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Barriers to health care for undocumented immigrants: A literature review

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With the unprecedented international migration seen in recent years, policies that limit health care access have become prevalent. Barriers to health care for undocumented immigrants go beyond policy and range from financial limitations, to discrimination and fear of deportation. This paper is aimed at reviewing the literature on barriers to health care for undocumented immigrants and identifying strategies that have or could be used to address these barriers. To address study questions, we conducted a literature review of published articles from the last 10 years in PubMed using three main concepts: immigrants, undocumented, and access to health care. The search yielded 341 articles of which 66 met study criteria. With regard to barriers, we identified barriers in the policy arena focused on issues related to law and policy including limitations to access and type of health care. These varied widely across countries but ultimately impacted the type and amount of health care any undocumented immigrant could receive. Within the health system, barriers included bureaucratic obstacles including paperwork and registration systems. The alternative care available (safety net) was generally limited and overwhelmed. Finally, there was evidence of widespread discriminatory practices within the health care system itself. The individual level focused on the immigrant's fear of deportation, stigma, and lack of capital (both social and financial) to obtain services. Recommendations identified in the papers reviewed included advocating for policy change to increase access to health care for undocumented immigrants, providing novel insurance options, expanding safety net services, training providers to better care for immigrant populations, and educating undocumented immigrants on navigating the system. There are numerous barriers to health care for undocumented immigrants. These vary by country and frequently change. Despite concerns that access to health care attracts immigrants, data demonstrates that people generally do not migrate to obtain health care. Solutions are needed that provide for noncitizens' health care.
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open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/RMHP.S70173
Barriers to health care for undocumented
immigrants: a literature review
Karen Hacker1,2
Maria Anies2
Barbara L Folb2,3
Leah Zallman4–6
1Allegheny County Health
Department, Pittsburgh, PA,
USA; 2Graduate School of Public
Health, 3Health Sciences Library
System, University of Pittsburgh,
Pittsburgh, PA, USA; 4Institute for
Community Health, Cambridge, MA,
USA; 5Cambridge Health Alliance,
Cambridge, MA, USA; 6Harvard School
of Medicine, Boston, MA, USA
Correspondence: Karen Hacker
Allegheny County Health Department,
542 4th Street, Pittsburgh,
PA 15219, USA
Tel +1 412 578 8008
Fax +1 412 578 8325
Email khacker@achd.net
Abstract: With the unprecedented international migration seen in recent years, policies that
limit health care access have become prevalent. Barriers to health care for undocumented
immigrants go beyond policy and range from financial limitations, to discrimination and fear
of deportation. This paper is aimed at reviewing the literature on barriers to health care for
undocumented immigrants and identifying strategies that have or could be used to address these
barriers. To address study questions, we conducted a literature review of published articles from
the last 10 years in PubMed using three main concepts: immigrants, undocumented, and access
to health care. The search yielded 341 articles of which 66 met study criteria. With regard to
barriers, we identified barriers in the policy arena focused on issues related to law and policy
including limitations to access and type of health care. These varied widely across countries but
ultimately impacted the type and amount of health care any undocumented immigrant could
receive. Within the health system, barriers included bureaucratic obstacles including paperwork
and registration systems. The alternative care available (safety net) was generally limited and
overwhelmed. Finally, there was evidence of widespread discriminatory practices within the
health care system itself. The individual level focused on the immigrant’s fear of deportation,
stigma, and lack of capital (both social and financial) to obtain services. Recommendations
identified in the papers reviewed included advocating for policy change to increase access
to health care for undocumented immigrants, providing novel insurance options, expanding
safety net services, training providers to better care for immigrant populations, and educating
undocumented immigrants on navigating the system. There are numerous barriers to health care
for undocumented immigrants. These vary by country and frequently change. Despite concerns
that access to health care attracts immigrants, data demonstrates that people generally do not
migrate to obtain health care. Solutions are needed that provide for noncitizens’ health care.
Keywords: undocumented immigrants, health care, access, deportation, immigration and
migration
Background
Over the last decade, international migration has continued to rise despite the efforts
of many countries to tighten their borders.1 Factors such as conflict, discrimination,
and the lack of employment opportunities in countries of origin contribute to migration
patterns. Today, countries have used a variety of strategies to dissuade immigrants from
crossing their borders ranging from border patrol to identity checks, detention, and
deportation.2,3 With the unprecedented rates of migration, policies that disincentivize
migration have spread to health care. Internationally, many countries, including the US,
European nations, Scandinavia, Canada, and Costa Rica, have promulgated a range of
policies that limit access to health services.4–8 In the US for example, the Affordable
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Articles identified in PubMed
search
(N=341)
Records screened (N=123)
Full articles assessed for eligibility
(N=74) Excluded (N=8)
Excluded (N=54)
Excluded (N=218)
Studies included in qualitative
synthesis
(N=66)
Figure 1 Flow chart of review process.
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Hacker et al
Care Act excludes undocumented immigrants from access-
ing health insurance.9 In the European Union, policies that
limit undocumented immigrants’ access to health care are
widespread and vary substantially. These policies range from
denying all access to providing limited access to emergency
and preventive care.4
Throughout the literature, undocumented immigrants/
migrants, also referred to as illegal, irregular, and noncitizen,
are seen as underutilizing the health care system.10–12 This
underutilization not only puts their health at risk, as is the case
with infectious diseases, but may also put the general public’s
health at risk.13–15 Many papers examine the sequelae of
undocumented immigrants’ limited access to health care.16,17
This includes the lack of follow-up for tuberculosis and HIV/
AIDS, low immunization rates, and untreated mental health
issues.14,15 A number of factors are presumed to exacerbate
undocumented immigrants’ limited access to health care.
