Immigrants and health care--at the intersection of two broken systems

Immigrant Status Disparities in Hearing Health Care Use in the United States

OBJECTIVE

To determine whether immigrant status is associated with likelihood of audiogram and hearing aid use among US adults with hearing loss.

STUDY DESIGN

Cross-sectional study.

SETTING

Nationally representative data from 2009 to 2010, 2011 to 2012, 2015 to 2016, and 2017 to 2020 National Health and Nutrition Examination Survey (NHANES) cycles.

METHODS

This cross-sectional study of 4 merged cycles of NHANES included 12,455 adults with subjective (self-reported) or objective (audiometric) hearing loss. Sequentially adjusted logistic regressions were used to assess the association of immigration status with likelihood of having undergone audiogram among those with objective and self-reported hearing loss, and with likelihood of hearing aid use among candidates with objective hearing loss.

RESULTS

Immigrants were less likely to have received an audiogram among subjects with subjective (odds ratio [OR]: 0.81, 95% confidence interval [CI]: 0.75-0.87), and objective (OR: 0.76, 95% CI: 0.72-0.81) hearing loss, compared to nonimmigrants. The association persisted for those with subjective (OR: 0.88, 95% CI: 0.81-0.96), and objective (OR: 0.87, 95% CI: 0.80-0.96) hearing loss after adjusting for sociodemographic factors, comorbidities, insurance, and hearing quality, but disappeared in both groups after adjusting for English proficiency. Immigrants were less likely to use hearing aids (OR: 0.90, 95% CI: 0.87-0.93). However, this association disappeared (OR: 0.98, 95% CI: 0.93-1.04) in the adjusted model.

CONCLUSION

Immigrant status is a significant barrier to hearing health care and is associated with lower rates of audiometric testing and hearing aid use among individuals with hearing loss.

Brokering Resources during a Pandemic: Exploring How Organizations and Clinics Responded to the Needs of Immigrant Communities during COVID-19

Though COVID-19 has had sweeping implications, many immigrant groups in the United States have been disproportionately affected. The purpose of the present study is to explore the impact of COVID-19 on immigrant communities and how local immigrant-serving organizations (ISOs) have responded during the pandemic. The authors conducted in-depth qualitative interviews with executive directors and program coordinators of 31 ISOs and health clinics in Kentucky, North Carolina, and South Carolina. Findings highlight the needs of immigrants and refugees during the pandemic, including economic burden, lack of information, and limited access to testing and treatment for COVID-19. The authors find that ISOs have responded to these needs by providing basic supports, partnering with other local organizations to channel needed resources to immigrant communities, and collaborating with state-level entities to improve outreach, testing, and treatment. The authors also identify mechanisms that enabled the organizations to make nimble accommodations during the pandemic as well as the burden and compromises that these organizations have experienced. The authors argue that ISOs represent an important aspect of safety nets available for immigrants and provide insights into how other organizations can prepare for public health crises like COVID-19 in the future.

Disparities in COVID-19 health outcomes among different sub-immigrant groups in the US - a study based on the spatial Durbin model

Immigrants may be more vulnerable to coronavirus disease 2019 (COVID-19) than other sub-population groups due to their relatively low socioeconomic status. However, no quantitative studies have examined the relationships between immigrants and COVID-19 health outcomes (confirmed cases and related deaths). We first examined the relationship between total immigrants and COVID-19 health outcomes with spatial Durbin models after controlling for demographic, biophysical and socioeconomic variables. We then repeated the same analysis within multiple subimmigrant groups divided by those with original nativity to examine the differential associations with health outcomes. The result showed that the proportion of all immigrants is negatively associated with the number of confirmed cases and related deaths. At the continent and sub-continent level, we consistently found negative relationships between the number of confirmed cases and the proportion of all sub-immigrant groups. However, we observed mixed associations between the proportion of sub-immigrant groups and the number of deaths. Those counties having a higher prevalence of immigrants from Africa [Eastern Africa: â€"18.6, 95% confidence interval (CI): â€"38.3~â€"2.9; Northern Africa: â€"146.5, 95% CI: â€"285.5~â€"20.1; Middle Africa: â€"622.6, 95% CI: â€"801.4~â€" 464.5] and the Americas (Northern America: â€"90.5, 95% CI: â€" 106.1~â€"73.8; Latin America: â€"6.8, 95% CI: â€"8.1~â€"5.2) mostly had a lower number of deaths, whereas those counties having a higher prevalence of immigrants from Asia (Eastern Asia: 21.0, 95% CI: 7.7~36.2; Western Asia: 42.5, 95% CI: 16.9~68.8; South- Central Asia: 26.6, 95% CI: 15.5~36.9) showed a higher number of deaths. Our results partially support that some immigrants, especially those from Asia, are more vulnerable to COVID-19 than other sub-population groups.

Comparison of HIV Viral Suppression Between a Sample of Foreign-Born and U.S.-Born Women of Color in the United States

We investigate the association between nativity status (U.S.- vs foreignborn) and viral suppression among women of color (WOC) with HIV (HIV +) and whether this association was modified by education and housing.

METHODS

Data were from 549 HIV + WOC, who participated in the Health Resources and Services Administration-funded WOC Initiative 2009-2013. We used generalized estimating equation models to quantify the association between the respondents' nativity status and viral suppression.

RESULTS

After adjusting for covariates, foreign-born WOC were 2.2 times (95% confidence interval: 1.25, 3.85) more likely to achieve viral suppression than U.S.-born WOC. This association was not modified by education or housing status.

CONCLUSIONS

Despite facing barriers to care, foreign-born WOC were more likely to achieve viral suppression than U.S.-born WOC. Programs aiming to end the HIV epidemic and reduce HIV disparities in the U.S. should consider these findings as they provide a more nuanced understanding of HIV + WOC.

