Detained and Denied: Healthcare Access in Immigration Detention,
New York Lawyers for the Public Interest, 2017, 20 pp.
Authors: Sola Stamm et al
As the Trump administration threatens to deport an increasing number of immigrants, immigration advocates have
expressed concern over the state of health care treatment within detention centers. The New York Lawyers for Public Interest
(NYLPI) provides legal representation and advocacy work for undocumented immigrants in ICE custody. NYPLI reports in Detained
and Denied: Healthcare Access in Immigration Detention that immigrant detention facilities often provide sub-par health
care to detained individuals and fail to provide timely and adequate medical care to accommodate the medical needs of the
incarcerated population. Under the 14th Amendment of the U.S. constitution, detained immigrants have a right to
adequate healthcare. ICE itself also has issued official "performance-based standards" for medical care. NYPLI
collected information on the state of medical care at detention facilities through a review of complaint records and interviews
with 47 individuals with serious medical conditions who were held in immigration detention in the New York metropolitan area.
The researchers found recurring deficiencies in medical care, including incomplete intake assessments, lack of interpreters
for patient-doctor communication, denied or severely delayed medical care, and inadequate departure planning for continuing
medical care. These deficiencies, the authors argue, have endangered the lives of detainees and undermined their basic human
dignity. The report concludes with a recommendation that ICE detention facilities be mandated to comply with performance standards
regarding comprehensive health care and be held legally accountable for the care of detained individuals. (Mia
Fasano for The Immigrant Learning Center)
Living in an Immigrant Family in America: How Fear and Toxic Stress are affecting Daily Life, Well-Being,
The Henry J. Kaiser Family Foundation, December, 2017, 24 pp.
Authors: Samantha Artiga & Petry Ubri
According to this report, immigrant families from various backgrounds are living with increased fear and uncertainty
due to the current political climate. The election of Donald Trump has led to policies that increase immigration enforcement
and restrict the entry of immigrants from selected countries. These policies can potentially impact 23 million non-citizens
who live in the United States, as well as 12 million children who are predominantly U.S.-born. This Kaiser Family Foundation
brief uses focus groups with 100 immigrant parents from 15 countries as well as 13 telephone interviews with pediatricians
who serve immigrant families to understand how the political climate and enforcement policies since the 2016 presidential
election impact the daily lives and health of immigrant families. The report finds that the heightened stress many immigrant
families are experiencing can have broad effects on the life and daily routine of these families. Many immigrant parents report
difficulty in finding employment. Adults also feel insecure about their ability to stay in the U.S., and they limit their
time outside the home to reduce risk of deportation or interaction with law enforcement. Said one Latino parent, "Before,
there were many kids in the parks... but now... the kids spend more time inside these days because we are afraid of being
deported." In addition, children appear to be exposed to elevated levels of toxic stress. Parents report that their children
are experiencing more bullying at school, causing physiological, behavioral and mental health changes in children that can
lead to compromised development and poorer mental and physical health outcomes. In response to witnessing increased racism
and bullying since the 2016 election as well as changes in health care use, some pediatricians have taken steps to help immigrant
families feel safe including increasing communication to reassure confidentiality, having bilingual staff welcome families,
and writing letters to assist families facing deportation. (The Immigrant Learning Center's Public Education Institute)
Facilitating Health Communication with Immigrant, Refugee, and Migrant Populations Through the Use of
Health Literacy and Community Engagement Strategies: Proceedings of a Workshop
The National Academies of Sciences, Engineering, and Medicine, 2017, unpaginated
Rapporteur: Joe Alper
goal of this workshop was to identify approaches that will enable health care organizations to serve immigrant and refugee
populations "in a manner that allows all members of these communities to obtain, process, and understand basic health
information and the services needed to make appropriate health and personal decisions." This publication summarizes the
workshop's presentations and discussions, and highlights important lessons, practical strategies, and opportunities for using
the principles of health literacy to facilitate communication with newcomer populations. In accordance with the policies of
the National Academies, the workshop did not attempt to reach any conclusions or make any recommendations about needs and
future directions. Rather, it simply highlights the issues identified by speakers and workshop participants and calls attention
to programs and initiatives that show some promise of success. One important concern of participants was to earn the
trust of immigrant communities by responding to the climate of fear that surrounds immigrants today and to ensure that personal
information, if collected at all, is safeguarded. One model program is the "You are safe here" campaign of the San
Francisco Department of Public Health. Another approach is to probe more deeply into the experience of migrants, many of whom
have been tortured or have suffered other forms of trauma. As one participant said, "perhaps the most important thing
a clinician can do is to be curious and ask people about their experiences." The workshop gave examples of efforts to
address the social determinants of health, such as the work of the California Healthy Nail Salon Collaborative. Workshop
participants also learned about efforts on the part of health care organizations to partner with community-based organizations,
such as the Casa de Salud in the St. Louis metropolitan area. Finally, innovative programs to improve communication with newcomer
populations, such as the Let's Talk About Medicines project of Wisconsin Health Literacy, were described.
Pre-Migration Trauma Exposure and Mental Health Functioning among Central American Migrants Arriving
at the US Border,
PLoS One 12(1), January 10, 2017, 8 pp.
Authors: Allen Keller, Amy Joscelyne, Megan Granski, Barry Rosenfeld
In recent years, the influx of families and children from Central America arriving at the U.S. border has been
deemed an "urgent humanitarian situation." Examining how the experiences of migrants correspond with the requirements
for asylum status can powerfully inform public discourse and policy. This report focuses on migrants from the Northern
Triangle region, formed by El Salvador, Guatemala and Honduras, and considers their pre-migration trauma, current mental health
functioning, reasons for leaving the region, and rate at which they appeared to satisfy the legal criteria for asylum. Researchers
interviewed 234 adults seeking assistance at the Church of the Sacred Heart in McAllen, Texas and found that 83 percent of
participants cited violence as a reason for fleeing their country, 69 percent did not report violent events to the police
for fear of police corruption and gang-related retribution, and 90 percent are afraid to return to their native country. Based
on self-report symptom checklists, 32 percent of participants met the criteria for post-traumatic stress disorder, 24 percent
for depression, and 17 percent for both disorders. When considering the data against the criteria for asylum in the U.S.,
researchers found that 70 percent of the overall sample met the criteria for asylum. The findings indicate that with the high
degrees of trauma and psychological distress present in the population, the use of detention for these asylum-seekers may
be cruel and retraumatizing. (Grace Chen for The ILC Public Education Institute)
Organisational systems' approaches to improving cultural competence in healthcare: a systematic scoping
review of the literature,
International Journal for Equity in Health, 16:78 (2017), 19 pp.
Authors: Janya McCalman, Crystal Jongen, &
Noting that the scope of cultural competence has expanded beyond the interpersonal domain
to address system-level factors, the authors of this study set about to determine the evidence base for a systems approach
to eliminating inequities in health care. A systems approach "requires an amalgamation of attitudes, practices, policies
and structures to enable healthcare organizations and professionals to work effectively in culturally diverse situations."
A review of the literature from 2002 to 2015, examining health care interventions in Australia, Canada, New Zealand, and the
United States, produced nearly 3,000 studies touching on cultural competence in healthcare settings. However, only 141 studies
appeared to focus on systems-level approaches, and of those studies, only 15 studies included evaluation measures and were
deemed worthy of inclusion in the study. Three approaches that seemed particularly efficacious were: user engagement
in the development or implementation of strategies, organizational readiness, and delivery across multiple sites. However,
there is a clear need for additional studies in order to bolster the case for systemic approaches to cultural competence.
"...There is little guidance for healthcare organisations about how to identify what mix of cultural competence strategies
works in practice, when and how to implement them properly, or whether their investment in cultural competence interventions
will have the intended effects on client experiences or health outcomes."
Building an Organizational Response to Health Disparities: A Practical Guide to Implementing the National
National Committee for Quality Assurance, December, 2016, 59 pp.