These include their lack of knowledge, bureaucratic issues,
confusion about rules and regulations, and discrimination.18 To
date, however, we have not encountered a review focused spe-
cifically on the variety of barriers to health care beyond legal
regulations that undocumented immigrants currently face. Nor
have we found a review of strategies that have been used or
might be used to alleviate these barriers. Therefore, this paper
is aimed at reviewing the literature on barriers to health care
for undocumented immigrants and identifying strategies that
have or could be used to address these barriers.
Methods
To address our main study aim we conducted a literature
review using a systematic approach to examine peer-
reviewed literature related to barriers to health care faced by
undocumented immigrants. We also identified recommended
strategies for solutions within the literature reviewed.
Search strategy
Our literature search was conducted using PubMed by one
author (BF) to capture our three main concepts: immigrants,
undocumented, and access to health care. We limited our
search to articles written in English over the last 10 years. Var-
ious terms for immigrants were used, including immigrants,
foreigners, aliens, and migrants. In addition, a variety of
search terms for undocumented were used, including undocu-
mented, illegal, irregular, and noncitizen. The full search
strategy is provided in the “PubMed search strategy” section
of Supplementary materials. The search was designed to
retrieve articles on a wide range of subtopics within the main
topic but without being exhaustive, as would be required for
a complete systematic review. By incorporating systematic
review methods into the search, this study occupies a middle
ground between traditional narrative reviews, which do not
require documentation of search methods or defined crite-
ria in their choice of articles for inclusion, and systematic
reviews. We applied our search criteria on April 8, 2015 and
identified 341 journal article records (Figure 1). All records
were exported to an EndNote database for inclusion/exclu-
sion evaluation.
Article selection
We conducted a three-stage screening process starting with
a title review followed by an abstract review and ending
with a full-text article review. Articles were included if
they addressed barriers to health care for undocumented
immigrants and/or recommendations for strategies to solve
problems of access. For the purposes of this search, editorials
and opinion pieces were excluded.
In our title review stage, three authors (KH, MA, LZ)
independently reviewed the journal article titles to determine
whether they were relevant or irrelevant. Based on this title
review, 123 articles were included for review and 218 were
excluded. In our second stage, the authors independently
screened the abstracts of the remaining 123 articles and
determined that 74 initially met eligibility. Three reviewers
examined full-text articles for eligibility. Seven articles were
excluded as they were deemed to be opinion pieces and one
article was deemed irrelevant. After excluding these articles,
66 articles were included in the qualitative analysis that fol-
lowed (see Table S1; reviewed articles).
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Barriers to health care for undocumented immigrants
Abstraction
The reviewers then developed a data abstraction form and
independently applied it to three eligible articles. They then
reviewed their findings and developed an initial list of cat-
egories of barriers (eg, fear of deportation and insurance).
They independently abstracted information from 10 to
12 articles each and met to review the tool, finalizing the
list of categories of barriers. At this stage, one category was
removed and four were added, yielding the finalized abstrac-
tion tool. Authors were instructed to highlight any themes
that were not captured by the abstraction tool; however, no
further key themes emerged. Once abstraction was complete,
two authors (KH, LZ) met to review all of the data and
consolidate the themes into categories for both barriers and
recommendations.
Results
Barriers
The final categories for barriers identified from the literature
represent the multiple levels where the barriers to health
care for undocumented immigrants exist. These categories
include barriers experienced in the policy arena, in the health
care system, and at the individual level (Table 1). The policy
arena focused on issues related to both law and policy includ-
ing access to insurance for undocumented populations and
limitations to the type of health care that they could utilize.
The health care system focused on bureaucracy, capacity,
and the discriminatory practices that were present. The
individual level focused on the undocumented immigrants’
fears, stigma, and lack of capital (both social and financial)
that, in turn, created barriers to health care.
Table 1 Barriers to health care experienced by undocumented immigrants
Category Subcategory Description Number (%)
of articles
References
Policy arena Law/insurance Legal barriers including barred access
to insurance by law
50 (76) 1,4–8,13,16,20,22–62
Need for documentation
to get services/
unauthorized parents
Requirements that individuals show
documentation to get health care services,
often leading unauthorized parents to avoid
care for authorized children
18 (27) 1,2,6,13,36,38,43–45,51,
56–58,63,64
Health system External resource
constraints
Constraints beyond individual’s ability to pay
for services including work conicts, lack of
transportation, and limited health care capacity
(such as lack of translation services, cultural
competency, and funding cuts)
24 (36) 1,2,6,13,36–38,40,43–45,49,
51,56–58,63,64
Discrimination Discrimination on the basis of documentation
status resulting in stigma experienced by
undocumented immigrants
22 (33) 2,5–7,19,20,23,29–32,
34,35,41,42,45,47,50,57,59,
61,63–65
Bureaucracy Complex paperwork or systems required
to gain access to health care
17 (26) 1,2,8,16,19,20,24,36–38,40,41,
44,45,48,49,54,57,63–66
Individual level Fear of deportation Concerns about being reported to authorities
if they utilized services or provided their
documentation
43 (65) 2,4–8,13,16,20,23–25,29,
31,33,34,36–38,40,41,43–46,
49–51,53,56,57,59,60,62–70
Communication ability Not speaking or understanding the dominant
language to communicate with health care
providers. Also cultural challenges to
understanding the nuances of another culture
and expressing one’s problems so that they
are understood and not ignored
24 (36) 7,19,24,27,28,29,31,34,
36–38,41,42,44,47,53,
56,59–61,63,64,65,67
Financial resources Lack of personal nancial resources to
pay for services
30 (45) 1,6,8,13,22,23,26,27,29,
30,33,36–38,41,44–48,53,
57,60,62,63,65,67,71,72
Shame/stigma Not wanting to be a burden to society or
experiencing shame when seeking services
and concerns about being stigmatized when
seeking services
7 (11) 19,36,38,41,45,62,64
Knowledge of the health
care system
Little knowledge about how the “system”
works, what rights to health care exist, and how
to navigate the health care system at all levels
22 (33) 7–9,26,28,31,33,34,37,41,
44,47,53,54,57,58,60,62,
63,66,72,73
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Hacker et al
Policy
National policies excluding undocumented immigrants from
receiving health care were the most commonly cited barriers
to health care. Three quarters of the articles described legal
barriers including denying access to insurance. In some
nations, active surveillance of providers led to the denial
of care as providers feared losing their medical licenses
or criminal procedures. A commonly cited mechanism
for excluding undocumented immigrants from health care
was laws limiting access to insurance. Because insurance
was generally required for affordable care or required to
receive services at all, these laws effectively barred access
to care. The fact that medical repatriation was allowed in
many countries – that is, repatriation of a sick individual
to the country of origin against an individual’s will for the
purposes of medical care (which is often insufficient in the
country of origin) led to avoidance of care. In addition,
27% of articles described requirements that individuals show
documentation to get health care services as major barriers to
care. Often, this need for documentation “spilled over” and
affected authorized children of unauthorized parents, who
did not seek care for their children because of the inability
to provide documentation for themselves.