The legal violence of care: Navigating the US health care system while undocumented and illegible

Medical sociologists widely conceptualize illegality as a social determinant of health, implicating immigration law but not health care law in immigrant health disparities. Contributing to an emerging literature on legal violence in the context of health care, I explore how the Harris Health System in Houston, Texas legally affects low-income undocumented migrants' lives as they seek care. Drawing on eleven months of ethnographic and interview research with migrants and volunteers at a community-based organization, I argue that the health care system legally exacerbates migrant vulnerability in particular ways. Clerical staff follow medical protocol to deny migrants care on the basis of legibility (i.e., a photo ID), not legality (i.e., legal status), resulting in two classifications of illegality - what I term legible and illegible illegality. The former keeps migrants visible to the state but offers potential care, and the latter legally relegates migrants to the exploitative conditions of informal home care and/or a protracted state of suffering where, for many, death is the only recourse. This research shows that without substantive health reform, health practitioners - physicians, social workers, clerical staff, and home care workers - play an (in)direct role in shaping and normalizing immigrant health disparities.

Factors Associated With ED Use Among New Asian Immigrants in New Zealand: A Cross-Sectional Analysis of Secondary Data

INTRODUCTION

New Zealand has an ethnically diverse population and continues to host immigrants from different countries. The present study aimed to examine the factors associated with ED use among new Asian immigrants in New Zealand.

METHODS

A secondary analysis of 2016-2017 New Zealand Health Survey database. Univariate and multivariate logistic regression models were employed. A total of 414 new Asian immigrants were identified.

RESULTS

Asthma, diabetes, chronic pain, anxiety, hypertension, body mass index, waist measurement, perceived health status, and distress were associated with a significantly increased likelihood to ED visits. The multivariate logistic regression analysis revealed that asthma (adjusted odds ratio = 5.29, 95% confidence interval, 1.26-22.24) and perceived health status (adjusted odds ratio = 0.81, 95% confidence interval, 0.66-0.99) were factors associated with ED use among new Asian immigrants.

CONCLUSION

Asthma and perceived health status were the 2 key factors associated with ED use among new Asian immigrants in New Zealand. ED use among new Asian immigrants encompassed both chronic health conditions and mental health indicators.

Association of Documentation of Legal Residency Status with Nonprescribed Hormone Use Among Hispanic/Latina Trans Women in San Francisco

Undocumented immigrant trans Latinas face significant barriers to attaining gender-affirming health care and may use nonprescribed feminizing hormones. Without medical supervision, nonprescribed hormone use may lead to adverse health outcomes. This study aimed to determine if a history of being an undocumented immigrant was associated with nonprescribed hormone use among trans Latinas. We conducted a secondary analysis using baseline data from the 2016 Trans National study done in the San Francisco Bay Area. Two hundred five trans Latinas participated in the study, of whom 75 (37%) reported a history of being undocumented. We fitted a multivariable logistic regression model to determine whether having a history of being an undocumented immigrant was associated with nonprescribed hormone use while controlling for age, income, time living in San Francisco, history of sex work, and history of problems with accessing health care. The prevalence of nonprescribed hormone use was 55.9% among trans Latinas overall; however, for trans Latinas with a history of undocumented immigration status, the prevalence was 68%. There was a significant, independent association between nonprescribed hormone use and undocumented status (adjusted odds ratio [aOR]=3.20; 95% confidence interval [CI]=1.47–6.97). We also found that having a history of sex work was associated with nonprescribed hormone use (aOR=5.72; 95% CI=2.69–12.18). The prevalence of nonprescribed hormone use among trans Latinas was high and is associated with a history of undocumented status and sex work. These associations may indicate health care avoidance related to concerns of being criminalized due to their documentation status or source of income (i.e., sex work) among trans Latinas. These findings underscore the need to reduce barriers in gender-affirming care to increase access to medically supervised hormone use, particularly among individuals with a history of undocumented status and engaged in sex work.

Understanding the healthcare experiences and needs of African immigrants in the United States: a scoping review

BACKGROUND

Africans immigrants in the United States are the least-studied immigrant group, despite the research and policy efforts to address health disparities within immigrant communities. Although their healthcare experiences and needs are unique, they are often included in the "black" category, along with other phenotypically-similar groups. This process makes utilizing research data to make critical healthcare decisions specifically targeting African immigrants, difficult. The purpose of this Scoping Review was to examine extant information about African immigrant health in the U.S., in order to develop lines of inquiry using the identified knowledge-gaps.

METHODS

Literature published in the English language between 1980 and 2016 were reviewed in five stages: (1) identification of the question and (b) relevant studies, (c) screening, (d) data extraction and synthesis, and (e) results. Databases used included EBSCO, ProQuest, PubMed, and Google Scholar (hand-search). The articles were reviewed according to title and abstract, and studies deemed relevant were reviewed as full-text articles. Data was extracted from the selected articles using the inductive approach, which was based on the comprehensive reading and interpretive analysis of the organically emerging themes. Finally, the results from the selected articles were presented in a narrative format.

RESULTS

Culture, religion, and spirituality were identified as intertwined key contributors to the healthcare experiences of African immigrants. In addition, lack of culturally-competent healthcare, distrust, and complexity, of the U.S. health system, and the exorbitant cost of care, were identified as major healthcare access barriers.

CONCLUSION

Knowledge about African immigrant health in the U.S. is scarce, with available literature mainly focusing on databases, which make it difficult to identify African immigrants. To our knowledge, this is the first Scoping Review pertaining to the healthcare experiences and needs of African immigrants in the U.S.

The Impact of Acculturation and Racialization on Self-Rated Health Status Among U.S. Latinos

We investigate the Hispanic paradox by examining the relationship between acculturation and health status of Latinos to understand nuances among this growing heterogeneous population using a 2011 Latino Decisions survey. We find that acculturation remains an important determinant of Latino health; however, this varies based on whether the sample is restricted to immigrants or includes all Latino adults and on the measures of acculturation employed. We find Latino citizens reported better health than non-citizens; however, other acculturation measures, such as language use and time in the U.S. do not have a marked effect. Furthermore, skin color matters only for U.S.-born Latinos. Racialization is therefore important to consider within the context of the Hispanic paradox. Our findings suggest that some of the disadvantages stemming from minority status in the U.S. are more prominent among Latinos who have greater experience with the racial hierarchy of the U.S. and greater acculturation more broadly.

