Received: 20 December 2019 | Revised: 3 April 2020 | Accepted: 7 April 2020

DOI: 10.1111/phn.12734

P O P U L AT I O N S AT R I S K A C R O S S T H E
LIFE SPAN– C A SE S TUDIE S

Attitudes among working professionals toward immigrants and

refugees living in Ecuador: Impacts on health and well-being

Anne Dressel PhD, CFPH, MLIS, MA, Assistant Professor1 | Elízabeth Falconí DS,
Researcher, Member, Bioethics Committee | Heidi Luft PhD, RN, Assistant Professor1 |
2

Maren Hawkins BA, PhD Student3 | Hugo Noboa MD, MPH, Senior Researcher4 |
Óscar Betancourt MD, MSc, Executive Director4 | Alexandria Sedar MSP, Alumna,
Sustainable Peacebuilding1 | Michele G. Shedlin PhD, Professor5

1
College of Nursing, University of
Wisconsin-Milwaukee, Milwaukee, WI, USA Abstract
2
Universidad San Francisco de Quito, Quito, Objective: To explore attitudes toward immigrants and refugees living in Ecuador.
Ecuador
Design and Measures: A transnationalism framework informed this qualitative study,
3
Joseph J. Zilber School of Public Health,
University of Wisconsin-Milwaukee,
which utilized a semi-structured interview guide to elicit responses from participants
Milwaukee, WI, USA about their attitudes toward immigrants and refugees. Interviews were conducted in
4
Fundación Salud Ambiente y Desarrollo Spanish, audio-taped, transcribed, coded, and analyzed in Spanish to identify emer-
(FUNSAD), Quito, Ecuador
5 gent themes. Demographic data were analyzed using SPSS.
Rory Meyers College of Nursing, New York
University, New York, NY, USA Sample: Participants (n = 50) were recruited from five sectors that interact with refu-
gees: health care, the press, the police, nongovernmental organizations, and educa-
Correspondence
Anne Dressel, College of Nursing, University tion. Fifty interviews were conducted with adults in Quito, Ecuador, in 2017.
of Wisconsin-Milwaukee, P.O. Box 413,
Results: Participants reported concerns about the health and well-being of immi-
Milwaukee, WI 53201, USA.
Email: banda@uwm.edu grants and refugees, expressed a willingness to assist them, but within limits, noted
discrimination and bias against refugees, and cited social policies and human rights as
Funding information
University of Wisconsin Milwaukee College factors that influenced their attitudes.
of Nursing
Conclusions: Our findings indicate that immigrants and refugees face challenges
which impact their health and well-being, according to participants in the study.
Social policies can influence attitudes, but are also affected by rapidly shifting im-
migration patterns. Migration flows in South America is an under-studied area of
research, with opportunity for further public health nursing inquiry.

KEYWORDS

Ecuador, global health, immigrant and refugee health, immigrants, refugees

Refugees, 2019). Many of these Venezuelans have sought asylum in

1 | I NTRO D U C TI O N
According to the United Nations High Commissioner on Refugees
(UNHCR), nearly 71 million people have been displaced from their
homes worldwide, with the greatest number of new asylum ap-
plications from Venezuela (United Nations High Commissioner on
Ecuador, which is home to the most refugees and asylum seekers
of any country in Latin America, with over 60,000 registered ref-
ugees (Pouilly, 2017). Current estimates from the United Nations
High Commissioner on Refugees (2018), however, suggest there are
547,000 refugees, asylum seekers, and immigrants from Venezuela
living in Ecuador, as well as 450,000 from Colombia.