In 2013, the federal Office of Minority
Health (OMH) issued the "enhanced" National CLAS Standards (Culturally and Linguistically Appropriate Services)
to guide health and health care organizations in their efforts to ensure health equity. This Toolkit, produced under OMH contract
with the National Center for Quality Assurance (NCQA), provides examples of resources available to support organizations committed
to the implementation of the CLAS standards. The toolkit is divided into four chapters that follow the organization of the
National CLAS Standards: Principal Standard; Governance, Leadership and Workforce; Communication and Language Assistance;
Engagement, Continuous Improvement and Accountability. Resources are categorized by the five groups that are likely
to experience disparities in care: people with disabilities, people with limited English proficiency, people with low
health literacy, racial/ethnic minorities, sexual and gender minorities. The LEP section of the Toolkit provides descriptions
and links to a variety of resources, including training materials and assessment tools. A panel of experts reviewed the content
of the Toolkit to ensure the quality and relevance of all materials.
Practicing Cultural Humility
American Counseling Association, Counseling Today, December 27, 2016, 6 pp.
Author: Sidney Shaw
endorses a revision to the Multicultural Counseling Competencies (MCCs) model, which has been a foundational document in the
counseling profession for several decades. The chief flaw in the model, according to Shaw, is the "self-assessment bias"
of the counselor, who typically overrates his/her abilities in relating to clients from diverse cultural backgrounds. Although
the insights of MCC remain valid, they need to be supplemented with what the author calls Multicultural Orientation (MCO).
This approach "privilege(s) the voice of clients and make(s) the counselor's own invisible privilege a little more visible."
It requires the counselor to practice "cultural humility," which involves "engag(ing) in collaborative, open
exploration with clients regarding their cultural identity as a salient factor in treatment." It also enables counselors
to practice "dynamic sizing," i.e. knowing under what circumstances to generalize cultural knowledge to specific
individuals. In addition, the approach helps to reduce the number of "microagressions" (reported by more than 50
percent of racial and ethnic minority clients). The paper concludes with a number of in-session recommendations for counselors
interested in embracing this new approach.
Ethnic Attrition and the Observed Health of Later-Generation Mexican Americans,
Institute for the Discussion of Labor, Discussion Paper No. 10062, August 8, 2016, 13 pp.
Authors: Francisca Antman,
Brian Duncan, & Stephen J. Trejo
This study suggests that there is a bias built into many studies of the
health condition of second and later generations of Mexican immigrants. These studies often show a pattern of worsening health
outcomes with each successive generation. The authors point out that there is a major flaw in these studies, in that they
rely on the reported ethnic self-identification of survey respondents. "Ethnic attrition" occurs whenever a U.S.-born
descendent of a Mexican immigrant fails to self-identify as Mexican. Such individuals "are generally more likely
to display health outcomes closer to those of non-Hispanic whites compared with individuals who identify as Mexican Americans."
The data used in this study came from the 2000-2014 waves of the National Health Interview Survey, the major source of detailed
data on a broad range of health outcomes and related characteristics of the U.S. population. Ethnic attrition rates
are greatest for children of intermarried parents.
Pursuing Health Equity through Welcoming Work
Welcoming America, 2016, 10 pp.
Authors: M. Mayor & Jennifer Drive
Pursuing Health Equity through
Welcoming Work describes replicable strategies to promote health equity as part of efforts to integrate immigrants into
community life. The report draws on key points from a Welcoming America panel discussion and uses data from governmental agencies
and scholarly research to highlight promising practices in Georgia, Pennsylvania, Virginia and New Hampshire. The authors
emphasize three key requirements for achieving health equity: involving immigrants in planning and research, overcoming social
and cultural barriers, and examining the effects of social and economic policies on health outcomes. Attention to these requirements
has led to successful initiatives at both local and state levels. In Atlanta, for instance, a health center worked with immigrant
community leaders to implement the "promotores de salud" model. Used in Latin America to raise awareness among Latinas
about reproductive health, this model has reached 11,000 community members in Atlanta. As an example of the "Health in
All Policies" approach from the American Public Health Association, New Hampshire's health equity plan promotes broader
agency partnerships to address the social determinants of health and provides periodic report cards to help identify issues
that require follow-up action. The authors advise that immigrant and refugee voices should be at the center of local and national
discussions on community health. (Jasmina Popaja for The Immigrant Learning Center Public Education Institute)
Racial and Ethnic Disparities in Mental Health Care for Children and Young Adults: A National Study
International Journal of Health Services, August 12, 2016, 15 pp.
Authors: Lyndonna Marrast, David U. Himmelstein, &
This study finds that black and Latino children and young adults receive substantially less
outpatient mental health and substance abuse care than their non-minority counterparts, even when controlling for income and
health insurance status. About 5.7 percent of white children and young adults saw a mental health specialist in a single year,
compared with about 2.3 percent for black or Hispanic young people. The authors note that the prevalence of most psychiatric
conditions is similar for all three groups. Among reasons suggested by the authors for these treatment disparities are: the
stigmas associated with mental illness in some groups and the shortage of behavioral health specialists in minority communities.
The authors also suggest that the disparities in mental health treatment for blacks and Latinos lead to high rates of school
discipline, such as suspensions and expulsions, and higher incarceration rates. For example, blacks and Hispanics account
for 63 percent of children detained in juvenile facilities. "Prisons and jails," the authors argue, "have become
de facto mental institutions," and the consequences for families and communities have been devastating.
Integrating Health Literacy, Cultural Competence, and Language Access Services: Workshop Summary
National Academies, Health and Medicine Division, July 18, 2016, 96 pp.
Rapporteur: Joe Alper
"roundtable" discussion focused on important lessons, practical strategies, and opportunities for creating greater
integration of health literacy, cultural competence, and language access services in the healthcare system. Held on October
19, 2015, the workshop brought together a select group of leaders in these three fields, including academics, health care
administrators, and advocates. Sponsors of the event included various agencies with the U.S. Department of Health and Human
Services, as well as non-governmental organizations such as the Aetna Foundation and Eli Lilly and Company. In accordance
with the policies of the National Academies of Sciences, Engineering, and Medicine, the workshop did not attempt to reach
conclusions or make recommendations, but instead focused on the issues identified by the speakers and workshop participants.
An initial presentation by Dennis Andrulis, senior research scientist at the Texas Health Institute, was followed by a panel
discussion addressing two key questions: what are the key concepts in this area, and what three things have changed
over time to facilitate integration? Another panel featured presentations from four organizations that have made progress
in achieving this kind of integration: the National Committee for Quality Assurance, the California Pan-Ethnic Health
Network, the Robert Wood Johnson Foundation, and Hofstra North Shore - LIJ School of Medicine. Upon conclusion of these sessions,
three breakout groups in the areas of research, policy, and services/care were formed to discuss developments and needs in
Improving Cultural Competence to Reduce Health Disparities
Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, March, 2016, 91 pp +
Prepared by: Minnesota Evidence-based Practice Center
In furthering its mission to improve the
quality, safety, efficiency and effectiveness of health care in the U.S., AHRQ conducts systematic reviews of health care
research to determine its strengths, limitations, and usefulness to practitioners. This review analyzed over 37,000
English-language citations dealing with the provision of "culturally appropriate health care" for racial/ethnic
minority populations, people with disabilities, and LGBT populations. Fewer than 100 studies met the rigorous standards for
inclusion in the final report. However, none of the included studies measured the effect of cultural competence interventions
on health care disparities. Most of the training interventions measured changes in professional attitudes toward the population
of interest but did not measure the downstream effect of changing provider beliefs on the care delivered to patients."
The report concludes by suggesting a new model for research that substitutes a "relational" for an "attributional"
model, i.e. instead of focusing on the internal characteristics of groups (or "culture"), which may not apply to
all members of a particular group, practitioners are urged to examine "the devaluation and exclusion of these groups
within the broader society." Another possible term for this approach, according to the authors, might be "diversity
A ‘Healthy Immigrant Effect' or a ‘Sick Immigrant Effect'? Selection and Policies Matter,
Institute for the Study of Labor, September 22, 2015, 25 pp.