Challenges for immigrant health in the USA-the road to crisis

The USA is home to more immigrants than any other country-about 46 million, just less than a fifth of the world's immigrants. Immigrant health and access to health care in the USA varies widely by ethnicity, citizenship, and legal status. In recent decades, several policy and regulatory changes have worsened health-care quality and access for immigrant populations. These changes include restrictions on access to public health insurance programmes, rhetoric discouraging the use of social services, aggressive immigration enforcement activities, intimidation within health-care settings, decreased caps on the number of admitted refugees, and rescission of protections from deportation. A receding of ethical norms has created an environment favourable for moral and public health crises, as evident in the separation of children from their parents at the southern US border. Given the polarising immigration rhetoric at the national level, individual states rather than the country as a whole might be better positioned to address the barriers to improved health and health care for immigrants in the USA.

Health and Mental Health Effects of Local Immigration Enforcement

We study the effect of two local immigration enforcement policies — Section 287(g) of the Illegal Immigration Reform and Immigrant Responsibility Act and the Secure Communities Program (SC) — on the health and mental health outcomes of Latino immigrants living in the United States. We use the restricted-use National Health Interview Survey for 2000–2012 and adopt a difference-in-difference research design. Estimates suggest that SC increased the proportion of Latino immigrants with mental health distress by 2.2 percentage points (14.7%), Task Force Enforcement under Section 287(g) worsened their mental health distress scores by 15 percent (0.08 standard deviation), and Jail Enforcement under Section 287(g) increased the proportion of Latino immigrants reporting fair or poor health by 1 percentage point (11.1%) and lowered the proportion reporting very good or excellent health by 4.8 to 7.0 percentage points (7.8% to 10.9%). These findings are robust to various sensitivity checks and have long-term implications for population health, public health expenditure, and immigrant integration.

Buffering the Uneven Impact of the Affordable Care Act: Immigrant-serving Safety-net Providers in New Mexico

We conducted a study in early 2014 to document how the initial implementation of the Affordable Care Act (ACA) affected health care provision to different categories of immigrants from the perspective of health care providers in New Mexico. Though ACA navigators led enrollment, a range of providers nevertheless became involved by necessity, expressing concern about how immigrants were faring in the newly configured health care environment and taking on advocacy roles. Providers described interpreting shifting eligibility and coverage, attending to vulnerable under/uninsured patients, and negotiating new bureaucratic barriers for insured patients. Findings suggest that, like past efforts, this recent reform to the fragmented health care system has perpetuated a condition in which safety-net clinics and providers are left to buffer a widening gap for immigrant patients. With possible changes to the ACA ahead, safety-net providers' critical buffering roles will likely become more crucial, underscoring the necessity of examining their experiences with past reforms.

Association between insurance status at diagnosis and overall survival in chronic myeloid leukemia: A population-based study

BACKGROUND

Chronic myeloid leukemia (CML) can be treated effectively with tyrosine kinase inhibitor therapy directed at BCR-ABL, but access to care, medication cost, and adherence may be barriers to treatment. This study was designed to determine whether the insurance status at diagnosis influences CML patient outcomes.

METHODS

The Surveillance, Epidemiology, and End Results database was used to identify 5784 patients, aged 15 years or older, who were diagnosed with CML between 2007 and 2012 and whose insurance status was documented at diagnosis. The primary outcome was 5-year overall survival (OS). Covariates of interest included the age at diagnosis, race, ethnicity, sex, county-level socioeconomic status, and marital status. OS was evaluated with a log-rank test and Kaplan-Meier estimates.

RESULTS

Among patients aged 15 to 64 years, insurance status was associated with OS (P < .001): being uninsured or having Medicaid was associated with worse 5-year OS in comparison with being insured (uninsured patients, 72.7%; Medicaid patients, 73.1%; insured patients, 86.6%). For patients who were 65 years old or older, insurance had less of an impact on OS (P = .07), with similar 5-year OS rates for patients with Medicaid and those with other insurance (40.2% vs 43.4%). In a multivariate analysis of patients aged 15 to 64 years, both uninsured patients (hazard ratio [HR], 1.93; P < .001) and Medicaid patients (HR, 1.83; P < .001) had an increased hazard of death in comparison with insured patients; patients younger than 40 years, female patients, and married patients also had a lower hazard of death.

CONCLUSION

These findings suggest that CML patients under the age of 65 years who are uninsured or have Medicaid have significantly worse survival than patients with other insurance coverage. Cancer 2017;123:2561-69. © 2017 American Cancer Society.

Changing the navigator's course: How the increasing rationalization of healthcare influences access for undocumented immigrants under the Affordable Care Act

A number of researchers have shown that brokers (e.g., navigators and street-level bureaucrats) bridge access to healthcare services and information for immigrant patients through rich personal relationships and a mission of ethical care. An open question remains concerning how the increasing rationalization of healthcare over the past few decades influences brokerage for undocumented immigrant patients. Drawing from fieldwork and interviews conducted in California, as the Affordable Care Act (ACA) was implemented, I develop the concept of the "double-embedded-liaison." While other studies treat brokers as acting either as gatekeepers or patient representatives, this study explains how brokers simultaneously operate on multiple planes when new roles are added. I argue that with more formalization and scrutiny at health centers, the impact of brokerage is destabilized and, subsequently, diminished. Two consequences of the double-embedded-liaison brokerage form are: (1) some brokers become disillusioned and exit -resulting in the loss of valuable resources at the health centers, and (2) immigrants move away from the health centers that historically served them. In looking at brokers' simultaneous performance as gatekeepers and representatives, this research extends brokerage typologies and street-level bureaucracy arguments that largely treat brokerage in a mono-planar rather than in a bi-planar mode. Furthermore, in examining the risks and opportunities brokerage brings to addressing health disparities, the study provides insights into the effects of replacing the ACA or repealing it all together in the Post-Obama era.