Public Health Nurs. 2020;00:1–8. wileyonlinelibrary.com/journal/phn© 2020 Wiley Periodicals, Inc. | 1

2 |
Some reasons for the large number of refugees and immigrants
in Ecuador include its Open Borders policy, which is part of the new
constitution that was enacted in 2008. The policy guarantees that
people can move freely through Ecuador's borders, and eliminates
visa requirements for citizens from any country who wish to stay in
Ecuador for up to 90 days (Acosta, 2016). The policy was amended in
2010, and visas are now required for citizens from 13 countries that
have had a high incidence of irregular migration, such as Afghanistan,
Bangladesh, Kenya, Nepal, and Somalia—all countries outside of
South America (Wagner, 2013).
In 2017, Ecuador passed the Human Mobility Law, which UNHCR
spokesperson Cécile Pouilly noted, “Regularizes the situation of
people on the move—including refugees, asylum seekers, state-
less persons, and victims of trafficking” (13 January 2017, para 1).
In addition, in 2000, Ecuador adopted the U.S. dollar as its official
currency, often referred to as “dollarization,” which has stabilized its
economy (Anderson, 2016).
Immigrants and refugees living in Ecuador regularly face chal-
lenges which impact their health and well-being, including dis-
crimination, social isolation, violence, food and housing insecurity,
challenges accessing health care, as well as social and economic
marginalization (Cordova & Janssen, 2017; Shedlin, Decena, Noboa,
& Betancourt, 2014; Shedlin et al., 2016). Concerns about refugees
and immigrants living in Ecuador are not limited to that country, as
transit migration has become increasingly common, with immigrants
and refugees moving on to other countries, including the United
States (Herrera, 2019).
Access to health services can be difficult for refugees and im-
migrants. Numerous studies have identified several challenges that
impact health care access among refugees, including continuity of
care, communication, and trust in the health care provider (Benson,
Haris, & Saaid, 2010; Brandenberger, Tylleskär, Sontag, Peterhans,
& Ritz, 2019; Sandre & Newbold, 2016; Worabo et al., 2016). While
these studies focused on refugees and migrants in high-income coun-
tries, their findings demonstrate a need for training for nurses and
other health care providers in the delivery of health care to refugees
and immigrants (Brandenberger et al., 2019), which, arguably, may be
impacted by the health care provider's attitudes toward these pop-
ulations. Indeed, implicit bias is an area that has been well-studied
(Fitzgerald & Hurst, 2017; Hall et al., 2015; Narayan, 2019).
Past research has often focused on the refugees’ own experi-
ences, including access to health care (Sandre & Newbold., 2016),
their impact on receiving countries, or why refugees are fleeing
their home countries (Cox, 2019; Esses, Hamilton, & Gaucher, 2017).
Research exploring the attitudes of various sectors, such as the
health care sector, of the receiving country is relatively new
(Cox, 2019; Esses et al., 2017), and has focused primarily on the
global north (Esses et al., 2017; IPSOS, 2016; Wike, Stokes, &
Simmons, 2016). Thus, a gap in the literature exists regarding atti-
tudes toward refugees and immigrants in Ecuador and other coun-
tries in South America. Furthermore, the UNHCR has observed that
migration flows in South America is an area of research that has been
neglected and is under-studied (Wagner, 2013).
DRESSEL et al.
The welfare of immigrants and refugees has implications for pub-
lic health nurses, who are uniquely situated to advocate for safe and
ethical care for immigrant populations (Fitzgerald, Myers, & Clark,
2017). In addition, public health nursing's focus on population and
subpopulation levels allows public health nurses to address systemic
inequities which impact immigrant and refugee health (American
Public Health Association & Public Health Nursing Section, 2013).
2 | O B J EC TI V E
The aim of this qualitative study was to explore attitudes toward im-
migrants and refugees living in Quito, Ecuador, among the different
sectors that interact with them, including health care professionals,
the police, teachers, the press, and nongovernmental organizations
(NGOs).