Health system
Health system barriers included external resource constraints,
costs to the individual, discrimination, and high bureaucratic
requirements. External resource constraints – or constraints
such as work conflicts (eg, health care offered during work
hours and fear of losing job due to time off seeking care),
lack of transportation, and limited health care capacity (eg,
lack of translation services, cultural competency, and funding
cuts) – were identified in 36% of articles. One area where
there was particularly limited capacity was in mental health
care for undocumented immigrants. One third of articles
discussed discrimination on the basis of nativity status; for
some subpopulations, discrimination on the basis of nativity
intersected with other forms of discrimination such as sexual
discrimination, placing subpopulations at particularly high-
risk of not receiving care. Finally, complicated bureaucracies
created insurmountable barriers for not only undocumented
immigrants but also providers wanting to provide care to
immigrants; 26% of articles described this issue. Often
bureaucratic regulations led to extensive paperwork require-
ments that were too complicated and costly to complete.
Individual
Individual barriers included fear of deportation, commu-
nication ability, financial resources, shame/stigma, and
knowledge about the health care system. Fear of deportation,
whether real or imagined, was identified as a barrier in 65%
of articles. Undocumented immigrants reported avoiding
health care and waiting until health issues were critical to
seek services because of their concerns of being reported to
authorities. This was seen in countries as diverse as France,
the US, and Denmark. A second barrier – noted in 36% of
articles – was communication, which not only included the
inability to speak the language of the dominant culture but
also included cultural discomfort with the way in which the
dominant culture communicated. It was noted that undocu-
mented immigrants were unable to communicate their
health concerns to care providers or were misunderstood by
those providers. For example, in one article, undocumented
immigrants felt that the emergency room physicians did not
fully believe their symptoms.19 Lack of financial resources
was also a significant barrier, as noted in 45% of articles,
and was particularly true in countries where undocumented
immigrants were excluded from all health care services or
had no access to insurance (the UK and Denmark). Eleven
percent of papers reported the issue of shame and/or stigma
as a barrier for accessing health care. Undocumented immi-
grants did not want to “be a burden on the system” or felt
that they would be stigmatized if they sought services even
in countries where services were available. Lastly, the final
individual barrier that was identified was a lack of knowledge
of the system itself. Undocumented immigrants often did
not know what services were available to them nor what
their rights to health care were. In addition, immigrants
often did not know how to utilize the health care system,
particularly when additional requirements were needed (ie,
France’s requirement to obtain authorization prior to access-
ing services).20 This was identified as a barrier in 33% of
the reviewed articles.
Recommendations
We identified five major categories of recommendations in
the reviewed papers relevant to addressing barriers to health
care for undocumented immigrants (Table 2). These cat-
egories are related to advocacy for policy change, insurance
options, expansion of the safety net, training of providers
to better care for immigrant populations, and education of
undocumented immigrants on navigating the system.
Advocacy for policy change included a range of possible
legislation to allow either full access to health care or varying
levels of access such as public health services. Insurance
options included special insurance programs through the
state available to undocumented immigrants and/or full
insurance benefits to employees regardless of their status.
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Table 2 Recommendations for improving barriers
Category Description Number (%)
of articles
References
Advocacy/legal change Expand health care access to all regardless of status,
delay deportation for those in care until the course of
treatment is completed, make undocumented immigrants
documented and give full rights to health care
31 (47) 1,2,8,16,22,24,25,29,31,
35,37–41,45,48–51,53,
57–59,61,65,66,71,73,74
Insurance Allow all residents to have access to state-funded
limited network health plan, “paid” or subsidized
insurance options, or provide insurance to all
workers regardless of status
9 (14) 1,8,23,44–46,48,58,59
Expansion of the
safety net
Expand the capacity of public, nonprot and free clinics
to render care to the population, especially for public
health services such as communicable diseases, maternal
and child health, and preventive care
Provide health and education in nonprot social
service or faith-based organizations
Enhance support for safety net providers through
state-funded vehicle
18 (27) 7,8,31,32,34–37,
40,44,60,63,64,66,
68,71,73,75
Training providers Train providers to better understand the needs of their
immigrant patients and utilize interpretation services
Train providers and update them on legal
mandates within the country
10 (15) 8,13,16,19,33,37,41,56,64,68
Education and outreach to
undocumented immigrants
Outreach to specic immigrant communities to
educate on the current laws and the system,
especially education regarding rights to health care
Provide culturally appropriate navigators in health
care environments to help undocumented immigrants’
access services
15 (23) 2,19,28,34,36,37,40,41,44,
46,47,59,60,69,72
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Barriers to health care for undocumented immigrants
Expansion of the safety net focused on increasing the
capacity of safety net providers (free clinics, state clinics,
federally qualified health centers and public hospitals, and
public health clinics) to service the population and receive
reimbursement. In addition, strategies to employ sliding
fee scales to accommodate low-income individuals and the
use of voluntary organizations were mentioned. Training
of providers included both training in the legal mandates of
the individual country and training in cultural competency.