Legal Status and Health Care: Mexican-Origin Children in California, 2001-2014

Using restricted data from the 2001-2014 California Health Interview Surveys, this research illuminates the role of legal status in health care among Mexican-origin children. The first objective is to provide a population-level overview of trends in health care access and utilization, along with the legal statuses of parents and children. The second objective is to examine the nature of associations between children's health care and legal status over time. We identify specific status-based distinctions that matter and investigate how their importance is changing. Despite the continuing significance of child nativity for health care, the descriptive analysis shows that the proportion of Mexican-origin children who are foreign born is declining. This trend suggests a potentially greater role of parental legal status in children's health care. Logistic regression analyses demonstrate that the importance of parental legal status varies with the health care indicator examined and the inclusion of child nativity in models. Moreover, variation in some aspects of children's health care coalesced more around parents' citizenship than documentation status in the past. With one exception, the salience of such distinctions has dissipated over time.

First-generation Korean immigrants' barriers to healthcare and their coping strategies in the US

This paper examines first-generation Korean immigrants' barriers to healthcare in the US and their strategies for coping with these issues by analyzing survey data from 507 Korean immigrants and in-depth interviews with 120 Korean immigrants in the New York-New Jersey area. It reports that more than half of Korean immigrants have barriers to healthcare in the US, with the language barrier being the most frequent response, followed by having no health insurance. Korean immigrants are not passive, but rather active entities who display coping strategies for these barriers, such as seeing co-ethnic doctors in the US, seeking Hanbang (traditional Korean medicine) in the US, and taking medical tours to the home country. However, their coping strategies are far removed from formal US healthcare as their behaviors are still restricted to the informal healthcare within the ethnic community or home country. This study methodologically and theoretically contributes to the literature on immigrants' healthcare behaviors by using a mixed-method approach and developing a specific framework for one particular immigrant group.

Detecting Dysglycemia Using the 2015 United States Preventive Services Task Force Screening Criteria: A Cohort Analysis of Community Health Center Patients

BACKGROUND

In 2015, the United States Preventive Services Task Force (USPSTF) recommended targeted screening for prediabetes and diabetes (dysglycemia) in adults who are aged 40 to 70 y old and overweight or obese. Given increasing prevalence of dysglycemia at younger ages and lower body weight, particularly among racial/ethnic minorities, we sought to determine whether the current screening criteria may fail to identify some high-risk population subgroups.

METHODS AND FINDINGS

We investigated the performance of the 2015 USPSTF screening recommendation in detecting dysglycemia among US community health center patients. A retrospective analysis of electronic health record (EHR) data from 50,515 adult primary care patients was conducted. Longitudinal EHR data were collected in six health centers in the Midwest and Southwest. Patients with a first office visit between 2008 and 2010 were identified and followed for up to 3 y through 2013. We excluded patients who had dysglycemia at baseline and those with fewer than two office visits during the follow-up period. The exposure of interest was eligibility for screening according to the 2015 USPSTF criteria. The primary outcome was development of dysglycemia during follow-up, determined by: (1) laboratory results (fasting/2-h postload/random glucose ≥ 100/140/200 mg/dL [5.55/7.77/11.10 mmol/L] or hemoglobin A1C ≥ 5.7% [39 mmol/mol]); (2) diagnosis codes for prediabetes or type 2 diabetes; or (3) antidiabetic medication order. At baseline, 18,846 (37.3%) participants were aged ≥40 y, 33,537 (66.4%) were overweight or obese, and 39,061 (77.3%) were racial/ethnic minorities (34.6% Black, 33.9% Hispanic/Latino, and 8.7% Other). Overall, 29,946 (59.3%) patients had a glycemic test within 3 y of follow-up, and 8,478 of them developed dysglycemia. Only 12,679 (25.1%) patients were eligible for screening according to the 2015 USPSTF criteria, which demonstrated the following sensitivity and specificity (95% CI): 45.0% (43.9%-46.1%) and 71.9% (71.3%-72.5%), respectively. Racial/ethnic minorities were significantly less likely to be eligible for screening yet had higher odds of developing dysglycemia than whites (odds ratio [95% CI]: Blacks 1.24 [1.09-1.40]; Hispanics 1.46 [1.30-1.64]; and Other 1.33 [1.16-1.54]). In addition, the screening criteria had lower sensitivity in all racial/ethnic minority groups compared to whites. Limitations of this study include the ascertainment of dysglycemia only among patients with available test results and findings that may not be generalizable at the population level.

CONCLUSIONS

Targeted diabetes screening based on new USPSTF criteria may detect approximately half of adult community health center patients with undiagnosed dysglycemia and proportionately fewer racial/ethnic minorities than whites. Future research is needed to estimate the performance of these screening criteria in population-based samples.

The inclusion of international migrants in Brazilian healthcare system policies: the case of Haitians in the state of Amazonas

Resumo A partir do enfoque etnográfico sobre as redes sociais articuladas em torno da questão do imigrante no Amazonas, o artigo reflete sobre como o Sistema Único de Saúde (SUS) respondeu às demandas colocadas por um contingente inesperado de novos usuários, tendo em vista os princípios doutrinários que lhe dão sustentação, especialmente o da equidade. O foco é a onda de imigração haitiana rumo ao Brasil, iniciada em fevereiro de 2010 pelos estados fronteiriços da região Norte: Acre, Rondônia e Amazonas, concentrando-se neste último, descrevendo alguns aspectos do período mais crítico da imigração (entre março de 2010 e março de 2012) e sua recepção pelo SUS.

A collaborative communitywide health fair: the process and impacts on the community

The purpose of this article is to describe the process of conducting a collaborative communitywide health fair, and the impacts of such health intervention programs on community members. A community health fair addresses the health access needs of underserved populations. The success or effectiveness of such community-based programs requires systematic approach to assessment, planning, implementation, and evaluation. The PRECEDE˜PROCEED model was used as the guiding framework. The health fair described in this article was coordinated by nurses and drew resources from multiple health providers and organizations. The fair provided opportunities for vulnerable populations to access and utilize appropriate and comprehensive health services, resources and education.