3 | M E TH O DS
3.1 | Design
This qualitative study employed a phenomenological approach
(Omery, 1983; Rodriguez & Smith, 2018) and transnationalism
framework (Rosemberg, Boutain, & Mohammed, 2016), which con-
siders the different sociopolitical, cultural, and political contexts
which must be taken into account when investigating the health
and well-being of immigrants, and builds on previous theories of
nursing inquiry such as transcultural nursing (Leininger, 1975),
cultural competence (Campinha-Bacote, 2002), cultural diversity
(Leininger, 1988), and assimilation and acculturation (Berry, 2003).
This study was also informed by previous research conducted in
Ecuador in 2009–2012, in which some members of the current study
team participated. The earlier investigation involved interviews with
96 Colombian refugees living in Ecuador, and yielded important
findings about factors that affect their health and well-being. For
example, food insecurity was the primary health risk identified by
Colombian refugees (Shedlin et al., 2016). In addition, stigma and dis-
crimination impacted access to health services, housing security, and
employment among refugees (Shedlin et al., 2014).
The current study team, which includes members from Ecuador
and the United States, developed a semistructured interview guide
in Spanish to elicit information about participants’ attitudes toward
migrants living in Ecuador. Two research team members developed
the guide based on findings from previous studies, such as how
stigma and discrimination affect migrant access to health care and
other social services (Shedlin et al., 2014, 2016). The interview guide
was shared with the rest of the team, which included the leader-
ship of Fundación Salud Ambiente y Desarrollo (FUNSAD), a well-re-
spected health, environmental, and development organization in
Quito. This NGO has extensive experience conducting research
studies throughout Ecuador and Latin America, and their feedback
was incorporated into the interview guide.
DRESSEL et al.
The interview guide included questions about participants’
personal experiences interacting with migrants; if they thought mi-
grants experienced discrimination or stigma, and if so, in what ways;
how migrants from different countries were viewed by Ecuadorians;
to what extent Ecuador should provide social services to migrants;
and anything else they might want to add. The interviews began by
collecting basic demographic information from participants, includ-
ing their age, sex, how long they had been employed in their current
position, political persuasion, and whether they had been a migrant
at some point in their lives.
The study was approved by the Institutional Review Boards at
the University of Wisconsin-Milwaukee, USA, and the Universidad
San Francisco de Quito, Ecuador.
While the terms refugees, immigrants, and asylum seekers have
specific definitions (UNHCR, 2020), it is important to note that the
majority of the people interviewed in this study used the terms in-
terchangeably, or grouped all categories together under the term
“migrants.” The term “migrants” is thus employed in this manuscript
in order to capture the essence of participant responses, unless oth-
erwise noted.
3.2 | Sample
Our convenience sample included 50 adults (n = 50), who were em-
ployed in professional capacities in Quito, the capital of Ecuador, in
various sectors that served or interacted with migrants. Participants
included 10 representatives from each of the following sectors:
health care, nongovernmental organizations (NGO's), education,
the police, and the press. We recruited participants via scripted tel-
ephone calls or e-mails to appropriate organizations, and snowball
sampling was also employed to identify 10 participants from each
sector. Fifty-five adults were contacted, and five declined to partici-
pate. Participants either signed a written consent form, or provided
verbal consent, which was documented by the interviewer.
3.3 | Data collection
Individual interviews were conducted with each participant in Quito
between July and December 2017. The interviews were conducted
at a location most convenient for participants and included their
place of work or their home office. The interviews were conducted
in Spanish, audio-taped, and transcribed in Spanish by an experi-
enced research team member, who is a native Spanish speaker, and
resident of Ecuador. She was supported in data collection by staff
at FUNSAD.
3.4 | Data analysis
Two U.S.-based bilingual research team members independently
read the transcriptions in Spanish multiple times, and integrated
| 3
their results for development of a codebook in Spanish for data
analysis. The codebook was shared with bilingual team members
in Ecuador for verification. The codebook was then used for line-
by-line qualitative data analysis (Ritchie, Lewis, & Nicholls, 2013) by
three U.S.-based team members, and emergent themes were identi-
fied and translated into English. The findings were again shared with
bilingual team members in Ecuador for verification.