F. Constant et al
The "healthy immigrant effect" refers to research showing that immigrants to the
U.S. and other countries tend to be healthier than comparable native-born populations. In this study, the researchers attempt
to tease out the reasons for this phenomenon. Using data from the Survey of Health Aging and Retirement Europe (SHARE),
the researchers compare the health status of immigrants in 16 European countries with that of immigrants in Israel. Israel
provides an intriguing and "unique" case study, as it is the only country that does not screen Jewish immigrants
by education level or health status. The study shows that immigrants to Israel have only a "fair" health status,
compared to their counterparts in Europe who are rated as "good." Compared to native Israelis, immigrants
to Israel "have also been diagnosed with major diseases, have more medical symptoms and more mobility limitations, use
more prescriptions drugs, have a higher number of hospitalizations, have lower cognitive skills, and suffer more from eyesight
problems." The researchers provide evidence that "self-selection alone does not explain the healthy immigrant
effect." Rather, the migration policy of the immigrant-receiving country may have a powerful impact on the health
status of arriving immigrants.
Creating Conditions to Support Healthy People: State Policies that Affect the Health of Undocumented
Immigrants and their Families,
UC Global Health Institute, UCLA Blum center on Poverty and Health in Latin America, UCLA
Center for Health Policy Research, 2015, 22 pp.
Authors: Michael A. Rodríguez, Maria-Elena Young, & Steven
This study attempts to rank states according to their record in promoting the health of undocumented
immigrants. The authors consider five areas to be important "social determinants of health," which they define as
"the circumstances in which people are born, grow up, live, work, and age - and that impact immigrants' ability to live
healthy lives. " The five policy areas are: the availability of public health and welfare benefits, such as children's
health insurance, prenatal care, and eligibility for SNAP; access to higher education; labor and employment practices, such
as the inclusion of undocumented workers in workers' compensation laws; the availability of driver's licenses; and state legislation
limiting participation in the federal Secure Communities enforcement program. The states with the highest scores were California
(9), Illinois (7), Washington (4), Colorado (2), and Texas (2). The states with the lowest scores were Ohio (-7), West Virginia
(-6), Mississippi (-6), Indiana (-6), Arizona, (-6) and Alabama (-6).
Improving Cultural Competence: A Treatment Improvement Protocol
Substance Abuse and Mental Health Services Administration (SAMHSA), 2014, 329 pp.
With a mission to reduce
the impact of substance abuse and mental illness, SAMSHA produces Treatment Improvement Protocols (TIPs) to provide evidence-based
and best practice guidance to clinicians, program administrators, and payers. A panel of non-federal clinical researchers,
clinicians, program administrators, and patient advocates debates their particular area of expertise until they reach a consensus
on best practices. This particular TIP explores the importance of cultural competency in treating substance abuse and mental
illness. The first chapter defines cultural competence and the rationale for pursuing it. The second chapter covers behaviors
and skills for cultivating cultural competence as well as attitudes conducive to working effectively with diverse client populations.
The third chapter discusses interviewing skills, assessment practices, and treatment planning. The fourth chapter discusses
"top-down" organizational strategies for achieving cultural competency. The fifth chapter reviews cultural knowledge
specific to individual racial and ethnic groups; and the final chapter explores the concept of "drug culture."
Implementing CLAS Standards and Improving Cultural Competency and Language Access: A Practical
Arizona Health Disparities Center, 2014, 15 pp.
is designed to promote use of the National Standards for Culturally and Linguistically Appropriate Services in Health and
Health Care (CLAS Standards) developed by the Office of Minority Health. Originally published in 2000, the CLAS standards
were revised in 2013. The Toolkit includes a short history of the CLAS standards movement, the rationale for their use, as
well as a side-by-side comparison of the original and revised versions of the standards. The publication also provides links
to resources useful in implementing each of the 15 standards.
Responding to Culture: Beyond Cultural Competence Training,
Robert Wood Johnson Foundation, March, 2014, 14 pp.
While cultural competence
training for health care professionals may increase awareness of cultural differences and of the need to address disparities
in health outcomes, it is not enough to produce real results. This is one conclusion of a national program of the Robert Wood
Johnson Foundation that funded 33 organizations to examine intervention to reduce health disparities with particular focus
on diabetes, cardiovascular disease, and depression. Entitled "finding Answers: Disparities Research for Change,"
the program evaluated strategies used in a variety of health care settings to determine what works - and what does not - to
improve prevention and care. This report summarizes the main conclusions of this research and urges four broad "strategies
for considering culture" as an integral aspect of quality improvement in health care. First, gather as much information
about patients' culture through patient and community input; second, build interventions based on patients' culturally-based
values, preferences, and perceptions; third, create patient educational materials with images and language that resonate
with the target population; and fourth, ensure sustainability of the overall effort especially during periods of staff turnover
or changes in the patient population. The report includes many practical examples of these strategies in action.
The website of Finding Answers has descriptions of the funded projects, as well as summaries of the published research
produced by them.
Hispanic Community Health Study Data Book: A Report to the Communities
U.S. Dept. of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute,
September, 2013, 58 pp.
Described as "the largest health study of Hispanic/Latino populations in
the United States," this publication presents data from 16,415 Hispanic adults recruited from a random sample of
households in the Bronx, Chicago, Miami, and San Diego between 2008 and 2011. Participants were given the opportunity to self-identify
as Cuban, Dominican, Puerto Rican, Mexican, Central American, or South American and health measures were reported accordingly.
Participants were selected to be representative of the local population rather than the broader U.S. population. Although
almost 80 percent of participants were born in other countries or Puerto Rico, the data does not differentiate between native-born
and foreign-born Hispanics. The primary purpose of the study was to identify the factors "that may have a protective
or harmful role in the development of cardiovascular disease..." The study found that prediabetes, diabetes, and obesity
were "very common" among Hispanics, with one out of three participants with diabetes unaware of having the disease.
The study also examined the prevalence of hypertension, smoking, depression and anxiety, sleep problems, and hearing problems.
Lifestyle factors such as diet and physical activity were also examined.
The Affordable Care Act & Mixed-Status Families: Frequently Asked Questions (FAQs),
National Immigration Law Center (NILC), October, 2013, 7 pp
NILC answers sixteen FAQs about
how the Affordable Care Act (ACA) affects mixed-status families in the U.S. The report defines a mixed-status family as "a
household made up of individuals with different citizenship or immigration statuses." Many of these families are
unsure if and/or how they can access health insurance through the ACA without putting their undocumented family members at
risk. Under the ACA "only U.S. citizens and people who are ‘lawfully present'" are eligible for health insurance.
However, ineligible (i.e. undocumented) family members may complete an application on behalf of an eligible family member
without being required to reveal their immigration status and risk apprehension. "The ACA codifies longstanding federal
guidance, known as the Tri-Agency Guidance, which...ensure[s] that applications do not require unnecessary information from
nonapplicants, because these inquiries deter eligible people from securing benefits for which they may be eligible."
Therefore, any information provided on ACA applications, NILC advises, "will not be used by U.S. Immigration and
Customs Enforcement (ICE)." NILC also encourages family members to apply for Medicaid or CHIP on behalf of eligible family
Is the United States Bad for Children's Health? Risk and Resilience among Young Children of
Migration Policy Institute (MPI), July, 2013, 28 pp.