Nativity and occupational class disparities in uninsurance and routine preventive care use among Asian Americans

Using data from 1,530 Asian respondents of the 2002-2003 National Latino and Asian American Study, we examined how nativity and occupational class are associated with uninsurance, no routine physical check-up in the past year and no dental/eye exam use in the past year using weighted multivariate logistic regression models. Recent immigrants had increased odds of uninsurance and no dental/eye exam use than US-born Asians which became nonsignificant after controlling for occupational class and covariates. Unemployed and service workers had increased odds of uninsurance than white-collar workers even after controlling for income and limited English proficiency (LEP). Approximately 35-40 % of blue-collar and service workers reported neither type of preventive care use. Even after controlling for LEP, income, uninsurance, having a regular doctor or place of care, service workers had significantly increased odds of no physical check-up and no dental/eye exam use and blue-collar workers had marginally significant increased odds of no dental/eye exam use. Significant occupational disparities exist in access and preventive care use with workers in service occupations being particularly underserved.

The double-edged sword of electronic health records: implications for patient disclosure

Objective Electronic health record (EHR) systems are linked to improvements in quality of care, yet also privacy and security risks. Results from research studies are mixed about whether patients withhold personal information from their providers to protect against the perceived EHR privacy and security risks. This study seeks to reconcile the mixed findings by focusing on whether accounting for patients’ global ratings of care reveals a relationship between EHR provider-use and patient non-disclosure.

Materials and methods A nationally representative sample from the 2012 Health Information National Trends Survey was analyzed using bivariate and multivariable logit regressions to examine whether global ratings of care suppress the relationship between EHR provider-use and patient non-disclosure.

Results 13% of respondents reported having ever withheld information from a provider because of privacy/security concerns. Bivariate analysis showed that withholding information was unrelated to whether respondents’ providers used an EHR. Multivariable analysis showed that accounting for respondents’ global ratings of care revealed a positive relationship between having a provider who uses an EHR and withholding information.

Discussion After accounting for global ratings of care, findings suggest that patients may non-disclose to providers to protect against the perceived EHR privacy and security risks. Despite evidence that EHRs inhibit patient disclosure, their advantages for promoting quality of care may outweigh the drawbacks.

Conclusions Clinicians should leverage the EHR's value in quality of care and discuss patients’ privacy concerns during clinic visits, while policy makers should consider how to address the real and perceived privacy and security risks of EHRs.

The great recession and health spending among uninsured U.S. immigrants: implications for the Affordable Care Act implementation

OBJECTIVE

We study the association between the timing of the Great Recession (GR) and health spending among uninsured adults distinguishing by citizenship/nativity status and time of U.S. residence.

DATA SOURCE

Uninsured U.S. citizens and noncitizens from the 2005-2006 and 2008-2009 Medical Expenditure Panel Survey.

STUDY DESIGN

The probability of reporting any health spending and the natural logarithm of health spending are our main dependent variables. We compare health spending across population categories before/during the GR. Subsequently, we implement two-part regression analyses of total and specific health-spending measures. We predict average health spending before/during the GR with a smearing estimation.

PRINCIPAL FINDINGS

The probability of reporting any spending diminished for recent immigrants compared to citizens during the GR. For those with any spending, recent immigrants reported higher spending during the GR (27 percent). Average reductions in total spending were driven by the decline in the share of the population reporting any spending among citizens and noncitizens.

CONCLUSIONS

Our study findings suggest that recent immigrants could be forgoing essential care, which later translates into higher spending. It portrays the vulnerability of a population that would remain exposed to income shocks, even after the Affordable Care Act (ACA) implementation.

Care of an undocumented immigrant: Case and comment

This commentary addresses the care of an undocumented immigrant with neuromyelitis optica in the context of a state law designed to deny state-funded medical services to individuals whose presence in the United States is unlawful. It considers specific circumstances in which the law would permit or require medical care for undocumented persons in state medical facilities, including a duty to "stabilize" an "emergency medical condition" and the provision of care necessary to "protect life or safety." It also addresses dilemmas clinicians may experience when faced with an apparent tension between their professional ethical obligations and legal rules aimed at enforcing immigration policies.

Undocumented Immigrants and Access to Health Care: Making a Case for Policy Reform

The growth in undocumented immigration in the United States has garnered increasing interest in the arenas of immigration and health care policy reform. Undocumented immigrants are restricted from accessing public health and social service as a result of their immigration status. The Patient Protection and Affordability Care Act restricts undocumented immigrants from participating in state exchange insurance market places, further limiting them from accessing equitable health care services. This commentary calls for comprehensive policy reform that expands access to health care for undocumented immigrants based on an analysis of immigrant health policies and their impact on health care expenditures, public health, and the role of health care providers. The intersectional nature of immigration and health care policy emphasizes the need for nurse policymakers to advocate for comprehensive policy reform aimed at improving the health and well-being of immigrants and the nation as a whole.

Parenting with a disability and child mental health: a propensity score analysis

Little research has examined the impact of having a parent with a disability on child mental health. This study used data from 7,116 families of children who participated in the 2006 National Health Interview Survey and propensity score matching (PSM) to investigate this question. Prior to PSM, differences in Child Mental Health Brief scores were significant with a moderate effect size. After PSM, differences in Child Mental Health Brief scores were still significant, but the effect size was small. Results indicate that much of the mental health risk for children of parents with disabilities is connected to related issues.