We utilized TRAPD (Translation, Review, Adjudication,
Pretesting, and Documentation) methodology (Harkness, Villar, &
Edwards, 2010) to guide translation into English of representative
quotes that are included in this article. Responses from the various
sectors allowed us to triangulate the data.
4 | R E S U LT S
Demographic information was collected from 49 of the 50 par-
ticipants, who ranged in age from 19 to 84, with a median age of
49. Forty-one percent of participants were female, and 59 percent
were male. Fifty-five percent described their political views as left
of center (liberal), 27 percent were apolitical, 6 percent were in the
center, 0 were right of center (conservative), and 12 percent de-
scribed their political views as “other.”
According to professional sectors that interact with and serve
migrants living in Quito, Ecuador, migrants face intersecting chal-
lenges that impact their health and well-being. Mental health and
stress were identified as notable health concerns, in addition to food
insecurity, and transactional sex.
Discrimination and bias impacted views toward migrants and
participants’ willingness to help them. Many participants noted they
had witnessed discrimination against migrants, and some also ex-
pressed discriminatory views themselves. While participants em-
phasized that migrants were a vulnerable group, there were often
limits to how much assistance they thought should be provided. For
example, participants noted that resources used for migrants meant
fewer services were available to Ecuadorian-born citizens. These
themes are explicated below.
4.1 | Health and well-being of migrants
While participants from all sectors expressed concern about the
health and well-being of migrants, these concerns were especially
prevalent among health professionals.
4.1.1 | Mental health and stress
Participants noted that displacement can impact the mental health
of migrants and their families, and be a significant source of stress.
They perceived that refugees did not choose to flee their coun-
try of origin, and that parents often did so to protect their chil-
dren and families. They inferred that exploitation, poverty, and
4 |
displacement could contribute to stress and mental health chal-
lenges among individuals, as well as families. For example, a health
care provider stated, “For me I think that the problem is more in
the situation of the mental health of the (migrant) population, of
women in this context because they are used, they are exploited
and this causes … a health problem, a relationship problem to-
wards their family, towards society and towards the environment
where they operate.” Another health professional said, “Those
with limited resources (such as migrants) have family stress prob-
lems that is reflected in children with fear, with relationship dif-
ficulties and with developmental problems in school;” and an NGO
professional stated, “…I am worried about mental health, what it
means to become displaced without it really being your life choice,
but you have to do it, often times to save your live, to save the life
of your children.”
4.1.2 | Malnutrition and food insecurity
Concerns about malnutrition and food insecurity among migrants
were expressed by participants, who identified food insecurity as
a primary cause of their economic challenges. They also noted the
connections between poverty and malnutrition, as well as larger
structural issues such as the connections between good nutri-
tion, good health, and the economy. Ensuring adequate food and
employment for refugees could help to address malnutrition, as
well as improve the overall economy. A health professional stated,
“If some (migrant families) do not have enough resources, there is
malnutrition, or at least underweight or short stature.” Another
health participant said, “If a family does not have a job, they will
not (be able to) feed their children. If they are small they will re-
main in malnutrition, and then that also implies a health problem.
I think that for any country, the good thing is to have a healthy
population that is productive, so if we generate jobs, imagine how
great it would be.”
4.1.3 | Survival/transactional sex
Colombian women living in Ecuador often face stigma related to
stereotypes about engaging in transactional sex. Participants in
our study reiterated this bias, even though it is not a verifiable
major practice, and responses from the police sector were espe-
cially strong in this regard. Respondents noted that some female
migrants engaged in transactional sex in order to provide for
their families. Transactional sex puts women at risk for contract-
ing sexually transmitted diseases, and contributes to stigma and
discrimination against female migrants. Participants understood
that transactional sex may be a means of survival for some mi-
grant women and their families. A health sector participant stated,
“Many (women) engage in sex work while they establish them-
selves, their partner establishes themselves, including cases I
have heard where their partner, their own husbands, sends them
DRESSEL et al.
to prostitute themselves so that they can stabilize themselves
economically and survive. You know what I mean? These are hard
times.”