Authors: Jennifer Van Hook, Nancy Landale, & Marianne
The authors wrote this paper for a health policy symposium convened by MPI in January
of 2013. The goal of the symposium was to "frame the major policy and practice issues affecting children (birth through
age 10) with immigrant parents." As childhood health disparities are associated with delays in cognitive development
and poor integration outcomes later in life, an examination of the health status of these children may have important public
policy implications. This paper reviews the available research on health outcomes for immigrant children, with particular
focus on the children of Mexican immigrants, who experience greater health risks than most other children. Although
the so-called "epidemiological paradox," i.e. the lower prevalence of several health conditions, such as allergies,
asthma and learning disabilities, among the children of immigrants, is well-documented, new data is "paint(ing) a considerably
more nuanced picture," especially when you dig down to the level of national origin groups. Like other children with
immigrant parents, children of Mexican parents, particularly those from lower socio-economic backgrounds, show a lower incidence
of asthma; however, Mexican children with the disease are "highly disadvantaged in access to high-quality care for chronic
health conditions." Mexican children also have the highest prevalence of obesity among all racial/ethnic groups in the
U.S. The authors review four factors that help to explain the poor health outcomes of children of Mexican immigrants: limited
English proficiency of many parents, low socioeconomic status of many families, parental legal status, and the dispersion
of Mexican immigrants to new destinations where they may be viewed with resentment and suspicion. The authors conclude that
the fate of these children may "stand at a crossroads." As children of immigrants now make up almost one-quarter
of all children, "promoting the health of children in immigrant families will maximize the long-term well-being and productivity
of tomorrow's adults."
Health Care for Immigrant Families: Current Policies and Issues
Migration Policy Institute, June, 2013, 19 pp.
Authors: Leighton Ku & Mariellen Jewers
This report assesses how the current health care system in the U.S. addresses the health care
needs of immigrants. Debunking the myth that immigrants abuse health care services, the report finds that immigrants, even
when covered by public or private insurance, see doctors less frequently and use emergency rooms at a lower rate than the
native-born. Low-income, immigrant children with private insurance, for instance, were significantly less likely to visit
a doctor's office in 2010 than low-income, native-born children at 44 percent versus 69 percent. Similarly, only 17 percent
of publicly insured (Medicaid or Medicare), low-income, immigrant adults overall visited an emergency room versus 25 percent
of low-income, native-born adults. Among uninsured adults, the rate was six percent for immigrants and 14 percent of the native-born.
Although low levels of insurance coverage (both public and private) does in part account for low utilization of health care
by immigrants, there are other reasons as well, including language barriers, cultural differences, and worries over whether
utilization will lead to deportation or revocation of legal status. The authors recommend that federal and state governments
expand Medicaid access to legal permanent residents; support non-profit, community health centers; and increase access to
interpreters. (Denzil Mohammed)
Cultural Competence in Health Literacy Primer,
Maryland Office of Minority Health and Health Disparities & University of Maryland School of Public Health, March, 2013,
Authors: Monica McCann, Olivia Carter-Pokras, Bonnie Braun, & Carlessia A. Hussein
In 2012, Maryland enacted a law requiring attention to cultural competency and health literacy in the curricula
of health profession degree programs. This primer is intended to help health educators, students, and practicing health
professionals learn how to reduce health disparities and improve health outcomes through culturally-sensitive and effective
communication with patients across the various health disciplines. The primer is unique in merging the fields of health literacy
and cultural competence, which are usually treated separately and often compete for time in already tight curricula. The primer
consists of six modules of instruction: health disparities, community strategies, bias and stereotyping, effective communication
skills, use of interpreters, and self-reflection and culture of health professions. Within each module, learning objectives
are listed by type of competency (K = knowledge; S = skill; and A = attitude), as well as by learning stage (novice, intermediate,
and advanced). The primer is a work in progress. Revisions will be made as new resources are identified for specific learning
objectives and as existing resources undergo standardized review.
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health
Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice,
Office of Minority Health (OMH), U.S. Department of Health and Human Services, April, 2013, 191 pp.
developed by OMH in 2000, the national CLAS Standards have been widely circulated and implemented. In 2010, OMH launched a
project to update the Standards to reflect growth in the field of cultural competency and increasing diversity in the nation.
The new Standards emerged out of an extensive consultation process with stakeholders and experts, many of whom recommended
clarification as to the Standards' intention, terminology, and implementation strategies. The Standards now reflect a broader
and more inclusive definition of culture, encompassing racial/ethnic, linguistic, religious/spiritual, sociological, and biological
markers of difference. The Standards are also directed toward a broader audience than the original Standards, including policy
makers and legislators, accrediting and credentialing agencies, educators, and community-based organizations. The 15 standards
are grouped into three categories: (1) Governance, Leadership, and Workforce; (2) Communication and Language Assistance;
and (3) Engagement, Continuous Quality Improvement, and Accountability. This publication contains both the standards
and a "blueprint" for the implementation of each standard. The Blueprint explains the purpose and components
of each standard, along with model implementation practices and useful resources. The Standards themselves are also available
in a separate file.
Information on Small Populations with
Significant Health Disparities: A Report on Data Collected on the Health of Asian Americans in Massachusetts,
Institute for Asian American Studies,
University of Massachusetts (Boston), November, 2012, 48 pp.
Authors: Carolyn Wong, Hannah Hosotani, & John Her
How can data collection procedures be improved to capture information on Asian populations with significant health disparities?
Hoping that the State of Massachusetts might become a model for the country, the authors offer a number of recommendations
to public authorities and private health care organizations. One is to conduct health surveys in local communities where many
Asian Americans live. Another is to use categories that reflect "sensitivity to ordinary people's understandings"
of their primary identity, which may not be "Asian." Another is to use interviewers speaking the languages of Asian
populations, so that findings are not biased towards fluent English-speakers. And finally, academic researchers should partner
with community-based organizations, especially those working in low-wage Asian communities, to gain access to hard-to-reach
Maximizing Health Care Reform for New York's Immigrants,
New York Immigration Coalition, Empire Justice
Center, & NYS Health Foundation,
February, 2013, 41 pp.
This paper contains a set of recommendations
on how New York can maximize the inclusion of immigrants in health care reform. The authors also devote special attention
to immigrants left out of federal reform. The paper is divided into five major sections: eligibility of non-citizens to participate
in New York's Health Benefit Exchange; documentation and verification requirements; marketing and outreach to immigrant communities;
community input and monitoring; and maintaining safety net services for the residual uninsured population. In developing these
recommendations, researchers undertook a review of the literature; conducted in-depth interviews with stakeholders and experts;
and analyzed the experience of three early-adopter states: Massachusetts, California, and Maryland. The authors hope that
the report will serve as a "blueprint" for advocates in working with state and local government partners on health
care reform, and that "New York can pave the way nationally as a model of immigrant inclusion."
Promoting appropriate use of physicians' non-English language skills in clinical care: Recommendations for policymakers, organizations and clinicians,
American Medical Association, 2013, 18 pp.
Authors: Marsha Regenstein, Ellie Andres, &
Produced by the Commission to End Health Care Disparities, an umbrella group consisting of more
than 70 state and specialty medical societies, this report seeks to improve the quality of communication and care given by
bilingual physicians, who may have varying levels of ability in one or more non-English languages. While nearly nine
out of ten hospitals report using bilingual providers to treat limited English proficient (LEP) patients, very few evaluate
their competence in non-English languages in any careful and systematic way. As there are a number of groups in the
process of development assessment tools for this purpose, the Commission seeks to encourage these efforts and to capture the
consensus of stakeholders on effective strategies for reducing disparities in treatment and health outcome due to language
barriers. The report provides separate recommendations for clinicians, healthcare organizations, and policy makers. Among
the recommendations for policy makers are: creating tools to assess and improve use of clinicians' non-English language skills,
developing payment models to cover the cost of interpreter services, and collecting and recording patients' language needs
at initial point of service. Health care organizations are urged to provide training to staff on how to work with interpreters
and to bring interpreters into clinical care teams. Finally, the Commission encourages physicians to use their bilingual
skills with patients "whenever doing so is safe and effective." In order to make this determination, physicians
may wish to ask a trained interpreter "to audit a handful of patient encounters and provide feedback on the quality of
the communication." Finally, the Commission proposes a research agenda to clarify outstanding issues, including developing
and testing "affordable and accessible (language) assessment tools for bilingual physicians and other health professionals
providing care to patients with LEP." (Lorin Mordecai)
Discharge, Deportation, and Dangerous Journeys: A Study on the Practice of Medical Repatriation,
Center for Social Justice (Seton Hall Law School) & New York Lawyers for the Public Interest, December, 2012, 55
Authors: Pyo lee, Erica Sibley, Todd Tolin, & Sarah Vader Woud
This study reviews almost
1,000 cases of forced or coerced medical repatriation, defined as the decision of a hospital to return a critically injured
or ill immigrant patient back to his/her native country without consent. Often the quality of care available to these
patients is inferior, family members and support networks are missing, and patients suffer and die. According to the authors,
the frequency of such cases will likely increase under the Affordable Care Act by reducing the pool of Medicaid Disproportionate
Share Hospital (DSH) payments and by excluding an estimated 4.3 million undocumented immigrants from coverage. By tolerating
coerced repatriation, the United States is violating its obligations under international human rights agreements. Moreover,
hospitals are, in effect, preempting the authority of the federal government to deport individuals and denying them due process.