O acesso aos serviços de saúde por emigrantes brasileiros nos Estados Unidos

A análise do atual contexto político e econômico existente nos EUA, que envolve o acesso e utilização de serviços de saúde pelos imigrantes, diz respeito aos mais de 20 milhões de indivíduos estrangeiros que residem naquele país e não possuem seguro de saúde. Essa população corresponde a 43,8% de 46 milhões de pessoas que não possuem cobertura de provedores privados de saúde nos EUA, sendo 10,5 milhões residentes sem a documentação exigida para viver no País. Para explorar as necessidades, o acesso e a utilização dos serviços de saúde americanos pelos emigrantes de Governador Valadares, MG, Brasil, o presente estudo entrevistou uma amostra de 14 emigrantes valadarenses selecionada por meio da técnica bola de neve. Foram elaboradas questões relacionadas à documentação, local de residência, profissões exercidas, necessidade, acesso e utilização de serviços de saúde. As informações recolhidas junto aos emigrantes residentes nos Estados de Massachusetts e Connecticut permitem afirmar a viabilidade do acesso e da utilização dos serviços de saúde subsidiados pelos governos federal e estaduais e de organizações não governamentais.

Health care expenditures among Asian American subgroups

Using two nationally representative data sets, this study examined health care expenditure disparities between Caucasians and different Asian American subgroups. Multivariate analyses demonstrate that Asian Americans, as a group, have significantly lower total expenditures compared with Caucasians. Results also point to considerable heterogeneities in health care spending within Asian American subgroups. Findings suggest that language assistance programs would be effective in reducing disparities among Caucasians and Asian American subgroups with the exception of Indians and Filipinos, who tend to be more proficient in English. Results also indicate that citizenship and nativity were major factors associated with expenditure disparities. Socioeconomic status, however, could not explain expenditure disparities. Results also show that Asian Americans have lower physician and pharmaceutical costs but not emergency department or hospital expenditures. These findings suggest the need for culturally competent policies specific to Asian American subgroups and the necessity to encourage cost-effective treatments among Asian Americans.

Providing care for immigrant, migrant, and border children

This policy statement, which recognizes the large changes in immigrant status since publication of the 2005 statement "Providing Care for Immigrant, Homeless, and Migrant Children," focuses on strategies to support the health of immigrant children, infants, adolescents, and young adults. Homeless children will be addressed in a forthcoming separate statement ("Providing Care for Children and Adolescents Facing Homelessness and Housing Insecurity"). While recognizing the diversity across and within immigrant, migrant, and border populations, this statement provides a basic framework for serving and advocating for all immigrant children, with a particular focus on low-income and vulnerable populations. Recommendations include actions needed within and outside the health care system, including expansion of access to high-quality medical homes with culturally and linguistically effective care as well as education and literacy programs. The statement recognizes the unique and special role that pediatricians can play in the lives of immigrant children and families. Recommendations for policies that support immigrant child health are included.

Characteristics of newly immigrated, Spanish-speaking Latinos who use the pediatric emergency department: preliminary findings in a secondary migration city

OBJECTIVE

This study aimed to assess Latino immigrant usage, access, and reason for coming to the pediatric emergency department (PED) and clarify parental perceptions, barriers, and concerns regarding Latino children's health.

METHODS

Interviews and questionnaires were verbally administered to a convenience sample of newly immigrated (<10 years in the United States) Latino parents of 57 patients presenting to the PED.

RESULTS

Compared with those with higher levels of acculturation, Latinos with lower levels of acculturation were more likely to use the PED to meet their children's health care needs. It seems that our PED has higher usage by Latino families compared with non-Latino families, which may be related to the lack of Latino-focused health infrastructure in our city. Once these families present to the PED, they do not seem to differ from overall users at our ED and nationally with regard to reason for visit.

CONCLUSIONS

Similar to many other secondary migration hubs across the United States, our city has experienced dramatic growth in its Latino population in the last several years. Although health care providers anecdotally report increased service to Spanish-speaking populations, very little is known about the health care experience of Latino families in our area. To provide both equal and expert care to Latino children in the PED setting, it is essential that providers have this information specific to the context in which they work.

Does an immigrant health paradox exist among Asian Americans? Associations of nativity and occupational class with self-rated health and mental disorders

A robust socioeconomic gradient in health is well-documented, with higher socioeconomic status (SES) associated with better health across the SES spectrum. However, recent studies of U.S. racial/ethnic minorities and immigrants show complex SES-health patterns (e.g., flat gradients), with individuals of low SES having similar or better health than their richer, U.S.-born and more acculturated counterparts, a so-called "epidemiological paradox" or "immigrant health paradox". To examine whether this exists among Asian Americans, we investigate how nativity and occupational class (white-collar, blue-collar, service, unemployed) are associated with subjective health (self-rated physical health, self-rated mental health) and 12-month DSM-IV mental disorders (any mental disorder, anxiety, depression). We analyzed data from 1530 Asian respondents to the 2002-2003 National Latino and Asian American Study in the labor force using hierarchical multivariate logistic regression models controlling for confounders, subjective social status (SSS), material and psychosocial factors theorized to explain health inequalities. Compared to U.S.-born Asians, immigrants had worse socioeconomic profiles, and controlling for age and gender, increased odds for reporting fair/poor mental health and decreased odds for any DSM-IV mental disorder and anxiety. No strong occupational class-health gradients were found. The foreign-born health-protective effect persisted after controlling for SSS but became nonsignificant after controlling for material and psychosocial factors. Speaking fair/poor English was strongly associated with all outcomes. Material and psychosocial factors were associated with some outcomes--perceived financial need with subjective health, uninsurance with self-rated mental health and depression, social support, discrimination and acculturative stress with all or most DSM-IV outcomes. Our findings caution against using terms like "immigrant health paradox" which oversimplify complex patterns and mask negative outcomes among underserved sub-groups (e.g., speaking fair/poor English, experiencing acculturative stress). We discuss implications for better measurement of SES and health given the absence of a gradient and seemingly contradictory finding of nativity-related differences in self-rated health and DSM-IV mental disorders.