An NGO professional said, “… These beautiful Colombian women
are very stigmatized as prostitutes, closely linked to sex work, this
generates a lot of opposition from the (Ecuadorian) population.”
Relatedly, a policeman stated, “Yes there is (discrimination against
Colombian and Venezuelan women), if they have that kind of think-
ing… it's because of the reputation they have given themselves…
that they are easy girls that come here just for money, so they will
do anything.”
4.2 | Discrimination and bias against migrants
All sectors expressed concerns about discrimination and bias
against migrants, and participants sometimes blamed the other
sectors for perpetuating stereotypes. They expressed concerns
about xenophobia, feeling threatened by the migrants’ cultural
beliefs and practices, and often blamed the media for negative
depictions of migrants. For example, one NGO participant stated,
“There is a lot of sensationalism, there is a mishandling of refugee
issues, there is a superficial management… there has been no work
to understand the problem, why people travel, why people come…
the media can often be very xenophobic.” A health care profes-
sional said, “I believe that discrimination is mostly cultural because
it is like we feel threatened with the culture that they (migrants)
bring with them… we suddenly feel threatened and the first reac-
tion is to defend ourselves.”
Another NGO participant stated, “…The middle class creates ste-
reotypes of crime and the problem is that the middle class has an
impact on the media, so the media reproduces the fears and vision
of the middle class and in this way a social imagery is constructed of
the ‘Colombian criminal or drug trafficker’ or the ‘Colombian prosti-
tute’… these stereotypes are built from the fears of the middle class
and transfer to the media.”
Some participants expressed concern about evolving discrimina-
tion against migrants, which must be addressed in order to avoid
becoming a racist society, like the United States. For example, a par-
ticipant from the education sector stated, “Discrimination is growing
and we are going to face some rather difficult phenomena, like in the
United States, many, very serious problems with discrimination, if we
don't take action in time.”
Finally, participants across all sectors made additional general-
izations about Ecuadorians, which influenced attitudes toward mi-
grants. These focused on how open and welcoming they perceived
Ecuadorians to be, or not, and not all participants shared those
perceptions. A health care professional said, “We (Ecuadorians) are
calm, we are not violent, actually we are welcoming… this benefits
those that come to our country, but at our expense, and it cannot be
this way.” Another health sector participant stated, “I believe that we
are welcoming and that at some point they think of us as fools and
we are taken advantage of…”
DRESSEL et al.
Some participants, however, were less cynical, as one education
sector participant noted, “I can say on average, Ecuadorian people
are supportive, they are gentle.”
4.3 | Willingness to help, but within limits
Perceptions about migrants shaped participants’ willingness to
help them. They recognized the vulnerability of migrants, but also
expressed concerns about them exhausting social services, such as
health care, which could limit access for Ecuadorians. Participants
across sectors were sensitive to the situation of migrants, but they
expressed limitations about the extent to which they should be
helped. This was especially evident among health care profession-
als who understood that refugees were a vulnerable population
and that they had an obligation to treat them, but this also entailed
concerns about how migrants may be impacting health care access
for Ecuadorians. For example, one health care provider stated, “I am
very concerned about the use of (healthcare) services… in any given
day, 25 to 35 percent of our (health) consultations or emergency
(health) services are for migrants… it is an investment and they need
it, but how are we going to recover (those costs)? …we don't have
resources for our own population. How can we solve that?” Another
said, “(Migrants) saturate our services and demand our first level ser-
vices and that creates competition with our population.”