In addition, hospitals often fail to inform immigrant patients of the immigration consequences of repatriation, which may
include a 10-year bar on reentry to the United States. The report includes many case histories and provides a series of recommendations
to the U.S. Congress, HHS, the Department of State, hospitals, states, state courts, and community groups and advocates, designed
to prevent the proliferation of this practice.
Black and Immigrant: Exploring the Effects of Ethnicity and Foreign-Born Status on Infant Health,
Migration Policy Institute, September, 2012, 21 pp.
This study challenges earlier research suggesting
"superior" birth outcomes among immigrant mothers when compared to their native born counterparts. Most immigrant
birth-outcome studies were based on data derived primarily from Mexican immigrant mothers. Using 2000-2003 data from
the National Center for Health Statistics, this study compares the prenatal behaviors and birth outcomes (preterm birth, low
birth weight, and small for gestational age) of non-Hispanic Black immigrant mothers to those of non-Black immigrants and
both Black and non-Black US-born mothers. The findings indicate that Black foreign-born mothers show a slight health advantage
over Black US-born mothers, and the author suggests that lifestyle choices among Black immigrant mothers, such as lower rates
of smoking, may play a role in better birth outcomes when compared to their US-born counterparts. However, the author notes
a lower likelihood among foreign-born Black mothers of beginning prenatal care during the first trimester when compared across
all groups. The study also finds that the health advantages of Black immigrant mothers disappear when compared to most
non-black foreign-born mothers, mirroring the "infant-health gap observed among US-born Black and non-Hispanic white
mothers." The author suggests that these disparities have a wider implication for the health of the overall Black population
residing within the US, and calls for further research to investigate the "socioeconomic mechanisms" behind these
inequities. (Dan McNulty)
the Delivery of Health Care: Eliminating Health Disparities through a Culturally & Linguistically Centered Integrated
Health Care Approach: Consensus Statements and Recommendations,
Office of Minority Health (OMH) & Hogg Foundation for Mental health, June, 2012, 28 pp.
is the fourth in a series of OMH-sponsored reports addressing the mental health needs of underserved populations. This
report grew out of a two-day expert panel meeting in 2011 looking at "the integration of behavioral health and primary
care services for racial and ethnic minority populations and those with limited English proficiency." A companion
technical report reviewing the literature on integrated approaches was also prepared. Among the key elements of such
an integrated approach are: the deployment of an integrated care team, consisting of multi-disciplinary and cross-trained
practitioners in both physical health and behavioral health; use of a single patient health and behavioral health history;
and development of unified treatment plan. The report recommends specific strategies to enhance cultural and linguistic competence
at the individual, community, practice, system, and workforce levels.These strategies are illustrated with examples of how
specific organizations have utilized these strategies in real world settings.
Community-Defined Solutions for Latino Mental Health Care Disparities,
UC Davis Center for Reducing Health Disparities, 2012, 79 pp.
In order to reduce mental
health disparities in minority populations, the California Department of Mental Health (Office of Multicultural Services)
launched the California Reducing Disparities Project, which established five Strategic Planning Workgroups (SPWs) to study
the following populations: African Americans, Asian/Pacific Islanders, Latinos, LGBTQ, and Native Americans. Funding for the
project was provided by Proposition 63, better known as the Mental Health Services Act, passed by the California voters in
2004. With staff support provided by the UC Davis Center, the 15-member Latino SPW got off the ground in 2009, quickly followed
by the creation of a stakeholder group called the California Latino Mental Health Concilio. The goal of the project
was to identify "community-defined, strength-based promising practices, models, resources, and approaches that may be
used as strategies to reduce disparities in mental health." The report's conclusions were shaped by input from
more than 550 Latinos who participated in community forums conducted in 13 cities and two high schools throughout the state.
According to the authors, this study is "the first of its kind to use a community-based, grassroots approach to identify
barriers and seek solutions to mental health care needs in historically unserved or underserved Latino communities."
Stressors associated with immigration, undocumented status, and poverty receive considerable attention in the study.
Based on evidence gathered from community informants and a literature review, the study recommends six "core strategies"
and seven "strategic directions" for adoption by stakeholders. The study concludes with capsule summaries of 16
programs in California that satisfy its seven-point criteria for being listed as promising in nature.
Health Care and the Illegal Immigrant,
Georgetown University Law Center, March, 2012, 60 pp.
Seeking to "steer a middle
course between the rhetorical extremes of the health care and immigration debates," the author of this article, Patrick
J. Glen, examines two questions in depth: first, whether unauthorized immigrants have a legal or constitutional
claim to health benefits when they lack status in a country; and second, whether there are compelling economic and public
health reasons for providing such benefits. The first section of the article discusses constitutional precedents relevant
to the legal question both in the Canadian and U.S. contexts, including a lengthy discussion of the 2010 Toussaintdecision
by the Canadian Federal Court barring an unauthorized immigrant from accessing the Canadian health care system. The author
concludes that deference to the authority of legislatures to set limits on alien access to benefits is a precedent that will
be hard to overturn. However, "under the U.S. Constitution and Canadian Charter no provision mandates that public coverage
be extended to illegal immigrants, but nothing forbids that choice as a matter of policy." And here the author
feels there are persuasive arguments for providing coverage, including the counterintuitive idea that such coverage would
actually lower costs to the overall healthcare system. Unauthorized immigrants, who are relatively healthier and younger than
the general population, would increase the risk pool for insurance, thereby helping to subsidize the sick. Moreover, by using
more preventive services, unauthorized immigrants would drive down the cost of more expensive emergency room and acute care
services. Finally, the author suggests that extending health care benefits to this population would contribute to public health
generally by allowing all people to have access to primary care, thereby reducing the threat of infection and contagious disease.
Language Proficiency and Health Status: Are Bilingual Immigrants Healthier?
(Article available by subscription only), Stanford University and Rice University, March, 2012, 36 pp.
in English fluency are often associated with progress in acculturation and improved health for immigrant populations in the
United States. However, as English fluency increases, native language fluency may decrease, producing possible negative
effects on both physical and mental health. This article seeks to examine the effect of both English and native language
fluency, or simultaneously maintaining native language fluency while increasing English language fluency, on self-rated physical
and mental health for immigrant populations. The authors examine the effect of language proficiency while controlling
for mediating variables such as socioeconomic status, family and social supports, stress, discrimination, age at migration,
and country of origin. Findings indicate that those who are bilingual, or proficient in both their native and English
languages, report better health on both physical and mental health self-rated scales, as compared to those who are native
language dominant or English language dominant. These findings are consistent with other studies on biculturalism, that
indicate that those who simultaneously maintain strong ethnic identities while also acculturating into their host society
show improved psychosocial well-being. (Patricia Lundgren)
Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language,
and Disability Status,
U.S. Department of Health and Human Services (HHS), Office
of Minority Health, October, 2011, 10 pp.