Access to health care for undocumented migrants: a comparative policy analysis of England and the Netherlands

The presence of undocumented migrants is increasing in many Western countries despite wide-ranging attempts by governments to increase border security. Measures taken to control the influx of immigrants include policies that restrict access to publicly funded health care for undocumented migrants. These restrictions to health care access are controversial, and evidence suggests they do not always have the intended effect. This study provides a comparative analysis of institutional, actor-related, and contextual factors that have influenced health care policy development on undocumented migrants in England and the Netherlands. For undocumented migrants, England restricts its access to care at the point of service, while the Netherlands restricts through the payment system for services. The study includes an analysis of policy papers and semistructured, in-depth interviews with various actors in both countries. Findings confirm the influence of such contextual factors as immigration considerations and cost concerns on health care policy making in this area. However, these factors cannot explain the differences between the two countries. Previously enacted policies, especially the organization of the health care system, affected the kind of restrictions for undocumented migrants. Concerns about the side effects of generous treatment of undocumented migrants on other groups played a substantial role in formulating restrictive policies in both countries. Evidently, policy development and implementation is critically affected by institutional rules, which govern the degree of influence that doctors and professional medical associations have on the policy process.

The Prevalence of Chronic Diseases among Migrants in Korea According to Their Length of Stay and Residential Status

Background

Migrant health is becoming public health issues, as the migrant populations are increasing and their length of stay is prolonged. This study aims to analyze the differences in prevalence of chronic diseases among migrants according to length of stay and residential status.

Methods

An initial population pool were 3,024 who were assessed with health screening programs by Migrant Health Association. 2,459 migrants were selected for final analysis. Via Stata 10 we conducted univariate logistic regression analysis to examine the effects of their length of stay and residential status on the prevalence of hypertension, diabetes, dyslipidemia, and obesity. In the final analysis, the result of each sex was adjusted for age, nationality, length of stay, and residential status via multiple logistic regression analysis.

Results

Longer length of stay tends to increase the prevalence of hypertension in male; 4-6 year stay-duration group demonstrated statistically significant excess compared to 1 year or less stay-duration group (adjusted odds ratio [OR], 1.39; confidence interval [CI], 1.01 to 1.92). After adjustment, male migrants stayed more than 7 year showed considerably higher dyslipidemia than male migrants stayed less than 1 year (adjusted OR, 1.95; CI, 1.05 to 3.64). Compared to the group with 1 year or less stay-duration, the prevalence of obesity in male was significantly higher among 4-6 year (adjusted OR, 1.65; CI, 1.17 to 2.32) and 7 year or more stay-duration group (adjusted OR, 1.65; CI, 1.11 to 2.45).

Conclusion

Longer length of stay correlated to higher prevalence of hypertension, dyslipidemia, and obesity among some population of migrants. So more researches and new developing policies are needed for this problem.

Estimating the effects of immigration status on mental health care utilizations in the United States

Immigration status is a likely deterrent of mental health care utilization in the United States. Using the Medical Expenditure Panel Survey and National Health Interview survey from 2002 to 2006, multivariable logistic regressions were used to estimate the effects of immigration status on mental health care utilization among patients with depression or anxiety disorders. Multivariate regressions showed that immigrants were significantly less likely to take any prescription drugs, but not significantly less likely to have any physician visits compared to US-born citizens. Results also showed that improving immigrants’ health care access and health insurance coverage could potentially reduce disparities between US-born citizens and immigrants by 14–29% and 9–28% respectively. Policy makers should focus on expanding the availability of regular sources of health care and immigrant health coverage to reduce disparities on mental health care utilization. Targeted interventions should also focus on addressing immigrants’ language barriers, and providing culturally appropriate services.

Take a stand commentary: how can medical anthropologists contribute to contemporary conversations on "illegal" im/migration and health?

Of the estimated 214 million people who have migrated from poorer to richer countries in search of a better life, between 20 and 30 million have migrated on an unauthorized, or "illegal," basis. All have health needs, or will in the future, yet most are denied health care available to citizens and authorized residents. To many, unauthorized im/migrants' exclusion intuitively "makes sense." As scholars of health, social justice, and human rights, we find this logic deeply flawed and are committed to advancing a constructive program of engaged critique. In this commentary, we call on medical anthropologists to claim an active role in reframing scholarly and public debate about this pressing global health issue. We outline four key theoretical issues and five action steps that will help us sharpen our research agenda and translate ourselves for colleagues in partner disciplines and for broader audiences engaged in policymaking, politics, public health, and clinical practice.

Transnational Migration and Global Health: The Production and Management of Risk, Illness, and Access to Care

Globalization, including the global flows of people, is clearly linked to disease transmission and vulnerability to health risks among immigrant populations. Anthropological research on transnational migration and health documents the implications of population movements for health and well-being. Studies of immigrant health reveal the importance of the social, political, and economic production of distress and disease as well as the structures and dynamics that produce particular patterns of access to health services. This review points to underlying political, economic, and social structures that produce particular patterns of health and disease among transnational migrants. Both critical and phenomenological analyses explore ideas of alterity and community, which underlie the production and management of immigrant health. Research on immigrant health underscores the importance of further attention to policies of entitlement and exclusion, which ultimately determine health vulnerabilities and accessibility of health care.

The mission of safety net organizations following national insurance reform

National health insurance reform will pose considerable challenges to the core missions of safety net organizations that serve the uninsured. Those who currently donate money or time will, rightly or wrongly, view uninsured recipients as less deserving on the whole. Nevertheless, safety net organizations can serve several critical functions that continue to justify their existence and support.One important mission is to maintain access for low-income uninsured until all elements of insurance reform are fully in place. Second, once the reform is implemented, people will need a great deal of assistance and encouragement to determine what they are supposed to do and where they are supposed to sign up. Third, substantial portions of the remaining uninsured will continue to lack affordable insurance options, and large numbers of people eligible for coverage will unavoidably undergo temporary gaps in coverage as their family and financial circumstances change. Finally, not all people with insurance will have affordable access to all needed care. Market conditions will continue pushing higher levels of patient cost-sharing through deductibles and co-payments.To serve these multiple needs, safety net organizations should consider adapting their missions and business models so that they accept both insured and uninsured patients under a sliding fee scale that varies charges according to ability to pay.