Education for immigrants included providing specialized
linguistically appropriate information on how to navigate
the health care system and on what rights were afforded to
undocumented immigrants. Authors also suggested using
navigators to help undocumented immigrants maneuver
through the health care system.
Advocacy/legal change
A variety of advocacy recommendations to change the
existing laws were suggested in the majority of the papers
reviewed (47%). These included not only changing laws to
provide full access to care regardless of citizenship but also
promoting legislation that would allow delayed deporta-
tion until treatment was completed. Others recommended
major immigration reform that would grant legal status to
undocumented immigrants after some period of time, thus
making health care exclusion laws irrelevant.
Insurance options
Several papers suggested newly configured insurance options
to support undocumented immigrants’ access to health care.
These included a range of options from a state-funded insur-
ance plan to a low-cost insurance plan with a limited network.
Most of the insurance strategies recommended required
undocumented immigrants to financially contribute at some
level in order to access care. Fourteen percent of papers
recommended changes in insurance options.
Expansion of the safety net
Twenty-seven percent of papers identified the need to expand
the existing safety net to accommodate the needs of undocu-
mented immigrants. This included expanding public and free
clinics and hospitals, particularly for conditions that put the
public’s health at risk (ie, tuberculosis [TB], and sexually
transmitted diseases) or those related to maternal and child
health (obstetrics and preventive care). They also noted that
current voluntary organizations such as food banks could be
important health care providers, particularly for prevention
and health education. Many papers noted that the safety net
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Hacker et al
system did not currently have capacity to take on this role
and called for increased state support to do so.
Training of providers
A number of papers (15%) noted that providers them-
selves needed additional training to appropriately care for
undocumented immigrants. A focus on cultural competency
was needed to improve existing services as well as any
new services. In some of the papers, it was also noted that
providers did not adequately understand the current policies
on access and might turn undocumented immigrants away
based on false information. Therefore, a number of papers
recommended additional training to keep providers up to
date on changing legislation related to access.
Education and outreach
Lastly, a number of papers (23%) argued for education and
specialized outreach to the undocumented immigrant com-
munity to facilitate their utilization of the health care system
and their understanding of the policies relevant to them in
the specific country. Several papers also recommended the
use of navigators or cultural ambassadors to help undocu-
mented immigrants maneuver through the bureaucracy and
obtain needed care.
Discussion
In this literature review, we identified 66 peer-reviewed
articles in the medical literature addressing barriers to
health care among undocumented immigrants. These articles
described multiple policy, health system, and individual
barriers to care for this population. Policy-level barriers
centered on legal barriers, particularly barred access to
insurance, and the need to show documentation to get
services. Health system barriers included external resource
constraints (such as lack of transportation), discrimination
within the health care system, and complex bureaucracies.
Finally, individual-level barriers identified included fear
of deportation, communication ability, lack of financial
resources, and experience of shame or stigma.
The barriers to health care for undocumented immigrants
are extensive and vary by country. Even in countries with more
lenient health care access laws for undocumented immigrants,
bureaucratic obstacles can be complex and have similar
effects to limiting care. The literature suggests that the legal
obstacles are not the only bureaucratic obstacles that undocu-
mented immigrants face; undocumented immigrants deal with
challenges that revolve around understanding the health care
system, shame, and fear of deportation. Tying access to health
care to deportation is perhaps the largest barrier to obtaining
services even in countries that offer access. It is well known that
immigrants overall and undocumented immigrants in particular
are underutilizing the health care system. The ramifications of
such obstacles might include a risk to the public’s health when
communicable diseases are involved or a risk for more serious
issues when health care is deferred.
Given the extent of immigration now and potentially in
the future, countries will continue to grapple with developing
strategies that serve the public’s health. Many of the recom-
mendations that we identified in the reviewed articles have not
been tested so it is difficult to ascertain whether or not they
would be deemed successful. Recommendations mentioned
frequently involved changing legislation to provide full health
coverage regardless of status. Other recommendations sug-
gested providing health care that was limited (by disease),
only preventive in nature, or of low-cost. Many countries
already have such systems in place.4,7,44
These secondary systems of health care for noncitizens
have restricted access to care and require complex and costly
bureaucracies to administer. Some of the recommendations
we encountered suggested that a thoughtfully constructed
(inclusive of preventive, acute, and secondary care) and
controlled (limited networks), system might offer a low-cost
alternative to full access.
Studies have documented that people migrate to flee
violence or persecution or for economic opportunities rather
than to obtain health care.21 It is therefore possible that
despite concerns that access to health care attracts undocu-
mented immigrants, integration of a noncitizens’ health care
option into national systems may not increase immigration.
However, more research is needed to better understand the
impact of the various recommendations we identified on
undocumented immigration, costs, and health outcomes.
Limitations
The literature search was limited to English language articles
from the last 10 years and run using PubMed. It is likely that
relevant articles are missing from this review that were pub-
lished in other languages, and indexed in databases besides
PubMed (such as PsycINFO and Embase, etc). Inclusion of
those missing articles could have added more information
on barriers and options for recommendations addressing
undocumented immigrants’ access to health care.
In addition, this review was designed to answer
a specific question about barriers to health care for
undocumented immigrants. Recommendations examined
were limited to those identified in the articles retrieved
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Barriers to health care for undocumented immigrants
for our review of barriers. We did not carry out a separate
review of strategies to address the provision of health care for
undocumented immigrants, and a literature review focused on
polices or strategies to address health care for this population
might provide additional evidence not mentioned in this
paper. Another review examining the impact of various health
services for undocumented immigrants would be needed.