Participants, however, also noted that migrants are vulnerable pop-
ulations and exhibited sensitivity to their situation. A health care profes-
sional noted, “They are a vulnerable group per their status as refugees,
their very status, their economic situation, their social and family situa-
tion.” Another health sector participant said, “If a patient in critical con-
dition comes to me and is not Ecuadorian, they are human, and as a
healthcare professional, it is a moral and ethical obligation to tend to
them.” An NGO participant said, “There are good people, I have met peo-
ple who have come, who have sweated and toiled trying to get out of
a situation that they were not looking for. I do not think anyone wants
to migrate… they migrate because their conditions are super adverse.”
All health sector participants noted that migrants in Ecuador
had access to health care because it is a human right. The right to
health care is guaranteed in Ecuador's constitution, and espoused by
the World Health Organization and the United Nations Sustainable
Development Goals, and influenced participants’ responses. For ex-
ample, one health care professional stated, “According to interna-
tional guidelines, a refugee has the right to receive medical attention
like any Ecuadorian.” Another stated, “As a health professional, we
have a moral and ethical obligation to give them (medical) attention;”
and, “…The Ministry (of Health) is under obligation, it is our responsi-
bility to care for all vulnerable groups.”
4.4 | Influence of social policies
The influence of social policies was noted in many participants’ re-
sponses across all sectors. As previously noted, the right to health
| 5
care is enshrined in Ecuador's Constitution, which guarantees ad-
ditional rights, such as education, to all people living in Ecuador.
Ecuador's Open Borders policy allows people from most countries
to enter Ecuador without a visa. In addition, Ecuador adopted the
U.S. dollar as its official currency in 2000. Thus, people working in
Ecuador are paid in U.S. dollars. The influence of these policies was
reflected in participants’ responses below.
4.4.1 | Ecuador's constitution
Participants cited Ecuador's Constitution and how well, or not, its
laws are actually implemented in practice in regards to providing so-
cial services to those living within Ecuador's borders. Participants
understood that the state has a duty to provide for its citizens, and
others living in Ecuador. For example, a health sector participant
noted, “Constitutionally, we have the duty and obligation to guard
the physical and mental health of all, not only of the Ecuadorians by
birth, but also of all the inhabitants, of all the people who live in our
country.” Another health care professional stated, “Per the consti-
tution, the government, the State has to guarantee attention to all
people within Ecuadorian territory…”
Participants noted, however, that there were challenges with
laws guaranteed in the Constitution, as one press sector participant
said, “…Our Constitution speaks of universal citizenship and yet we
see that these laws (in) practice contradict this principle.” A health
care professional stated, “Ecuador is a country that has fantastic
laws… but I think that in practice there are still barriers, it is still not
enough, I think there is a gap.”
It is interesting to note that an education professional said,
“There is universal citizenship… but I believe that there is a lot to in-
quire about the State's response to these (migrant) populations and
how it involves Ecuadorian civil society so that there can be more
knowledge, more or less about discrimination or xenophobia.” This
implies that more education is needed about Ecuador's laws and
constitutional responsibilities toward those living within its borders,
in order to decrease discrimination against migrants.
4.4.2 | Ecuador's open borders policy
Responses were also influenced by Ecuador's Open Borders policy.
Some participants noted their own experience with migration, and
hence the need to reciprocate. Others, however, questioned the Open
Borders policy and Ecuador's ability to adequately support the policy's
implementation in daily practice. For example, a press sector par-
ticipant noted, “...We should have an open border policy because we
ourselves are a country that has also migrated in many moments of his-
tory for many reasons… it is a bit illogical that having all of this history,
and all this experience of migration, that we cannot be a country that
receives (migrants).” Another press sector participant said, “Ecuador
should open its doors, but logically, to do this, we first have to educate
ourselves as Ecuadorians (and) generate adequate infrastructure.”
6 |
Relatedly, some questioned the policy all together, as an educa-
tor stated, “I have experience in several areas… and I have friends
throughout the country always tell me that they do not agree with
the borders having been opened and that their (migrant) visa or pass-
port is not required.”
