Portal de Periódicos da CAPES

International migration and its influence on health

2022; Wiley; Volume: 45; Issue: 5 Linguagem: Inglês

10.1002/nur.22262

1098-240X

Allison Squires, Roy Thompson, Tina Sadarangani, Polina Amburg, Kathy Sliwinski, Cedonnie A. Curtis, Bei Wu,

Interpreting and Communication in Healthcare

What would it take for you to leave your home and everything you know? What if you left knowing you might not be able to return? If you had to leave quickly, what would you take with you? These are questions that many immigrants must grapple with because of their circumstances. Before the COVID-19 pandemic, the global migration of humans had reached the highest levels in recorded human history. International Organization for Migration (IOM) is the global institution that studies and helps inform international laws regarding human migration. This organization posits that 1 in every 30 persons globally is classified broadly as a migrant (IOM, 2022). As the world transitions into the COVID-19 postpandemic phase, it is estimated that the number of global migrants will return to prepandemic levels within a decade, if not sooner (IOM, 2021). The IOM has promulgated a set of internationally standardized definitions for people who have migrated in Table 1. Although the broadest term is migrant, other terms may be useful to clinicians and researchers, and appreciated by clients and participants, because they classify migrants into various terms that convey the basis for the migration or the migrant's status. Examples are migrant worker, asylum seeker, refugee, undocumented migrant, and immigrant. Notably, IOM stresses that no human being should be classified as illegal in reference to their residential status in a country. The term illegal is reductive, dehumanizing, xenophobic, and oftentimes rooted in racist ideas. Immigrants face many challenges when adapting to life in the host country, including when navigating the healthcare system. Common challenges immigrants experience when navigating the healthcare system are language barriers, changes in socioeconomic status, changes in social support networks, barriers with acculturation, and lack of health insurance and access to quality healthcare services (Bridgewater & Buzzanell, 2010; Cárdenas & de la Sablonnière, 2017; Covington-Ward et al., 2018; Derr, 2016; Gimeno-Feliu et al., 2019; Kim et al., 2012; Li et al., 2019; Matsunaga et al., 2010; Rudmin, 2010; Stimpson et al., 2013; Tartakovsky et al., 2017; Tegegne, 2018). This editorial will broaden our understanding of the intersections of migration and health outcomes, with implications for nursing and midwifery practice and health researchers. Specifically, we will emphasize how researchers can improve equitable inclusion in research of people who have immigrant status. Consistent with previous editorials in the “Learning the Language of Health Equity” series, our examples will focus on the context in the United States. The international readers of Research in Nursing & Health, however, will find common themes that are relevant to migrant populations in their home countries. All the authors on this team are either immigrants, children of immigrants, or partners to them. Immigrants comprised 15% of the US population by 2019, which totaled 44 million individuals (Gelatt & Muzaffar, 2022; Schmidt, 2019). Among adult immigrants (ages ≥18 years) in this group, 21.9 versus 20.3 million were females compared to males, respectively, and 2.5 million children were present. One in seven US residents are immigrants, while one in eight residents is a US-born citizen with at least one immigrant parent (Health Coverage of Immigrants & KFF, 2022). The road to US citizenship is oftentimes challenging and may take between 3 and 10 years depending on immigrants' birth countries (Wong & Bonaguro, 2020). In 2018, although similar proportions of immigrants and native-born people living in the United States had obtained at least a college degree (one-third), the fractions differ markedly for those having less than a high school diploma: 27% of immigrants versus 9% of those born in this country (Table 2). These statistics have implications for health literacy. Immigrants comprise a sizable fraction of the country's labor force in many industries, comprising 1/6 of US workers (28.4 million) by 2018. Immigrants account for over one-third of all farming, fishing, and forestry workers—as well as nearly 25% of individuals working in information technology and the mathematical sciences (American Immigration Council, 2020). The largest number of immigrants work in the healthcare and social service industries, which employed >4 million immigrants (Table 3). Further, about 7% of the US nursing and midwifery is workforce comprised of internationally educated nurses (Ghazal et al., 2020). As immigrants' children become working adults, some lack documentation of their birth or legal status because they were brought to the United States by their parents at very young ages. These individuals became temporarily protected from deportation through the Deferred Action for Childhood Arrivals (DACA) Act (Venkataramani et al., 2017). Among DACA recipients, about 14,000 are enrolled in health professions education programs; however, in most US states they are barred from licensure examinations which would allow in them in clinical practice (Sofer, 2019). According to the American Immigration Council (2020), immigrants in the United States also contribute