Because the review aimed to examine barriers in general
rather than compare barriers by country, we are unable to
present comparisons across countries. Further research would
be needed to answer this question. Lastly, we were strictly
focused on undocumented immigrants and are unable to com-
ment on barriers to care for documented (legal) immigrants.
Conclusion
There are numerous and wide-ranging barriers to receipt of
health care for undocumented immigrants. These barriers are
not only legal in nature but also encompass challenges inher-
ent in “undocumented” or illegal status. They include policy
limitations, the fear of disclosure, and the lack of both social
and financial assets. Given the current level of undocumented
immigrants worldwide, these barriers will continue to impact
human health. Additional research is needed to determine
the effect of implemented health policies on undocumented
immigrant health and decisions to immigrate.
Disclosure
The authors report no conflicts of interest in this work.
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... Hence, further studies on individual factors affecting access to health care should be conducted [11]. In a review article, individual-level barriers to health care access included financial status, knowledge of health care system navigation, and communication with the health care providers [12]. ...
... Communication with the health care providers was another potential barrier [12]. This study captured satisfaction in the communication domain and the perceived quality and safety of care within the acceptability domain. ...
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b> Introduction: Health care system navigation and communication with the providers are the barriers to health care access. Recently, a new health care model with the provider’s reform mechanism was introduced in Saudi Arabia. The national goal of financial reform is to provide Saudi nationals, residents, and visitors with timely access to health care. This study aimed to assess the long-term beneficiaries’ satisfaction with access to health care and explore the influencing factors and barriers, including cost and communication with the providers and probable solutions. Methods: In this cross-sectional self-administered online survey, we used the validated “6A,” namely, affordability, acceptability, adequacy, accessibility, availability, and awareness (30 items) of perceived access to health care questionnaire. The primary outcome variable was the overall satisfaction with access to health care among the long-term beneficiaries and caregivers. Demographic variables were used as predictors of the level of satisfaction. Results: A total of 118 health care long-term beneficiaries completed the questionnaires. The mean age of the participants was 49 years. Most participants were beneficiaries from the Ministry of Health ( n = 62; 52.5%). Only 42 participants (35.6%) reported a high level of satisfaction. Low satisfaction level was mainly reported by non-Saudi, retired males living in big cities. Similarly, those who paid the health care services in cash reported a significantly low level of satisfaction. Moreover, the level of satisfaction was significantly associated with insurance coverage. Discussion: The first application of the “6A” perceived access to health care questionnaire in Saudi Arabia identified that 35.6% were poorly satisfied with access to health care. However, the rate is lower than that reported in six European countries, which ranged from 53% to 55%. Since after 4 years of health reform, payment methods for health services were identified as a significant predictor of variation in the mean scores of accesses to health care. Further national-level studies exploring access to health care are needed on long-term beneficiaries who are retired and those who live in rural and remote areas. In future health sector reform and health system research, addressing unaffordable to pay services is required.
... Individual-level barriers to HIV services include fear of deportation and negative social consequences of HIV status disclosure, such as stigma, discrimination, social isolation and job loss [17][18][19][20]. The fear of deportation is reported mainly among undocumented migrants, since their access to the services may lead to the discovery of their undocumented status by authorities [9,[21][22][23]. Fear of negative side effects of antiretroviral therapy (ART) is also another factor that impedes access to HIV services for MLHIV [20,24,25]. ...
... Their untreated HIV may result in reducing the body's immune system which can contribute to a higher risk of acquiring opportunistic infections or co-infections. Another identified barrier, which is also in line with previous findings [9,21,23,46], was the status of being undocumented migrant workers, which led to a fear of getting caught by authorities and of being jailed or deported. The fact that there are undocumented Indonesians working abroad seems to also reflect both poor distribution and access to necessary information about procedures and requirements to become a migrant worker and poor recruitment process of potential migrant workers in the study settings. ...
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Migrant populations are one of the vulnerable groups to HIV transmission and its consequences. They are also reported to experience delayed entry or linkage into HIV services and have poorer HIV-related health outcomes. This study aimed to understand barriers to accessing HIV care services in host countries among Indonesian, male, former (returned) migrant workers living with HIV. The study was carried out from December 2020 to February 2021. It utilised a qualitative design employing in-depth interviews to collect data from twenty-two returned migrant workers from Eastern Indonesia, recruited using the snowball sampling technique. A qualitative data analysis framework was used to guide a step-by-step analysis of the findings. Findings demonstrated that limited host-country language proficiency, lack of knowledge regarding healthcare systems in host countries and having ‘undocumented’ worker status were barriers to accessing HIV care services. Data also revealed the unavailability of HIV care services nearby migrants’ work locations, long-distance travel to healthcare facilities, and challenges in accessing public transportation as barriers that impeded their access to the services. Other factors limiting the participants’ access to HIV services were identified as the transient and mobile nature of migrant work requiring frequent relocation and disrupting work–life stability. Additionally, in lieu of formal HIV services, many participants self-medicated by using over-the-counter herbal or ‘traditional’ medicines, often because of peer or social group influence regarding the selection of informal treatment options. Recommendations arising from this study demonstrate the need to improve pre-departure information for migrant workers regarding the healthcare system and access procedures in potential host countries. Data from this study also indicate that social services should be available to assist potential migrants to access legal channels for migrant work overseas, to ensure that Indonesian migrants can safely access healthcare services in the countries for which they are providing migrant labour. Future studies to understand barriers to accessing HIV care services among various migrant groups living with HIV are warranted to build evidence for potential social policy change.
... Preexisting deterrents to preventive health care services, such as language barriers, financial limitations, and low health insurance rates [7,8], are now compounded by a turbulent US political environment [9], mistrust in health care in marginalized communities [10], and the novelty of the COVID-19 vaccine [11]. In particular, the implementation of the new public charge rule, which went into effect just before the pandemic began in February 2020, led to a decline in enrollment in safety-net programs (i.e., Medicaid, WIC, and SNAP) among US-born children, particularly in regions with a higher share of noncitizens. ...
