A Systematic Review of Medical-Legal Partnerships Serving Immigrant Communities in the United States

Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review

OBJECTIVE

The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity.

INTRODUCTION

To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system.

INCLUSION CRITERIA

This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies).

METHODS

This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format.

RESULTS

Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems.

CONCLUSIONS

Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally.

REVIEW REGISTRATION

DalSpace dalspace.library.dal.ca/handle/10222/80835.

Medical Care for Newly Arrived Displaced Persons

Medical Care for Displaced PersonsThe United Nations High Commissioner for Refugees reports that more than 100 million people have been forcibly displaced from their homes due to persecution, conflict, violence, and human rights violations. Displacement has profound health impacts. Here, Jain and colleagues review medical care for newly displaced persons.

Health Justice Partnerships: An International Comparison of Approaches to Employing Law to Promote Prevention and Health Equity

This article traces the development and growth of health justice partnerships (HJPs) in three countries: the United States, Australia and the United Kingdom.

Intersectionality and adolescent medicine: an overview

PURPOSE OF REVIEW

This review defines intersectionality, discusses recent studies that use an intersectional framework in adolescent health research, and outlines ways where clinicians can use intersectionality to address health disparities in youth of color through clinical practice, research, and advocacy.

RECENT FINDINGS

Research using an intersectional framework can identify populations at risk for certain disorders or behaviors. Recent studies in adolescent health research using an intersectional lens identified lesbian girls of color as an at-risk population for e-cigarette use, demonstrated lower skin color satisfaction among Black girls of all ages predicted greater binge-eating disorder symptoms, and showed that two-thirds of Latine (gender-neutral term that refers to people with Latin American roots) youth who recently immigrated to the United States experienced at least one traumatic event during their migration journey, putting them at risk for PTSD and other mental health disorders.

SUMMARY

Intersectionality refers to how multiple social identities intersect to produce a specific experience that reflects overlapping systems of oppression. Diverse youth contain multiple identities that intersect to produce unique experiences and health inequities. Using an intersectional framework acknowledges that youth of color are not homogenous. Intersectionality becomes an important tool to care for marginalized youth and advance health equity.

Pandemic-Related Stress and Resilience Among Latinx Mothers with a History of Depression: Differences by Immigration Status

This study explores the impact of the COVID-19 pandemic on low-income, Latinx mothers in Southern California with a history of depression, including undocumented mothers and members of mixed status families. Drawing participants from a parent study that provided a maternal depression intervention to Head Start mothers (n = 119), this mixed method study integrates qualitative and quantitative data in a convergent design. Thirty-four mothers completed semi-structured qualitative interviews and standardized questionnaires in the fall of 2020. Mothers shared overwhelming economic difficulties, with the majority reporting that their family income decreased and half reporting that they were unable to pay for housing. Stressors were compounded for undocumented mothers and members of mixed-status families who were excluded from major relief programs. Stress affected maternal mental health, and mothers with precarious status reported differences in functioning. Mothers also identified positive ways that they coped with adversity. Results show that Latinx mothers with a history of depression, particularly mothers with precarious immigration status, continue to suffer considerable economic, social, and emotional impacts of the COVID-19 pandemic. Social workers can support the human rights of this population by advocating for financial relief, food assistance, and the expansion of medical-legal partnerships and physical and mental health services.

Legal Relief for Children in Immigrant Families: A Mixed-Methods Study

Objective: Immigration status is a known social driver of health. Little research exists on addressing concerns about immigration status in primary care. The objective of this study is to understand the experiences of immigrant families that received a clinical-community intervention to address immigration-related concerns. Methods: We conducted a mixed-methods study: an embedded experimental design study. We implemented an immigration-focused legal needs screening tool and referral intervention at one academic primary care clinic in January 2018. Caregivers who screened positive for immigration-related concerns and were referred to a local immigration law firm were invited to participate in a semi-structured interview. Interviews were recorded, de-identified, transcribed, and systematically coded using an inductive content analysis approach. A modified constant comparative method was used to iteratively review codes, identify emerging themes, and resolve differences through consensus. Results: Nineteen caregivers reported immigration-related legal concerns, seven of whom were interviewed. Most (84.2%) were mothers, identified as Hispanic (94.7%), were from Mexico (52.6%), and reported persecution and fear of returning to their country of origin (57.9%). In interviews, we identified three major themes: (1) families were motivated to immigrate due to mental health trauma and persecution; (2) families sought legal services for several immigration-related concerns; and (3) families experienced challenges in navigating the legal system, with which clinics may assist. Conclusion: This study demonstrates the need for immigration-related services in primary care settings and the feasibility and potential benefits of implementing a legal screening and referral intervention.

