Jordan (5) o Palestine (6) o Other: (7) ________________________________________________ Please enter your zip code below: ________________________________________________________________ Please fill in the closest street intersection you live by (this information will ONLY be used for aggregate mapping purposes): ________________________________________________________________ 57 What gender do you identify with? o Male (1) o Female (2) o Prefer not to answer (3) How old are you (in years)? ________________________________________________________________ What religion do you generally follow? o Christian (1) o Muslim (2) o Jewish (3) o No Religion (4) o Others: (5) ________________________________________________ 58 What is the highest degree attained or level of schooling you have completed? o No schooling completed (1) o Nursery schooling to 8th grade (2) o Some high school, no diploma (3) o High school graduate, diploma, or the equivalent (ex. GED) (4) o Associate degree (5) o Bachelor's degree (6) o Graduate and above degree (7) How many people are included in your household (including yourself)? ________________________________________________________________ How many children (under 18 years of age) are in your household? ________________________________________________________________ What is your current marital status? o Currently married (1) o Divorced (2) o Separated (3) o Widowed (4) o Never married (5) o Other: (6) ________________________________________________ 59 Which one of the following best describes your employment status (BEFORE any changes due to the COVID Pandemic)? Are you (circle only one): o Employed for pay outside your home (1) o Self-employed (2) o Student (3) o Homemaker (4) o Unemployed (5) o Retired (6) o Other: (7) ________________________________________________ Has your employment status changed since the COVID pandemic? o Yes: Please explain how it has changed (1) ________________________________________________ o No (2) Do you own (with or without a mortgage) or rent your house? o Own (1) o Rent (2) How long have you lived: (please answer both options) ▢ In this house (years): (1) ________________________________________________ ▢ In the City of Dearborn (years): (2) ________________________________________________ 60 What is your total combined annual household income (BEFORE the COVID Pandemic)? (total gross salaries and wages) o Less than $5,000 (1) o $5000 to $9,999 (2) o $10,000 to $14,999 (3) o $15,000 to $19,999 (4) o $20,000 to $24,999 (5) o $25,000 to $34,999 (6) o $35,000 to $49,999 (7) o $50,000 to $74,999 (8) o $75,000 to $100,000 (9) o More than $100,000 (10) Has the household income changed DUE TO the COVID Pandemic? o Yes: Please explain how it has changed (1) ________________________________________________ o No (2) 61 Mental Health Questions: How often have you (in the past 3 months BEFORE the COVID-19 restrictions in Michigan) been able to do the following: Always (1) Most of the About half the time (2) time (3) Sometimes (4) Never (5) Been able to concentrate on whatever you’re doing? (1) Been so o restless that it was hard to sit o still? (2) Lost sleep over worry about something? (3) Felt you could not overcome difficulties? (4) Been feeling reasonably happy, considering all things going on in life? (5) Felt afraid as if something awful might happen? (6) o o o o o o o o o o o o o o o o o o o o o o o o o o o o Please tell us a little more about any of the mental stress you were facing BEFORE the COVID-19 pandemic ________________________________________________________________ Now thinking about your mental health (which includes stress, depression, and problems with emotions), what percent of the time BEFORE COVID did you feel the following? (Please move the sliders horizontally to the appropriate percentage): 0 10 20 30 40 50 60 70 80 90 100 62 Not good mental health () Poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation () Fear about your own physical health or that of loved ones? () Fear that you will not have access to health facilities for care? () How often have you (in the past 2 months SINCE the COVID-19 restrictions in Michigan) been able to do the following: Always (1) Most of the About half the time (2) time (3) Sometimes (4) Never (5) o o o o o o o o o o o o Been able to concentrate on whatever you are doing? (1) Been so o restless that it was hard to sit o still? (2) Lost sleep over worry about something? (3) Felt you could not overcome difficulties? (4) Been feeling reasonably happy, considering all things going on in life? (5) Felt afraid as if something awful might happen? (6) o o o o o o o o o o o o o o o o 63 Please tell us a little more about any of the mental stress you are facing SINCE the COVID restrictions began in Michigan: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Now thinking about your mental health (which includes stress, depression, and problems with emotions), what percent of the time SINCE COVID restrictions began in Michigan, did you feel the following? (Please move the sliders horizontally to the appropriate percentage): 0 10 20 30 40 50 60 70 80 90 100 Not good mental health () Poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation () Fear about your own physical health or that of loved ones? () Fear that you will not have access to health facilities for care? () Ever SINCE the COVID restrictions began in Michigan, have you had any fear or worry of worsening chronic health problems? o Yes (1) o No (2) 64 Physical Health Questions: What is your weight (Ibs)? ________________________________________________________________ What is your height (ft and inches)? ▢ Feet (1) ________________________________________________ ▢ Inches (2) ________________________________________________ In the last 12 months, have you visited a doctor or other health care provider? o Yes (1) o No (2) What type of health facility did you visit most recently for yourself (or for your children)? o Doctor's clinic (1) o Government/Municipal (2) o Camp (3) o Healthy facility (4) o Pharmacy (5) o Used Telemedicine (6) o Other: (7) ________________________________________________ 65 What service did you go for on your most recent visit? o Family planning (1) o Health check-up (2) o Immunization (3) o Treatment for child (4) o Treatment for self (5) o Other: (6) ________________________________________________ Do you currently have any of the following chronic illnesses? (Select all that apply) ▢ Diabetes (1) ▢ Heart disease (2) ▢ Asthma (3) ▢ Other (please specify) (4) ________________________________________________ ▢ I do not have any chronic illness (5) Are you covered by any health insurance? o Yes (1) o No (2) 66 What type of health insurance? o Employment (1) o State health insurance (2) o Medical reimbursement (3) o Community program (4) o Other: (5) ________________________________________________ o I don't know (6) How often do you consume the following? Daily (1) 2-3 times a week (2) Once a week Once a (3) month (4) Never (5) Milk (1) Beans (lentils, green o beans, lima beans) (2) o Green vegetables (3) o o o o Fried foods (7) o Chicken/meat/seafood Fruits (4) Eggs (5) (6) o o o o o o o o o o o o o o o o o o o o o o o o o o o o 67 Harmful Habits Questions Do you currently smoke cigarettes? o Yes (1) o No (2) Has this (smoking cigarettes) changed since the COVID restrictions began in Michigan? o I smoke more than before (1) o I smoke the same amount as before (2) o I smoke less than before (3) Do you currently smoke or use tobacco in other forms? o Pipe (1) o Cigar (2) o Hookah (3) o Chewing (4) o Other: (5) ________________________________________________ o I don't use tobacco in any form (6) 68 Has this (using tobacco in other forms) changed since the COVID restrictions began in Michigan? o I use it more than before (1) o I use the same amount as before (2) o I use less than before (3) Do you drink alcoholic beverages? o Yes (1) o No (2) BEFORE the COVID situation in Michigan, how many days per week or per month in general did you have at least one drink of any alcoholic beverage (such as beer, wine, malt beverage or liquor)? ▢ Days per week (1) ________________________________________________ ▢ Days in a month (2) ________________________________________________ SINCE the COVID restrictions in Michigan began, how many days per week or per month in general did you have at least one drink of any alcoholic beverage (such as beer, wine, malt beverage or liquor)? ▢ Days per week (1) ________________________________________________ ▢ Days in a month (2) ________________________________________________ Please use the comment box below to leave us any further comments/feedback on this survey. ________________________________________________________________ 69 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 70 BIBLIOGRAPHY 71 BIBLIOGRAPHY Abdallah-Hijazi, M., Anderson-Carpenter, K. 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