Article
Although it is widely acknowledged that racialized minorities may report lower COVID-19 vaccine willingness compared to non-Hispanic white individuals, what is less known, however, is whether the willingness to receive the COVID-19 vaccine also differs by citizenship. Understanding disparities in vaccine willingness by citizenship is particularly important given the misleading rhetoric of some political leaders regarding vaccine eligibility by citizenship status. This study used the 2020 California Health Interview Survey (n = 21,949) to examine disparities in vaccine willingness by race/ethnicity and citizenship among Asian, Latinx, and non-Hispanic white individuals. Overall, 77.7% of Californians indicated that they were willing to receive the COVID-19 vaccine if it was made available. However, there were distinct differences by race/ethnicity and citizenship. Asian people, regardless of citizenship, had the highest predicted probability of vaccine willingness, accounting for demographic, socioeconomic, and health factors. Non-citizen Latinx and non-citizen non-Hispanic white people had higher predicted probabilities of vaccine willingness compared to their US-born counterparts, accounting for demographic, socioeconomic, and health factors. Our results reveal that although vaccine willingness may be high among non-citizen individuals, it may not necessarily translate into actual vaccine uptake. Furthermore, while individual-level factors may account for some of the differences in vaccine willingness by race/ethnicity and citizenship, other institutional and structural barriers prevent vaccine uptake.
... Undocumented immigrant populations, who are often at the center of debates about expanded coverage, face multiple barriers to healthcare access, including delays or avoidance of care due to inability to pay, lack of transportation, or the requirement to supply citizenship or legal residency documentation. Individuals who fear deportation are forced to choose between healthcare and family security (Doshi et al., 2020;Hacker et al., 2015;Kennedy, 2018;Box 14.2). ...
... Immigrants living without documentation may hold well-founded fears about engaging with the healthcare systems, which, subsequently may decrease access to healthcare. 57,58 Our study adds to this existing work by demonstrating similar concerns accessing vaccines, even outside of the traditional healthcare system. ...
Article
In this community-partnered study we conducted focus groups with non-English speaking immigrant and refugee communities of color in 4 languages to understand their perspectives on COVID-19 vaccines, barriers to accessing vaccines, and recommendations for healthcare providers. We used a mixed deductive-inductive thematic analysis approach and human centered design to guide data analysis. 66 individuals participated; 85% were vaccinated. The vaccination experience was often positive; however, participants described language inaccessibility, often relying on family members for interpretation. Community-based organizations played a role in connecting participants to vaccines. Unvaccinated participants expressed fear of side effects and belief in natural immunity. Participants shared recommendations to providers around increasing vaccine access, improving language accessibility, and building trust. Results from our study show numerous barriers immigrant and refugee communities of color faced getting their COVID-19 vaccine, but also highlights opportunities to engage with community partners. Future implications for research, policy, and practice are described.
... It is important to acknowledge that not all undocumented migrants may be aware of or be able to access these resources. Fears of unwilful deportation to their countries of origin following medical treatment, humiliation, stigma and the lack of both social and financial capital have been documented as some of the factors that shape most undocumented immigrants' health-seeking behaviours (Hacker et al., 2015). ...
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Abstract Purpose – Pandemics pose challenges to all groups of people and all aspects of human lives. Undocumented migrants are likely to face more challenges during global pandemics. The purpose of this paper is to explore the possible challenges of undocumented immigrants in Canada and the USA in the ongoing COVID-19 pandemic. Design/methodology/approach – From existing literature, the authors examined the challenges of undocumented migrants in Canada and the USA and suggested recommendations to address those challenges at both policy and national levels. Findings – The undocumented status of some international immigrants makes them vulnerable in their host nations. They face myriad challenges in their host countries, spanning from economic, health, social isolation and employment challenges, and these are further exacerbated during pandemics such as the ongoing COVID-19. The provision of culturally sensitive and safe policies may support this particular population, especially in times of crisis like the COVID-19 pandemic. Originality/value – This paper provides critical insights into the possible intersections that worsen the vulnerability of undocumented migrants in pandemic crises like COVID-19. Further, this review serves to initiate the discourse on policy and interventions for undocumented immigrants during pandemics or disease outbreaks.
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Introduction: Worldwide, our societies are characterised by increasing diversity, which is greatly contributed to by people who have migrated from one country to another. To provide person-centred care, healthcare staff need to consider the personal background, biography and preferences of people with care needs. Little is known about the care preferences of older migrants and minority ethnic groups. The purpose of this planned scoping review is to explore and systematically investigate current research addressing the care preferences of older migrants and minority ethnic groups. In addition, gaps requiring further research will be identified. To the best of our knowledge, this scoping review will be the first to synthesise the literature regarding the preferences in nursing care of older migrants and minority ethnic groups. Methods: A scoping review will be conducted to identify and analyse the care preferences of older migrants and minority ethnic groups (population 60 years or older with various care needs). Based on the research aim, we will systematically search the electronic databases MEDLINE (via PubMed), CINAHL (via EBSCO) and PsycINFO (via EBSCO). We will include literature published in English and German with no restrictions regarding the publication date. The identified records will be independently screened (title/abstract and full text) by two reviewers. Data from the included studies will be extracted by one and verified by a second researcher. We will analyse the identified preferences with an inductive content analysis and will narratively present the review results in the form of tables. Ethics and dissemination: There are no ethical concerns related to conducting this study. We will discuss our results with practitioners in the field of nursing care of older people with migration backgrounds. We will present our results and make them available to the public at (inter) national conferences and in the form of peer-reviewed and practice articles.