After a careful review, with more than 400 public comments on
draft standards, HHS adopted final data standards for race, ethnicity, sex, primary language and disability status. The new
standards permit the collection and analysis of data about ethnic groups within the broader Hispanic, Asian, and Pacific
Islander populations. The standards are designed to reveal disparities in health status among people in specific groups, whose
conditions are often masked in current data collection practices, and to facilitate the development of targeted interventions
to reduce these disparities. The new standards were required under Section 4302 of the Affordable Care Act.
Addressing Health Disparities and Health Literacy Challenges in the South Asian Community:
Conference (October 9, 2010) Summary Report and Recommendations
South Asian Total Health Initiative, UMDNJ, and other sponsors, June, 2011, 28 pp.
This report provides detailed
summaries of all conference plenary and workshop sessions. The conference drew 126 participants, including 28 faculty members.
Plenary sessions dealt with the meaning and significance of health literacy in multicultural communities, the state of current
research on the subject of health disparities in South Asian communities, and innovative models for reaching these communities.
Three workshops focused on health disparities in diabetes, cancer, and tuberculosis. Another three workshops discussed innovative
strategies to address health disparities, including complementary and alternative medicine, chronic disease management, and
the development of multimedia solutions for health promotion. The report concludes with a series of recommendations relating
to policy planning and resource development, data collection and research, community education and professional training,
and networking and partnerships.
Assuring Health Equity for Minority Persons with Disabilities: A Statement of Principles and
U.S. Dept. of Health and Human Services Advisory Committee on Minority Health
(ACMH), July, 2011, 17 pp
This is the third in a series of reports by ACMH designed to ensure that health care
reform responds to the needs of vulnerable populations. While people with disabilities experience worse health outcomes
than the general population, the report finds that "minorities with disabilities are doubly burdened by their minority
status." The report makes five recommendations: first, raise awareness about the health inequities experiences by persons
with disabilities, especially minorities; second, improve care and treatment by devoting attention to "the
culturally specific differences among people with disabilities, and among subgroups of that population;" third,
require cultural competency for all health care providers and professionals; fourth, improve research and practice on
disabilities in minority populations; and fifth, strengthen the health care workforce to ensure high quality care for people
Educating Clinicians About Cultural Competence and Disparities in Health and Health Care (Abstract
Journal of Continuing Education in the Health Professions, 2011, 12 pp.
Authored by Robert C. Like,
Professor and Director of the Center for Healthy Families and Cultural Diversity, UMDNJ, this paper outlines the role that
the continuing medical education (CME) profession can play in reducing disparities in service access and health outcomes.
The paper reviews CME initiatives in cultural competency around the country, discusses the reaction of medical professionals
to them, and makes a series of thoughtful recommendations to improve their effectiveness. Among these recommendations are
the development of "a new type of ‘participatory CME' through active engagement and collaboration with patients,
consumers, and advocates as the ‘faculty experts'..." and greater use of social media to facilitate on-going communication
on cultural competency among medical professionals.
National Standards for Healthcare Interpreter Training Programs,
on Interpreting in Health Care, April, 2011, 38 pp.
The publication of these standards culminates a two-year
process, involving a review of existing training curricula, consultation with an expert advisory committee, the convening
of ten focus groups, and online surveys seeking feedback on draft standards. The standards are intended to apply to
all preparatory training programs regardless of their duration or sponsorship. They cover core content to be mastered before
an aspiring interpreter begins professional work in the field. More demanding areas of healthcare interpreting, such
as proficiency in simultaneous interpreting, are omitted from the standards because they may be addressed in advanced training.
In addition to content standards in such areas as modes of interpreting, message conversation, and interpreting ethics,
the document also outlines a set of recommended instructional strategies, as well as guidelines for program design and
operation. The Council recommends some flexibility in implementing the standards for speakers of "languages of
National Immigration Policy and Access to Health Care: A Position Paper,
American College of Physicians (ACP), 2011, 18 pp.
ethics and mindful of legal requirements under EMTALA (Emergency Treatment and Active Labor Act), the ACP -- the nation's
largest medical specialty society representing 130,000 internists -- developed this position paper to voice concerns over
"unsustainable" policies limiting immigrant access to health care. The College, for example, opposes provisions
of the Affordable Care Act barring undocumented immigrants from paying out-of-pocket for health insurance coverage. The College
also opposes any effort to require physicians to report on the legal status of their patients. The College also laments the
low levels of insurance coverage for the U.S. born children of immigrants, many of whose parents refrain from seeking coverage
for their children out of fear of possible deportation. Another issue of concern to ACP is the absence of testing for communicable
diseases, and low levels of vaccinations, among undocumented immigrants - gaps in the health care system that threaten the
health status of all Americans. Finally, ACP urges the federal government to strengthen the network of safety-net health
care facilities around the country that provide primary care for the poor and uninsured.
The Health of the Newest New Jerseyans: A Resource Guide,
Center for Health Statistics, Office of Policy & Strategic Planning,
NJ Dept. of Health and Senior Services, February, 2011, 72 pp.
This report provides detailed information on
the health status of foreign-born residents of New Jersey. With the exception of infectious disease and HIV/AIDS, where nativity
data is lacking, the report covers a wide array of illnesses, such as heart disease, stroke, diabetes, and cancer, and provides
incidence data both by race/ethnicity and by nativity. Most comparisons are between native-born and foreign-born in
broad racial/ethnic categories, i.e. Black, White, Hispanic, and Asian. Health outcomes for specific national groups are not
given, even though the report notes that "each foreign-born group comes to the U.S. with its own health advantages and
health disadvantages." In general, "overall health outcomes for the foreign-born for many leading causes of mortality
and morbidity are quite favorable." However, the longer the period of residence in the United States, the more
the foreign-born appear to resemble the native-born. "As time spent in the United States increases, nativity differences
in health diminish."
Culturally Effective Care ToolkitAdvancing Effective Communication, Cultural Competence,
and Patient-and Family-Centered Care: A Roadmap for Hospitals,
American Academy of Pediatrics, 2011, 22 pp.
The Academy describes this publication as
a "practical, hands-on resource to help practicing pediatricians and their office staff provide culturally effective
care to their patients and families." The toolkit provides short summaries of key issues, such as health beliefs
and practices, nutritional questions, child development and mental health norms, interpretive services, and health literacy.
The toolkit includes a selected listing of supplemental tools and resources in each area.
The Joint Commission, August, 2010, 93 pp
This report culminates a multi-year project of The Joint Commission to develop new accreditation
standards for hospitals for addressing the language and communication needs of diverse patient populations. This publication
provides guidance to hospitals in complying with the new standards. Each of six chapters covers a separate component on the
continuum of care: admission, assessment, treatment, end-of-life care, discharge and transfer, and organizational readiness.
The report urges hospitals to "embed effective communication, cultural competence, and patient- and family-centered care
practices into (their) core activities," rather than viewing them as stand-alone initiatives. Copies of the old and new
standards are included in the appendices to the publication, along with explanations as to why particular standards were revised.
The new standards were approved in December 2009 and released to the field in January 2010. They will be published in the
2011 hospital accreditation manual, initiating a pilot implementation phase. Full implementation is expected to occur in 2012.
A System of Care Team Guide to Implementing Cultural and Linguistic Competence(CLC),
Technical Assistance Partnership for Child and Family Mental Health, July, 2010, 14 pp.
offers practical suggestions as to how local communities can organize to deliver culturally and linguistically competent mental
health care. It discusses the role and compensation of the CLC Coordinator; budgeting suggestions for CLC; the
role of the CLC committee; the importance of the CLC plan; and examples of how all staff members and community partners
can contribute to the goal of CLC. The Guide provides links to many tools and templates, including a sample CLC coordinator
position description, suggested hiring tips, and a CLC budget spreadsheet. The Partnership operates under contract with the
federal Child, Adolescent and Family Branch, Center for Mental Health Services (SAMHSA), U.S. Dept. of Health and Human
The High Costs of Language Barriers in Medical Malpractice,
National Health Law Program & School of Public Health, University of California, Berkeley, 2010,
This study analyzed 35 closed claims of medical malpractice based on inadequate language assistance.