4.4.3 | Dollarization of the economy
Respondents identified dollarization of the economy, which refers
to Ecuador's adoption of the U.S. dollar as its currency in 2000, as a
factor that contributed to migration to Ecuador. Some respondents
felt the opportunity to earn U.S. dollars allowed migrants to use
Ecuador as a “trampoline”—that is, migrants would come to Ecuador
to earn and save U.S. dollars, and then “jump” to another location
in South America or the United States. One health sector partici-
pant stated, “What you see is a trampoline, so if I (as a migrant)
come here (to Ecuador)…, my purpose is then to move to the United
States.”
Another noted, “What is seen now are Cuban and Venezuelan
citizens, a great percentage of whom come for the ease of migrat-
ing to another place… in short… I would say that 50 percent of the
people who come are in transit.” Finally, a police sector participant
stated, “…We have dollarization and that is one of the main reasons
why the majority of Latin American citizens come here. Ecuador is
the only country in South America that has the dollar; that is an im-
portant economic opportunity.”
Ecuador's policies impacted attitudes across all sectors about
why refugees come to Ecuador, what rights they have or should have
upon their arrival, and to what extent Ecuador can adequately guar-
antee those rights.
5 | D I S CU S S I O N
Participants expressed concern about mental health and stress
among migrant populations, a finding which adds to the literature
about mental ill health among refugee populations. In a study of
Syrian refugees in Sweden, Tinghög et al. (2017) found that mental ill
health included anxiety, low subjective well-being, and depression.
Kartal and Kiropoulos (2016) noted similar findings, as well as stress,
among refugees resettled in Austria and Australia. Participants in
our study also noted that migrants often faced malnutrition and
food insecurity, which verifies previous research among refugees
in Ecuador and elsewhere, including in the United States (Maharaj,
Tomita, Thela, Mhlongo, & Burns, 2017; Nunnery & Dharod, 2017;
Shedlin et al., 2016).
Participants noted that xenophobia existed in Ecuador, and
often blamed other sectors, especially the press, for propagating
stereotypes against migrants. It is important to note the wide va-
riety of cultures that exist across Latin America and the Caribbean.
Neighboring Colombians may share more cultural practices with
Ecuadorians, and thus may be perceived to assimilate more readily
DRESSEL et al.
into Ecuadorian society, as compared to migrants who come from
places farther away, like Cuba, whose cultures and traditions may
have more in common with other Caribbean island nations, than with
countries in South America.
Given that all participants were working professionals, most
were well-educated with a broad worldview. Hence, several ex-
pressed concerns about Ecuador becoming a racist society, “like the
United States.” This speaks to the relevance of the transnationalism
framework that was used in this study, and how social and political
processes present in one country can influence attitudes in another.
The transnationalism framework also allows for consideration about
“transit migration” or the idea expressed by some participants about
migrants coming to Ecuador in order to earn U.S. dollars, and then
“jump” or move to another country, like the United States. The trans-
nationalism framework reminds us that what happens in countries
that we may perceive to be far away, can have impacts in the United
States and elsewhere.
Relatedly, most participants were aware that “refugee” has a spe-
cific legal status, and at times their responses were slightly altered
based on whether they were talking about refugees, specifically, or
migrants in general. Participants were generally aware that refugees
are entitled to certain rights, by virtue of their refugee status.
Research has demonstrated how public attitudes about mi-
grants are shaped by news media (Dempster & Hargrave, 2017;
Esses et al., 2017), and the influence of news delivered via social
media is a relatively new area of research that warrants further study
(Dempster & Hargrave, 2017). Participants in our study, especially
within the police sector, reiterated a bias about female Colombian
migrants engaging in transactional sex, even though this is not a
verifiable major practice. This finding, however, confirms previous
studies related to discrimination toward refugees perpetuated by
law enforcement (Crawley & Skleparis, 2018; Shedlin et al., 2014).
Social policies also impacted attitudes toward migrants.