Beyond welfare reform: reframing undocumented immigrants' entitlement to health care in the United States, a critical review

This article addresses the main scholarly frames that supported the deservingness of unauthorized immigrants to health benefits in the United States (U.S.) following the passage of the Personal Responsibility Work Opportunity Reconciliation Act (PRWORA), known as the Welfare Reform bill, in 1996. Based on a critical literature review, conducted between January 1997 and March 2011, this article begins with an analysis of the public health rhetorics that endorsed immigrants' inclusion into the U.S. health safety net. In this vein, the "cost-saving" and "the effortful immigrant" frames underscore immigrants' contributions to society vis-à-vis their low utilization of health services. These are complemented by a "surveillance" account that claims to protect the American public from communicable diseases. A "maternalistic" frame is also discussed as a tool to safeguard families, and particularly immigrant mothers, in their roles as bearers and caretakers of their American-born children. The analyses of the "chilling" and the "injustice" frames are then introduced to underscore major anthropological contributions to the formulation of counter-mainstream discourses on immigrants' selective inclusion into the U.S. health care system. First, the "chilling effect," defined as the voluntary withdrawal from health benefits, is examined in light of unauthorized immigrants' internalized feelings of undeservingness. Second, an "injustice" narrative highlights both the contributions and the limitations of a social justice paradigm, which advocated for the restoration of government benefits to elderly immigrants and refugees after the passage of PRWORA. By analyzing the contradictions among all these diverse frames, this paper finally reflects on the conceptual challenges faced by medical anthropology, and the social sciences at large, in advancing health equity and human rights paradigms.

Undocumented immigrants and their use of medical services in Orange County, California

Does an undocumented immigration status predict the use of medical services? To explore this question, this paper examines medical care utilization of undocumented Latino immigrants compared to Latino legal immigrants and citizens, and non-Latino whites in Orange County, California. Data were collected through a random sample telephone survey of 805 Latinos and 396 non-Hispanic whites between January 4 and January 30, 2006. Findings show that undocumented immigrants had relatively low incomes and were less likely to have medical insurance; experience a number of stresses in their lives; and underutilize medical services when compared to legal immigrants and citizens. Predictors of use of medical services are found to include undocumented immigration status, medical insurance, education, and gender. Undocumented Latinos were found to use medical services less than legal immigrants and citizens, and to rely more on clinic-based care when they do seek medical services.

Acculturation in Hispanics and childhood poisoning: are medicines and household cleaners stored properly?

BACKGROUND

Unintentional poisonings are a major public health issue in the United States (US). With the increasing number of Hispanics in the US, childhood poisoning is a salient public health issue to address within this population. There is a paucity of research examining the relationship between acculturation in Hispanics and the safe storage of medicines and cleaners. The purpose of the study was to determine if demographic variables, such as acculturation in Hispanics, age, gender and education, were predictive of incorrectly storing medicines and household cleaners.

METHODS

We conducted a study among parents/guardians of small children at two pediatric primary care clinics in the Dallas/Fort Worth (DFW) Metropolitan area. We enrolled 201 parents to identify where they stored medicines and household cleaners, and measured acculturation with the Short Acculturation Scale for Hispanics.

RESULTS

Of Hispanic participants, 49% were categorized as less acculturated (n = 99) while 21% were more acculturated (n = 42). Less acculturated participants were over 4 times more likely to store medicines incorrectly, and participants with a high school education or less were over 3 times more likely to improperly store cleaners. With each additional child in the household, the risk for improper storage of cleaners increased by 44%.

CONCLUSION

The fact that children of less acculturated families are at greater risk for poisoning and have lower levels of education demonstrates the need for readable educational materials on this salient topic. Because social networks are integral in Hispanic culture, especially among new immigrants, poison prevention messages should be disseminated by interpersonal communications.

Financial effect of instituting Deficit Reduction Act documentation requirements in family planning clinics in Oregon

BACKGROUND

The study was conducted to estimate the long-term costs for implementing citizenship documentation requirements in a Medicaid expansion program for family planning services in Oregon.

STUDY DESIGN

A decision-analytic model was developed using two perspectives: the state and society. Our primary outcome was future reproductive health care costs due to pregnancy in the next 5 years. A Markov structure was utilized to capture multiple future pregnancies. Model inputs were retrieved from the existing literature and local hospital and Medicaid data related to reimbursements. One-way and multi-way sensitivity analyses were conducted. A Monte Carlo simulation was performed to simultaneously incorporate uncertainty from all of the model inputs.

RESULTS

Screening for citizenship results in a loss of $3119 over 5 years ($39,382 vs. $42,501) for the state and $4209 for society ($63,391 compared to $59,182) for adult women. Among adolescents, requiring proof of identity and citizenship results in a loss of $3123 for the state ($39,378 versus $42,501) and $4214 for society ($63,391 instead of $59,177).

CONCLUSION

Screening for citizenship status in publicly funded family planning clinics leads to financial losses for the state and society.

Determinants of usual source of care disparities among African American and Caribbean Black men: findings from the National Survey of American Life

PURPOSE

The Aday-Andersen model was used as a framework for investigating the contribution of immigration status (i.e., nativity and acculturation), socioeconomic factors, health care access, health status, and health insurance to usual source of health care (USOC) in a nationally representative sample of African American (n=551) and Caribbean Black men (n=1,217).

METHODS

We used the 2001-2003 National Survey of American Life, a nationally representative household survey of non-institutionalized U.S. Blacks to conduct descriptive and logistic regression analyses.

RESULTS

Older age, more health conditions, neighborhood medical clinic access, and health insurance were associated with higher odds of reporting a USOC. Odds were lower for men with lower-middle incomes and poorer mental health status. Having health insurance was associated with higher odds of reporting a USOC for African American men but lower odds among Caribbean Black men. Odds were higher in the presence of more health conditions for African American men than for Caribbean Black men.

CONCLUSIONS

Health care reform policies aimed solely at increasing health insurance may not uniformly eliminate USOC disparities disfavoring U.S. and foreign-born non-Hispanic Black men.