billions of dollars in taxes. Immigrant-led households across the United States contributed a total of US$308.6 billion in federal taxes and US$150.0 billion in combined state and local taxes in 2018. Undocumented immigrants in the United States paid an estimated US$20.1 billion in federal taxes and US$11.8 billion in combined state and local taxes in 2018. DACA recipients and those meeting its eligibility requirements paid an estimated US$1.7 billion in combined state and local taxes in 2018 (Legido-Quigley et al., 2019). Immigrants’ health is impacted by their eligibility for health insurance in the United States. Rules about immigrants' access to health insurance are set by the states and vary widely (Hacker et al., 2015). These variations affect immigrants of all ages and their access to primary, secondary, and tertiary health services—which sometimes contribute to inequities in health and healthcare outcomes based on geography (Woolhandler & Himmelstein, 2017). All individuals lawfully present in the United States meet certain eligibilities for Medicaid and can purchase insurance through the Affordable Care Act which also has the moniker Obamacare (Health Coverage for Immigrants & HealthCare.gov, 2022). Nurses, midwives, and researchers should be cognizant that, depending on the state, individuals eligible for Medicaid would include but not be limited to low-income families, certain qualified pregnant women and children, those receiving supplemental security income, children and adults at or below 133% of the poverty level, and those with citizenship or lawful resident status (Centers for Medicare and Medicaid Services, [Medicaid, 2022]). Twenty-nine states provide Medicaid coverage for all pregnant women as well as all children (Health Coverage of Immigrants & KFF, 2022). Immigrants, whether they are citizens or not, become eligible for Medicare at age 65 so long as they have worked the requisite 40 calendar quarters (3-month period) in the United States (Zallman et al., 2013). Among older adult immigrants, 24% have no insurance coverage and are oftentimes restricted by the eligibility criteria for Medicare or Medicaid. Immigrants without employer-sponsored health insurance have challenges affording the private health insurance market since they are not eligible for the federal insurance exchange (Health Coverage of Immigrants & KFF, 2022; Reyes & Hardy, 2015; Sadarangani & Kovner, 2017). Yet immigrants of working age are net contributors to private insurance pools as well as Medicare—meaning they contribute more money than they spend on services (Choi, 2006; Lu & Myerson, 2020; Zallman et al., 2018). Because insured adult US citizens use more health services as compared to immigrants with insurance, the insurance pools are dependent upon immigrants' contributions for their financial solvency (Himmelstein et al., 2021). Undocumented immigrants in the United States have few options for health insurance coverage, even if they can afford private insurance (Cohen & Schpero, 2018; Health Coverage of Immigrants & KFF, 2022). One misconception about health insurance coverage for undocumented immigrants is that they can receive Medicaid or other forms of government-sponsored health insurance or benefits. In fact, undocumented individuals are not eligible for any kind of federally sponsored health insurance or welfare benefits (Health Coverage for Immigrants & HealthCare.Gov, 2022). Being an undocumented immigrant reduces access to health insurance and delays access to health services, resulting in poorer health outcomes (Chi & Handcock, 2014; Joseph, 2017; Martinez et al., 2015; Perreira et al., 2018). The only exception is that in some states a pregnant woman may receive health insurance through Medicaid (Health Coverage of Immigrants & KFF, 2022). An individual's process of migration will have an impact on their health across their lifespan (Abubakar et al., 2018). The impact of migration on immigrants' health outcomes differs based on their birth country, which is known as the social determinant of the health of “nativity,” the time in their life when they migrated, and the geography and living conditions where they settle (Wickramage et al., 2018). For example, an individual who migrates voluntarily compared to another who has little to no choice (e.g., refugees, asylum seekers) will have very different health profiles and outcomes. The stress of forced migration experienced by many undocumented immigrants has a long-term impact on their physical, emotional, and psychological well-being (Aspinall, 2007; Chen et al., 2017; Jannesari et al., 2020; Lee et al., 2016; Mendelsohn et al., 2014; Willen, 2012). Empirical studies on immigrants' health reveal paradoxes and inconsistencies that reflect heterogeneity in health outcomes and the origins of health inequities. Immigrants are generally healthier with lower mortality relative to their US-born counterparts, however, these advantages diminish or disappear over time—a phenomenon known as the Immigrant Health Effect or Paradox (Antecol & Bedard, 2006; Fuller Thomson et al., 2013; Markides & Rote, 2019; Palloni & Arias, 2004; Shor et al., 2017). For example, Black immigrants ages 50–60 years living in the United States >15 years were 4.3 times more likely to develop hypertension relative to those who emigrated 15 years were 17% more likely to have serious psychological distress versus their US-born counterparts. Immigrants' length of time of residence in the United