Participants regularly cited the Constitution, dollarization of the
economy, and other social policies, and drew upon a human rights
framework (Sen, 2004) in their responses. These policies influenced
their willingness to help migrants, but within limits, as some partic-
ipants were concerned about the impact they could have on ser-
vices for Ecuadorians. These attitudes were confirmed by previous
research (Wike et al., 2016) conducted in a European context, which
found that 50% believe that refugees will take jobs and be a burden
on the social service sector.
It is important to note that attitudes toward migrants may be
evolving since 2017, with the overwhelming influx of migrants
from Venezuela in recent years, which has made it more difficult
for Venezuelans to access refugee resources in Ecuador (Miller &
Panayotatos, 2019). While migrants from Colombia have been mi-
grating to Ecuador for decades, and have more established social
networks within the country, accommodating new migrants from
Venezuela, who often enter Ecuador via transit through Colombia,
has raised serious challenges and resulted in recent restrictions
on entry requirements for Venezuelans (Millions of refugees from
Venezuela are straining neighbours’ hospitality, 2019). These
DRESSEL et al.
changes in immigration patterns into Ecuador may have influenced
attitudes toward migrants, especially recent arrivals from Venezuela,
and replication of this study would be useful to learn how and to
what extent attitudes toward refugees and immigrants have changed
since 2017, as this may impact their health and well-being.
Finally, with a record high of over 70 million displaced people around
the world (UNHCR, 2019), nursing research must examine factors that
impact the health and well-being of migrants, which includes the atti-
tudes of those serving these vulnerable groups. As previously noted,
migration flows in South America are under-studied (Wagner, 2013);
and due to transit migration, migrants in Ecuador and other parts of
South America may later migrate to the United States and other
high-income countries (Herrera, 2019). Thus, there is a need for nurse
researchers to understand the challenges faced by migrants in order
to inform efficacious nursing interventions. Furthermore, for interven-
tions to be effective, nurses must be aware of our own implicit biases
(Fitzgerald & Hurst, 2017; Hall et al., 2015; Narayan, 2019) and ensure
that nursing practice is grounded in cultural humility (Foronda, 2020),
as this can have implications for the care provided to migrants.
6 | LI M ITATI O N S
This study was limited to adult participants from five distinct sec-
tors who serve and interact with migrants. Thus, it does not include
information from elected officials, the general population in Quito,
or from migrants themselves. This study was also limited to partici-
pants in Quito. Attitudes toward migrants may vary among adults
living in other parts of Ecuador, especially those living in border
areas. Finally, all study participants were employed professionals.
Attitudes among low-income people in Ecuador or those who are
unemployed may differ from those in our study.
7 | CO N C LU S I O N
There is a lack of research about migration flows in South America
according to the UNHCR, especially within the nursing profession.
Our study may stimulate ideas for future nursing research about the
health and well-being of immigrants and refugees living in South
America, and the broader transnational context of immigrant and
refugee health. Public health nurses can play a key role in investi-
gating and addressing health challenges faced by immigrants and
refugees, and can advocate for more equitable policies to improve
the health and well-being of migrants living in Ecuador, the United
States, and around the world.
AC K N OW L E D G E M E N T S
This work was supported by University of Wisconsin-Milwaukee
College of Nursing Start-Up Funds.
D I S C LO S U R E S
The authors have no conflict of interest to declare.
| 7
E T H I C A L S TAT E M E N T
The study was approved by the Institutional Review Boards at the
University of Wisconsin-Milwaukee, USA, and the Universidad San
Francisco de Quito, Ecuador.
ORCID
Anne Dressel https://orcid.org/0000-0002-2254-1815
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How to cite this article: Dressel A, Falconí E, Luft H, et al.
Attitudes among working professionals toward immigrants
and refugees living in Ecuador: Impacts on health and
well-being. Public Health Nurs. 2020;00:1–8. https://doi.
org/10.1111/phn.12734