The claims were against a single insurer operating in four states in the West. All claims were adjudicated between 2005
and 2009. Major themes in the cases included the following: "failure to provide competent oral interpretation; failure
to provide written translations of important documents, e.g. informed consent forms and discharge instructions; inadequate
documentation; and allegations of discrimination." The insurance carrier paid out over $5 million in damages, settlements,
and legal fees on the 35 cases.
What's in a Word? A Guide to Understanding Interpreting and Translation in Health Care,
National Health Law Program in cooperation with NCIHC and ATA, April, 2010, 27 pp.
guide is designed to clarify the differences and commonalities between interpreting and translation, to identify the skill
sets required for each, to identify standards of practice, to review progress towards national certification, to define the
role and functions of the interpreter and translator, and to summarize the modes and methods of interpreting and translation.
A final section of the guide discusses procedures for hiring interpreters and translators.
Confronting Inequities in Latino Health Care, Special Issue of the Journal of General Internal Medicine,
Abstracts and links to in-depth news releases on each article, October, 2009, 4 pp.
An important theme of this series of articles is that the country
of birth and immigration status of Latinos affect the quality of health care they receive in the U.S. The nine studies examine
topics such as rates of hypertension, diabetes, health insurance coverage, discrimination, quality of care, and spiritual
beliefs. Predictably, lack of insurance and undocumented status are associated with poor health outcomes. The authors argue
for attention to the needs of the Latino population in the current health care reform debate.
Moving to the Land of Milk and Cookies: Obesity among the Children of Immigrants,
Migration Policy Institute, Sept., 2009, 8 pp
Based on a federal longitudinal study of
21,000 children from kindergarten to 8th grade, 25% of whom were children of immigrants, this study concludes that
children of immigrants are a high-risk group for obesity, and that poverty doesn’t fully explain their vulnerability.
Obesity cuts across all socio-economic levels, but tends to be higher among boys, Hispanics, and non-Hispanic whites. By 8th
grade, 49% of immigrant boys were obese or overweight, compared to 33% of native-born. The authors speculate as to causes,
e.g. "many immigrants originate from countries in which food insecurity and stunting pose significant health risks to
children, so they may be unaccustomed to protecting children from the opposite problem that comes from overeating."
The Health and Cognitive Growth of Latino Toddlers: At Risk or Immigrant Paradox?
Bruce Fuller et al, Maternal and Child Health Journal, June 25,
2009, 14 pp.
Looking primarily at Mexican immigrant mothers, most living in households earning $25,000 or less
annually and with limited educational backgrounds, the authors of this study explore the causes and consequences of "the
immigrant paradox," i.e. the fact that Mexican and other Latino immigrant newborns display robust birth weight and low
mortality compared to whites and African-Americans. The study finds that these early advantages do not persist over
time. Instead, these children at 24 months of age display higher rates of obesity and asthma and lagging cognitive development.
These results have important implications for federal policy makers interested in designing effective intervention strategies.
State Practices in Health Coverage for Immigrants: A Report for New Jersey,
Rutgers Center for State Health Policy, June, 2009, 29 pp.
report surveys the landscape of health coverage for immigrants in New Jersey. Although New Jersey provides more public coverage
and safety net programs for immigrants than most other states, New Jersey appears to lag behind other states with large immigrant
populations in its outreach and enrollment success. The report contains descriptions of outreach strategies employed in California,
Illinois, Massachusetts, and New York, and concludes that "culturally-attuned outreach efforts and improved enrollment
processes" will be "critical factors in the success of any public program to cover immigrants and their children."
An earlier CSHP reportprovided esimates of children and parents without health insurance in New Jersey, including non-citizens.
NJ FamilyCare Outreach, Enrollment and Retention Report,
Submitted by the Outreach, Enrollment and Retention Working Group in Response
to the New Jersey Health Care Reform Act of 2008, NJ Office of the Child Advocate, May, 2009, 32 pp + appendices
under a provision of the NJ Health Care Reform Act of 2008, this Working Group was charged with developing a plan to improve
outreach to low and moderate income families eligible to participate in NJ FamilyCare. One of the subcommittees of the Working
Group examined the challenge of "Overcoming Barriers to Immigrant and Minority Access" (OBIMA).
The report contains numerous recommendations, either building on existing initiatives or employing new approaches based on successful
outreach strategies used in other states. The report also emphasizes collaboration among various departments of state government, such
as the Department of Education which tracks the location of limited English proficient students in local school
districts, and urges expanded use of incentives to community-based organizations to enroll uninsured individuals.
Improving Access to Language Services in Health Care: A Look at National and State Efforts,
Policy Brief, Mathematica Policy Research, Inc., April, 2009, 10 pp.
policy brief focuses on the three states that have been most active in legislating access to language services in health care:
California, Minnesota, and New York. The authors discuss the history and scope of various legislative initiatives in those
states. They also identify key challenges facing states and stakeholders seeking to develop language services, including setting
up information technology systems to support the collection and management of data on primary language, promoting appropriate
use of language services by clinical staff, ensuring the quality of language services, and developing payment mechanisms for
The State of Asian American, Native Hawaiian and Pacific Islander Health in California Report,
A report from the California Asian Pacific
Islander Joint Legislative Caucus, Prepared by the University of California Asian American Pacific Islander Policy Multi-Campus
Research Program, Health Work Group, April, 2009, 67 pp.
By disaggregating California's Asian American Pacific
Islander group, comprising over 14% of the state's population, into some of its many ethnic sub-groups, and investigating
the health characteristics of each group, this report sheds important light on the health needs of particular communities
and appropriate policy responses to those needs. Koreans and Vietnamese, for example, have uninsured rates higher than the
state average. Filipinos have high obesity and smoking rates. Childhood asthma rates are highest among South Asians. Vietnamese
experience mental distress at higher rates than other groups. The authors urge further efforts to disaggregate other communities,
particularly the South Asian category, into Indian, Pakistani, Bangladeshi and Sri Lankan sub-groups.
More than Words Toolkit Series,
series of 7 short publications outline the requirements for effective document translation, a process often approached haphazardly
and without full understanding of its complexity. Tool One (Getting Started with Translations in Health Care) lays out the basic
steps in the process, cautions against use of unqualified bilingual staff as translators, and emphasizes the importance of
document meaning, context and purpose, as opposed to "word-for-word replacement operations." Tool Three (Developing the Translation Brief: Why and How) describes how to provide formal instructions
for the translator, based in part on an analysis of potential "source culture bias" in the original document. Tool Six (Assessing Translation - A Manual for Requesters) outlines a tested procedure for
evaluating the quality of translations.
A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency,
National Quality Forum, April, 2009, Public Version, 11 pp.
an attempt to "bring the cultural competency movement to the next level," the National Quality Forum (NQF), a broad-based
coalition of stakeholders in the healthcare industry dedicated to the definition and measurement of quality care, has produced
this "comprehensive framework – a road map – for measuring and reporting cultural competency." The framework
consists of four guiding principles, and 45 endorsed practices within seven domains: leadership, integration into management
systems and operations, patient-provider communication, care delivery and supporting mechanisms, workforce diversity and training,
community engagement, and data collection. The framework is intended for all healthcare organizations, but has applicability
to the broader human service field. The significance of this document is that NQF standards become the primary standards used
to measure the quality of healthcare in the United States. Full report is available by purchase only.
Webinars on Language Access in Health Care,
Polyglot Systems, 2008-2009.