Integration of Waiting Room “Know Your Rights” Education into Medical Care of Immigrant Patients in a Federally Qualified Health Center: A Case Study

Background: Federally qualified health centers (FQHCs) are implementing innovative interventions to address heightened anxieties of immigrant patients amid changing immigration policies.

Purpose: To describe the integration of “Know Your Rights” legal rights education in clinic waiting rooms of an FQHC in Los Angeles, California.

Methods: This is a qualitative study using key informant interviews, direct field observations, and document review.

Results: Collaboration with community health workers and local immigrant-serving community-based and legal organizations was key to intervention design and implementation.

Conclusion: Integrating legal education into medical care is one action health centers can take to support immigrant patients, address their complex realities, and optimize patients.

Recognizing and Breaking the Cycle of Trauma and Violence Among Resettled Refugees

Purpose of Review

The number of refugees across the globe continues to grow, leaving a large proportion of the global population in a vulnerable state of health. However, the number of robust clinical interventions has not kept apace. This paper provides a general review of literature on the trauma and violence that refugees face, the impact on health outcomes, and some of the promising models for clinical intervention.

Recent Findings

Refugees experience a cycle of trauma, violence, and distress that begins before migration and continues during migration and after resettlement. It has been challenging to develop robust clinical interventions due to the cumulative and cyclic effects of trauma, as well as the unique experiences of trauma that each refugee community and each refugee individual faces.

Summary

Trauma-informed care is a critical component of health care. Developing stronger guidelines for trauma-informed care will help clinicians better provide inclusive and equitable care for refugee patients.

Immigrant family legal clinic: A case of integrated student supports in a community school context

Research is growing on the ways K-12 schools can address immigration policy and assist in mediating its impact on students and families. Community schools are poised to address these issues through integrated student supports by taking an asset-based perspective that views community members and organizations as powerful constituents in the struggle for educational equity. We report the findings of a qualitative case study of the implementation of a school-based legal clinic for immigrant families in a high-poverty urban neighborhood. We applied an equity-minded school change framework to examin the range of services offered by the clinic, the process of integrating the clinic's work into the life of the school, and the perspectives of teachers regarding the intersection between immigration and education.

Diverse community leaders' perspectives about quality primary healthcare and healthcare measurement: Qualitative community-based participatory research

Background

Healthcare quality measurements in the United States illustrate disparities by racial/ethnic group, socio-economic class, and geographic location. Redressing healthcare inequities, including measurement of and reimbursement for healthcare quality, requires partnering with communities historically excluded from decision-making. Quality healthcare is measured according to insurers, professional organizations and government agencies, with little input from diverse communities. This community-based participatory research study aimed to amplify the voices of community leaders from seven diverse urban communities in Minneapolis-Saint Paul Minnesota, view quality healthcare and financial reimbursement based on quality metric scores.

Methods

A Community Engagement Team consisting of one community member from each of seven urban communities —Black/African American, Lesbian-Gay-Bisexual-Transgender-Queer-Two Spirit, Hmong, Latino/a/x, Native American, Somali, and White—and two community-based researchers conducted listening sessions with 20 community leaders about quality primary healthcare. Transcripts were inductively analyzed and major themes were identified.

Results

Listening sessions produced three major themes, with recommended actions for primary care clinics.

#1: Quality Clinics Utilize Structures and Processes that Support Healthcare Equity.

#2: Quality Clinics Offer Effective Relationships, Education, and Health Promotion.

#3: Funding Based on Current Quality Measures Perpetuates Health Inequities.

Conclusion

Community leaders identified ideal characteristics of quality primary healthcare, most of which are not currently measured. They expressed concern that linking clinic payment with quality metrics without considering social and structural determinants of health perpetuates social injustice in healthcare.

Flourishing: migration and health in social context

Health and the capacity to flourish are deeply intertwined. For members of vulnerable migrant groups, systemic inequalities and structural forms of marginalisation and exclusion create health risks, impede access to needed care and interfere with the ability to achieve one's full potential. Migrants often have limited access to healthcare, and they frequently are portrayed as less deserving than others of the resources needed to lead a healthy and flourishing life. Under these circumstances, clinicians, healthcare institutions and global health organisations have a moral and ethical obligation to consider the role they can-and do-play in either advancing or impeding migrants' health and their capacity to flourish. Drawing on case studies from three world regions, we propose concrete steps clinicians and health institutions can take in order to better serve migrant patients. These include recommendations that can help improve understanding of the complex circumstances of migrants' lives, strengthen collaboration between care providers and non-medical partners and transform the social, economic and structural circumstances that impede flourishing and harm health. Developing new strategies to promote the flourishing of precarious migrants can strengthen our collective ability to re-envision and redesign health systems and structures to value the health, dignity and bodily integrity of all patients-especially the most vulnerable-and to promote flourishing for all.