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Purpose of Review To identify how recent immigration policies have affected the health of children in immigrant families (CIF). Recent Findings As the number of children and families arriving to the US border has increased, so too have immigration policies directly targeting them. Summary Anti-immigrant policies increase the dangers experienced by children migrating to the USA, while also limiting access to needed resources and medical care for CIF inside the country, including many who are US citizens. The resultant deprivation and toxic stress are associated with adverse consequences for children’s physical and mental health.
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Emerging evidence suggests that the COVID-19 pandemic has extracted a substantial toll on immigrant communities in the United States, due in part to increased potential risk of exposure for immigrants to COVID-19 in the workplace. In this article, we use federal guidance on which industries in the United States were designated essential during the COVID-19 pandemic, information about the ability to work remotely, and data from the 2019 American Community Survey to estimate the distribution of essential frontline workers by nativity and immigrant legal status. Central to our analysis is a proxy measure of working in the primary or secondary sector of the segmented labor market. Our results indicate that a larger proportion of foreign-born workers are essential frontline workers compared to native-born workers and that 70 percent of unauthorized immigrant workers are essential frontline workers. Disparities in essential frontline worker status are most pronounced for unauthorized immigrant workers and native-born workers in the secondary sector of the labor market. These results suggest that larger proportions of foreign-born workers, and especially unauthorized immigrant workers, face greater risk of potential exposure to COVID-19 in the workplace than native-born workers. Social determinants of health such as lack of access to health insurance and living in overcrowded housing indicate that unauthorized immigrant essential frontline workers may be more vulnerable to poor health outcomes related to COVID-19 than other groups of essential frontline workers. These findings help to provide a plausible explanation for why COVID-19 mortality rates for immigrants are higher than mortality rates for native-born residents.
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Background: Five telemedicine simulations were created during the coronavirus disease 2019 (COVID-19) pandemic to elucidate implicit biases and enhance awareness of social determinants of health among nursing students. Social determinants affect overall health, functioning, and quality-of-life outcomes and risks. Implicit biases are related to patient-provider interactions, treatment decisions and adherence, and ultimately patient health outcomes. Purpose: This article explains the simulation development and content, describes the student learning outcomes, and presents faculty insights that highlight the necessity of simulation experiences in nursing education. Method: Five telemedicine simulations that presented different social determinants of health and implicit biases were created for undergraduate nursing students. Results: Nursing students increased knowledge related to social determinants and their own implicit biases. Conclusion: Telemedicine simulations were effective in assisting nursing students recognize their own implicit biases and the economic challenges of individuals living in poverty, as well as the potential influence of social determinants of health. [J Nurs Educ. 2022;61(X):XXXXXX.].
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Immigration is a key political issue in the United Kingdom. The 2014 Immigration Act includes a number of measures intended to reduce net immigration, including removing the right of non-European Economic Area migrants to access free health care. This change risks widening existing health and social inequalities. This study explored the experiences of undocumented migrants trying to access primary care in the United Kingdom, their perspectives on proposed access restrictions, and suggestions for policymakers. Semi-structured interviews were conducted with 16 undocumented migrants and four volunteer staff at a charity clinic in London. Inductive thematic analysis drew out major themes. Many undocumented migrants already faced challenges accessing primary care. None of the migrants interviewed said that they would be able to afford charges to access primary care and most said they would have to wait until they were much more unwell and access care through Accident & Emergency (A&E) services. The consequences of limiting access to primary care, including threats to individual and public health consequences and the additional burden on the National Health Service, need to be fully considered by policymakers. The authors argue that an evidence-based approach would avoid legislation that targets vulnerable groups and provides no obvious economic or societal benefit. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
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Newly immigrated persons, whatever their origin, tend to fall in the lower socioeconomic levels. In fact, failure of an asylum application renders one destitute in a large proportion of cases, often resulting in a profound lack of access to basic necessities. With over a third of HIV positive failed asylum seekers reporting no income, and the remainder reporting highly limited resources, poverty is a reality for the vast majority. The purpose of the study was to determine the basic social processes that guide HIV positive undocumented migrant's efforts to gain health services in the UK. The study used the Grounded Theory Approach. Theoretical saturation occurred after 16 participants were included in the study. The data included reflections of the prominent factors related to the establishment of a safe and productive life and the ability of individuals to remain within the UK. The data reflected heavily upon the ability of migrants to enter the medical care system during their asylum period, and on an emerging pattern of service denial after loss on immigration appeal. The findings of this study are notable in that they have demonstrated sequence of events along a timeline related to the interaction between the asylum process and access to health-related services. The results reflect that African migrants maintain a degree of formal access to health services during the period that they possess legal access to services and informal access after the failure of their asylum claim. The purpose of this paper is to examine the basic social processes that characterize efforts to gain access to health services among HIV positive undocumented African migrants to the UK. The most recent estimates indicate that there are a total of 618,000 migrants who lack legal status within the UK. Other studies have placed the number of undocumented migrants within the UK in the range of 525,000-950,000. More than 442,000 are thought to dwell in the London metropolitan area. Even in cases where African migrants enter the UK legally, they often face considerable difficulty in their quest to gain legal employment due to barriers inherent to the system that grants work permits. With over a third of HIV positive failed asylum seekers reporting no income, and the remainder reporting highly limited resources, poverty is a reality for the vast majority.
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Objectives: We sought to understand how local immigration enforcement policies affect the utilization of health services among immigrant Hispanics/Latinos in North Carolina. Methods: In 2012, we analyzed vital records data to determine whether local implementation of section 287(g) of the Immigration and Nationality Act and the Secure Communities program, which authorizes local law enforcement agencies to enforce federal immigration laws, affected the prenatal care utilization of Hispanics/Latinas. We also conducted 6 focus groups and 17 interviews with Hispanic/Latino persons across North Carolina to explore the impact of immigration policies on their utilization of health services. Results: We found no significant differences in utilization of prenatal care before and after implementation of section 287(g), but we did find that, in individual-level analysis, Hispanic/Latina mothers sought prenatal care later and had inadequate care when compared with non-Hispanic/Latina mothers. Participants reported profound mistrust of health services, avoiding health services, and sacrificing their health and the health of their family members. Conclusions: Fear of immigration enforcement policies is generalized across counties. Interventions are needed to increase immigrant Hispanics/Latinos' understanding of their rights and eligibility to utilize health services. Policy-level initiatives are also needed (e.g., driver's licenses) to help undocumented persons access and utilize these services.