States was positively associated with a higher prevalence of depression and serious psychological distress (Ikonte et al., 2020). Foreign-born Latinos and other immigrants had a higher risk of developing diabetes versus US-born Latinos. Additionally, the length of time living in the United States was positively associated with higher diabetes incidence among foreign-born non-Hispanic immigrants (Weber et al., 2012). Similarly, foreign-born Asian adults have significant diabetes disadvantages compared to native-born Asian counterparts (Dias et al., 2020; Engelman & Ye, 2019; Gee et al., 2009). For noncommunicable diseases, the prevalence of cardiovascular disease, stroke, hypertension, diabetes, and some cancers (especially those associated with infectious agents) is often higher among some immigrants relative to their US-born counterparts; while in other groups, the rates of cardiovascular disease and stroke are substantially lower (Castañeda et al., 2015; Gimeno-Feliu et al., 2019; Luiking et al., 2019; Morey, 2018; Rodriguez et al., 2021; Vargas et al., 2017; Yeo, 2017). Evidence also highlighted progressively poorer overall health status among older immigrants such as the increasing prevalence of diabetes found among middle-aged Latino men in California (Engelman & Ye, 2019; Vega et al., 2009). This paradox also emerges among children of immigrants after several generations of residing in the United States. Health outcomes for immigrant children ages <18 are worse relative to native US counterparts and these patterns persist into adulthood and span across generations, regardless of immigrants' birth countries or culture (Andre & Dronkers, 2017; Cobo et al., 2010; Docquier et al., 2009; Gee et al., 2009; Gelatt, 2020; Ichou & Wallace, 2019; Sadarangani & Kovner, 2017; Salami et al., 2021; Siemons et al., 2017; Singh et al., 2013; Stimpson et al., 2013; Vargas & Ybarra, 2017). Poorer health outcomes may also relate to biases of “grouping” immigrant populations by common identifiers, such as ethnicity (e.g., Asian) or language, as we have stressed in previous editorials (Amburg et al., 2022; Nava et al., 2022; Niles et al., 2022). Wu et al. (2021) developed one of the first comprehensive frameworks for immigrant health with a specific focus on oral health-associated outcomes. We have adapted the model to apply to any disease or condition an immigrant may experience. It helps deepen our understanding about immigrant health using a lifespan approach (Figure 1). This conceptual model underscores the specific considerations for healthcare providers as well as researchers. Research with immigrant populations requires different strategies for engagement and other considerations. The first is the integration of cross-language research methods into the study's design if the immigrant population does not already speak English or the language of their destination country. Researchers should not assume there are reliable and valid translations of standardized survey instruments and measures; in fact, it is more often the case that translations have been poorly done and not tested for variations associated with dialects and nativity. The qualifications of, timing, use of, and roles of interpreters in the research study need to be planned for well in advance. For those pursuing precision health studies that rely on technology to track personal health data of any kind, there are multiple ethical challenges to overcome and plan for when designing a research study. First, understanding how technology is used by the population is critical. Many immigrant populations may rely on prepaid minutes for cell phones and may be reluctant to use said minutes for research purposes. Second, any technology that can involve location tracking can present problems for immigrants, regardless of their legal status. While data privacy laws in the European Union are quite strict, they are not in the United States. Immigration and Customs Enforcement (ICE) services have been known to use cellphone data to track immigrants regardless of their legal status or whether or not they have a history of justice engagement. Researchers relying on wearable devices or cell phones for their data collection purposes may increase the risk of immigrant populations or their households as persons residing in immigrant households frequently have mixed legal statuses of the residents residing there. Finally, as with all underrepresented and marginalized populations, researchers need to be aware of “health equity tourism” with immigrant populations. Dr. Elle Lett was the first to name the phenomenon of “health equity tourism” (Garcia, 2022). It occurs when historically privileged researchers decide to conduct studies with the aforementioned populations with no previous training in health equity research methods or track record of working with the community of interest, let alone acknowledgment of the work already completed by scholars from these communities (Garcia, 2022). This practice reinforces the historical sources of structural factors that contribute to health inequities and reflects the entitlement researchers often feel they have to conduct research with any person or group. As with all the groups, we have referred to in this editorial series along with the ones who will be the topic of future editorials, partnering with expert researchers is key for culturally humble research practices. The first clue about a migrant's health status can come from their migration story (asked as part of a health assessment), or how they categorize themselves based on the terms defined in Table 1. One key factor unique to immigrant populations that most health professionals will not often integrate into their assessment practices is asking about an individuals' country of origin and their previous experiences with healthcare services. Knowing the country of origin of the immigrant is important for the healthcare provider to provide person-centered care and gauge health risks. For example, many immigrants may come from areas of the world where exposures to toxic chemicals are common, such as pesticides long banned in the United States at sensitive windows of development that may pose risk for future health conditions or disease processes (Adjei et al., 2019; Bowe et al., 2017; Durand & Massey, 2010; Everett et al., 2017; Garip & Asad, 2016; Kamimura et al., 2018). In clinical practice, nurses and midwives can adopt and advocate for improving immigrant health in several ways through intentional changes in how they work with the population. Culturally humble practices with immigrants that will enhance assessment data include asking about their heritage and noting that in the chart. For example, dispelling myths about access to insurance coverage can be an incredibly helpful action nurses and midwives can take to develop productive provider–patient relationships as well. Another important part of a health assessment is verifying the person's language preference. Even if the person speaks some English (the most commonly spoken language in the United States and that spoken by most healthcare providers), they may not have the vocabulary or comprehension to fully understand what happens during a healthcare encounter without the use of an interpreter. Once language preference is captured accurately, it becomes easier for healthcare teams to meet the person's civil right to an interpreter—something that has been codified into law in the United States since the 1960s (Squires & Youdelman, 2019). Accurate language preference data in the chart helps improve the chance that an interpreter can be accessed at important points, like for patient education about medications. Ensuring that only certified interpreters are used (meaning please do not pull in your "bilingual" colleague unless it is an emergency) also helps reduce the risk of adverse events and inequities in health outcomes. Inconsistent or inappropriate use of language access services contributes to said inequities, which include but are not limited to delayed access to healthcare services, medication errors, increased length of stay, increased readmissions to the hospital, and higher rates of adverse events—across all points of the lifespan (Barwise et al., 2019; Dilworth et al., 2009; Flores, 2005; Gerchow et al., 2021; Harris et al., 2017; Hoek et al., 2020; Ju et al., 2017; Narayan & Scafide, 2017; Ramirez et al., 2008; Rocque & Leanza, 2015; Shommu et al., 2016; Silva et al., 2016; Tam et al., 2020; Terui, 2017). Nurses, midwives, and other healthcare professionals who fail to engage interpreters appropriately may also increase their organization's risk for legal liability (Squires & Youdelman, 2019). A final action nurses, midwives, and researchers can take to foster culturally humble practices with immigrants that reduce health inequities is ensuring that this population is part of antiracism trainings offered by healthcare organizations. We acknowledge that antiracist training is necessary because the electronic and print media is saturated with negative images and deficit framing of immigrants. For example, immigrants from some racial and ethnic groups are oftentimes stereotyped in the media as poor and dependent on public assistance; coming to the United States to “take” jobs; and portrayed as being more prone to criminality. Conversely, they may also be portrayed as a “model minority”—as is often the case with Asian immigrants—which may cause healthcare providers to underestimate health issues. Since all healthcare professionals are vulnerable to these media stereotypes, antiracism training could mitigate inequitable treatment of immigrants in healthcare settings. Partnering with community-based groups (e.g., religious organizations, schools, cultural centers, etc.) for these trainings can be a productive relationship-building step that builds trust and may draw more people to seek health services when they need them, instead of at a later point when their needs have become more urgent. Among populations at risk to experience health inequities, immigrants should be considered a unique group. Their identities are the product of multiple intersecting factors and are strongly influenced by their migration experiences. Through intentional clinical and research practices tailored to the complexity of their identities, nurses, midwives, and researchers have the potential to make a significant contribution to reducing healthcare inequities experienced by immigrants across their lifespans. All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. All authors (Dr. Polina Amburg, Dr. Roy Thompson, Dr. Tina Sadarangani, Kathy Sliwinski, BSN, RN (PhD Candidate), Dr. Cedonnie Curtis, Dr. Allison Squires, Dr. Bei Wu) equally contributed to the editorial concept and design, drafting the editorial, and critical revision of the editorial for important intellectual content. The authors declare no conflict of interest. No data are available for this manuscript.