A for-profit language technology provider for health care organizations, Polyglot Systems has produced a series
of five free webinars on the subject of language access for hospital patients. Each webinar features national experts in the
field. Among the topics covered are: language and cultural barriers in health care: a growing crisis (September 18,
2008), leveraging data to improve the quality and availability of language services (November 18, 2008), using technology
to improve language access (December 9, 2008), the Prolingua platform for hospital admissions and patient instructions (January
9, 2009), and funding sources for language services (April 1, 2009).
Undocumented Immigrants in New Jersey's State and County Psychiatric Hospitals,
New Jersey Department of the Public Advocate, February, 2009, 11 pp.
This report examines the plight of 55 undocumented immigrants in state psychiatric hospitals,
deemed medically ready for release into less costly residential health care facilities but who cannot be placed into such
facilities because of their lack of eligibility for federal benefits. In some instances, patients were in (or eligible for)
legal status at one time, but lacked the capacity to file the necessary legal papers. Among the recommendation in this report
are the assignment of staff to work exclusively with this population and the possible establishment of a state-funded community
placement option for such patients, which might prove more cost effective than prolonged hospital stays.
Robert Like, MD, et al, "Educating Physicians to Provide Culturally
Competent, Patient-Centered Care,"
Perspectives (New Jersey Association of Family Physicians), Summer, 2008, 11 pp.
In 2005, the New Jersey legislature
passed a law requiring all physicians to complete cultural competency training as a condition of re-licensure and mandating
the inclusion of such training in the curriculum of New Jersey medical schools. This article reviews the requirements of the
law, as well as related legislation elsewhere in the United States One of the six required New Jersey training areas
deals with techniques for overcoming language barriers, including best practices in working with interpreters. The article
features a extensive listing of web-based continuing education and professional development courses in cultural competence
in health care.
Cultural and Linguistic Competence Implementation Guide,
Technical Assistance Partnership for Child and Family Mental Health, January, 2008, 116 pp.
this Guide, the Child, Adolescent and Family Branch of the Center for Mental Health Services (SAMHSA) noted that the mental
health field "has changed little" since the 1989 release of Towards a Culturally Competent System of Care,
and that "there is still only limited understanding of how to operationalize cultural competence." The Guide is
organized around six domains: governance and organizational structure; services and supports; planning and continuous
quality improvements; collaboration; communication; and workforce development. Within each domain, the Guide provides specific
implementation strategies and related performance indicators, along with examples of best practices in the field. The major
premise of this Guide is that Cultural and Linguistic Competence (CLC) must be infused through every aspect of the mental
health system of care. "This requires transformation at the policy, administrative, practice, and consumer levels of
Based on research conducted at 60 hospitals in the United States, this report recommends
a common planning framework to address the growing linguistic and cultural diversity of hospital patients. The report
argues that planning must be on-going and that solutions must be tailored to the needs and circumstances of individual hospitals.
Serving Patients with Limited English Proficiency: Results of a Community Health Center
National Association of Community
Health Centers (NACHC), June 16, 2008, 19 pp.
Representing over 1,150 community
health centers in the United States, NACHC undertook a survey of its membership to determine the extent to which limited English
proficient patients are served by local centers and the range of techniques used to bridge the language gap. Among other things,
the report found that one in every three patients seen in local centers is LEP, and that 74% of centers use bilingual
nonclinical staff, 59% use bilingual clinical staff, 47% use staff interpreters, 27% use telephonic and/or video services,
and 15% use external language agencies.
Hospitals, Language, and Culture: A Snapshot of the Nation,
The Joint Commission, 2007, 107 pp.
report analyzes how 60 selected hospitals around the country are providing health care to culturally and linguistically
diverse patients and offers recommendations for improving hospital responsiveness to this patient population.
Language Services Resource Guide for Health Care Providers,
National Health Law Program, October,
2006, 186 pp.
This useful guide contains state-by-state listings of language service
associations, providers, and trainers. It also includes a directory of web-based health information resources in foreign languages.
Other sections cover assessment tools and signage.
Certification of Health Care Interpreters in the United States: A Primer, a Status Report and
Considerations for National Certification,
The California Endowment, September,
2006, 95 pp.
Author Cynthia E. Road compares and contrasts nine different existing
certification programs for health care interpreters, as well as the eight state certification programs that were in various
stages of development at the time of publication. She also explains the various strategies for providing quality assurance
in interpreting, of which certification (assessment) is only one part. These strategies include appropriate recruiting, language
screening, training, monitoring, and continuing education.
Globalization, Migration Health, and Educational Preparation for Transnational Medical Encounters,
Peter H. Koehn, Global Health 2006 2:2
This article argues for a new paradigm in medical training called
“transnational competence (TC).” Noting that more than 700 million people cross international borders every
year, whether as visitors, businesspersons, or immigrants, the author argues that the quality of health care, as well as the
success of disease prevention efforts, hinge on the ability to identify “ the special circumstances that surround and
define each individual’s health.” According to the author, TC as a model is preferable to traditional
culture-competence education, which tends to reify cultural characteristics within particular groups, ignoring intra-group
variations, as well as differences of class, generation, experience, and education. The author proposes a far-reaching
set of reforms in medical school education designed to prepare a new generation of medical students for “ethnically
and socially discordant clinical encounters.”
The Interpreter's World Tour: An Environmental Scan of Standards of Practice for Interpreters,
Publication of The California Endowment
for the National Council on Interpreting in Health Care, March, 2005, 44 pp.
As part of an effort to draft a national code of ethics for interpreters in health care, this project reviewed
145 standards documents in 11 languages from 25 countries, including 36 U.S. states. The scan was inclusive of all fields
of interpreting. The scan uncovered both similarities and contradictions in these documents.
Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker
Center for Cultural Competence, Georgetown University Center for Child and Human Development, Spring/Summer 2004, 39 pp.
Defining cultural brokering as "the act of bridging, linking, or mediating between
groups or persons of different cultural backgrounds for the purpose of reducing conflict or producing change," this report
spells out the four primary functions of cultural brokers (liaisons, cultural guides, mediators, and catalysts for change) and
the many contexts in which they work. Most cultural brokers assume multiple roles and may not work exclusively as cultural
brokers. Cultural brokers, for example, may be health care professionals, social workers, or community members. They may work
at community health centers, hospitals, government offices, community-based organizations, or religious institutions. The
report features numerous case examples of successful cultural brokering initiatives. The authors also see cultural brokering
as an "essential" to the reduction of health disparities for racial and ethnic populations.
Language Access: Helping Non-English Speakers Navigate Health and Human Services, National Standards for Culturally and Linguistically Appropriate Services in Health Care,
National Conference of State Legislatures, January, 2003, 24
As the U.S. population has become more diverse, language has emerged as a critical
factor in health care access and quality. This report indicates that the language gap can lead to delays in or denial of service,
unnecessary tests, more costly or invasive treatment of disease, racial or ethnic disparities in insurance, and other problems.
The report surveys the demographic landscape and current governmental efforts to address language access, focusing on four
states that are using federal matching payments from Medicaid and SCHIP to pay for language interpretation. The report also
outlines "next step" options for states and the federal government.
Final Report, Office of Minority Health, U.S. Dept. of Health and Human Services, March, 2001, 132 pp.
1997, the Office of Minority Health (OMH) began a study and consultation process leading to the publication of this standard-setting
document four years later. A prime motivation for this project was widespread dissatisfaction with the earlier
patchwork of standards that often left health care providers without clear guidance as to what constitutes culturally and
linguistically appropriate services (CLAS). OMH consulted with numerous stakeholders in the field, and after publication of
draft standards in the Federal Register, received comments from 413 individuals and organizations. The standards were published
in final form in 2000. The 14 standards are organized by themes: Culturally Competent Care (1-3), Language Access Services
(4-7), and Organizational Support for Cultural Competence (8-14). Part II of the Report discusses each standard in detail,
covering intent, supportive research, and implementation issues.