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To explore health-seeking behaviour and experiences of undocumented migrants (UMs) in general practice in relation to mental health problems. Qualitative study using semistructured interviews and thematic analysis. 15 UMs in the Netherlands, varying in age, gender, country of origin and education; inclusion until theoretical saturation was reached. 4 cities in the Netherlands. UMs consider mental health problems to be directly related to their precarious living conditions. For support, they refer to friends and religion first, the general practitioner (GP) is their last resort. Barriers for seeking help include taboo on mental health problems, lack of knowledge of and trust in GPs competencies regarding mental health and general barriers in accessing healthcare as an UM (lack of knowledge of the right to access healthcare, fear of prosecution, financial constraints and practical difficulties). Once access has been gained, satisfaction with care is high. This is primarily due to the attitude of the GPs and the effectiveness of the treatment. Reasons for dissatisfaction with GP care are an experienced lack of time, lack of personal attention and absence of physical examination. Expectations of the GP vary, medication for mental health problems is not necessarily seen as a good practice. UMs often see their precarious living conditions as an important determinant of their mental health; they do not easily seek help for mental health problems and various barriers hamper access to healthcare for them. Rather than for medication, UMs are looking for encouragement and support from their GP. We recommend that barriers experienced in seeking professional care are tackled at an institutional level as well as at the level of GP. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Objective: To identify policies that increase access to health care for undocumented Mexican immigrants. Materials and methods: Four focus groups (n=34 participants) were conducted with uninsured Mexican immigrants in Los Angeles, California. The feasibility and desirability of different policy proposals for increasing access were discussed by each group. Results: Respondents raised significant problems with policies including binational health insurance, expanded employer-provided health insurance, and telemedicine. The only solution with a consensus that the change would be feasible, result in improved access, and they had confidence in was expanded access to community health centers (CHC's). Conclusions: Given the limited access to most specialists at CHC's and the continued barriers to hospital care for those without health insurance, the most effective way of improving the complete range of health services to undocumented immigrants is through immigration reform that will bring these workers under the other health care reform provisions.
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Undocumented immigrants are less likely than other residents of the United States to have health insurance. Their access to publicly funded health programs has become increasingly limited since the passage of welfare reform in 1996 and varies from state to state. This is reflected in less preventive health care, including prenatal care, and poorer health outcomes, including those associated with childbirth. The U.S.-born children of undocumented immigrant women are U.S. citizens, and the nation's public health is enhanced by assuring that all who reside in the United States, including undocumented immigrants, have access to quality health care. © 2008 by The American College of Obstetricians and Gynecologists.
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Migrants without residence permits are de facto excluded from access to healthcare in Germany. There is one exception in relevant legislation: in the case of sexually transmitted infections and tuberculosis, the legislator has instructed the local Public Health Authorities to offer free and anonymous counseling, testing and, if necessary, treatment in case of apparent need. Furthermore, recommended vaccinations may be carried out free of charge. This study intends to comprehensively capture the services for undocumented migrants at Public Health Authorities in Germany. An e-mail survey of all Local Public Health Authorities (n = 384) in Germany was carried out between January and March 2011 using a standardized questionnaire. One hundred thirty-nine of 384 targeted local Health Authorities completed the questionnaire (36.2%), of which approximately a quarter (n = 34) reported interaction with 'illegal' immigrants. Twenty-give authorities (18.4%) gave the indication to carry out treatment. This outpatient treatment option is mostly limited to patients afflicted with sexually transmitted infections with the distinct exception of human immunodeficiency virus/acquired immune deficiency syndrome. The study highlights the gap between legislation and the reality of restricted access to medical services for undocumented migrants in Germany. It underlines the need of increased financial and human resources in Public Health Authorities and, overall, the simplification of national legislation to assure the right to healthcare. © The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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In this article, I examine the various meanings of Mexican and Central American migrant women's utilization of private food assistance programs. I present findings from 20 months of ethnographic fieldwork conducted between 2008 and 2011 with migrant women, public health workers, and staff and volunteers of food assistance programs in Santa Barbara County, California. I discuss the barriers undocumented women face in accessing formal health care and the social and moral obligations that underpin these women's role in feeding others. I also document the ways in which private food assistance programs are orienting toward a focus on health in service delivery, and how women depend on provisions from these programs to support feeding practices at home. I argue that these findings are significant for current engagement by critical medical anthropologists in studying framings of "the clinic" and cultural beliefs about "deservingness." © 2015 by the American Anthropological Association.
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A nation of immigrants, the United States currently has more foreign-born residents than any other country; approximately 28% of these foreign-born residents are undocumented immigrants-individuals who either entered or are currently residing in the country without valid immigration or residency documents. The complex and constantly changing social, political, and economic context of undocumented migration has profound effects on individuals, families, and communities. The lack of demographic and epidemiologic data on undocumented immigrants is a major public health challenge. In this article, we identify multiple dimensions of vulnerability among undocumented persons; examine how undocumentedness impacts health and health care access and utilization; and consider the professional, practice, and policy issues and implications for nurses. Copyright © 2015 Elsevier Inc. All rights reserved.
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The aims of this overview are to provide a brief historical review of federal, state, and local immigration policies and to examine the historical origin and current constructions of the undocumented immigrant. We discuss how past and current policies promote, regulate, restrict, and deter immigration into the United States and access to health services and draw implications for the profession of nursing. Copyright © 2015 Elsevier Inc. All rights reserved.