Hide Notes 

Slide 1: Analysis of Needs and Barriers to Health Care Delivery for Immigrants in the USA LUCINA M. VENDER NURSING 501 FEBRUARY 2010
Slide 2: #1-Introduction: The Impact and Implications of Health Care Disparity • The USA is a highly advanced country educationally, • • • • • industrially, and in medical technologies Despite tightening of borders the flow of immigrants continues Communities are unprepared to accept this influx from multiple perspectives including health care delivery Disparities exist and are continuous and persistent and for some groups widening including immigrants The current national debate creates opportunity to highlight the positive and address the negative aspect of USA health policy As the largest group of health care providers the nursing community must assume a leadership role (Bolton, 2004, Ann Rev Nurs Res, p. 40 & Porter, 2004, Ann Rev Nurs Res, p. 54)
Slide 3: #2- Objectives: Immigrant Health Care Delivery  Identify and define “At Risk-Vulnerable” populations  Identify scope of issues  Identify relevant barriers  Discuss potential solutions and recommendations  Expand upon the role of nursing in facilitating health care delivery improvements
Slide 4: #3- Background Information: Key Issues • Expanding immigrant population • Diversity of ethnic backgrounds • Existing health care disparities in delivery • Multitude of contributing factors or barriers – Individual related Issues – Provider related Issues – System related Issues • Controversies in relation to equity • Nursing advocacy and position statements
Slide 5: #4- At Risk or Vulnerable Populations  Those individuals less likely to obtain appropriate quantity and quality of medical care  Any group of people whose health care needs exceeds the average and who are at greater risk (than the average person) for poor health status or reduced health care access (Pauly, 2007, Health Affairs, p. 1305 & Ferguson, 2007, Health Affairs, p. 1358 & Villarruel, 2004, Ann Rev Nurs Res, p.1)
Slide 6: #5- Expanding and Diverse Immigrant Population • 40-50 million current immigrants in USA • 6-8 million “undocumented (lacking written record)” illegal immigrant – – Entered USA Illegally or Surreptitiously Entered USA Legally but Stayed Beyond VISA Retrictions • Undocumented immigrants concentrated in 6 states: California/Texas/Florida/New York/New Jersey/Illinois • 5 largest ethnic groups: Mexican/Chinese/Filipino/Indian/Cuban • Among “Greatest Risk” for health care disparities: undocumented Immigrants (Guttmacher, 1984, J Health Polit Policy Law, p. 504 & Dwyer, 2004, Hastings Center, p. 35 & Kandula, 2004, Ann Rev Public Health, p. 359 & Messias, 2004, Ann Rev Nurs Res, p. 123)
Slide 7: #6- Immigrant Population Existent Health Care Disparities • “Disparities” = inequality or inequities signified by • • • • differences in environment, utilization, quality of care, health status or particular health outcome. 2001 Hispanics and Asians ↑ Cerebral Hemorrhage 2002 Hispanics less likely to undergo cancer screening (Cervical, Breast, Colon) 2002 80% Latinos children did not receive needed mental health services for ↑ incidence suicidal thoughts and depression 2002 Hispanics less likely to receive hypertension or cholesterol lowering therapies (Bolton, 2004, Ann Rev Nurs Res, p. 45,47,50 & Yeo, 2004, Ann Rev Nurs Res, p. 66)
Slide 8: #7- Immigrant Health “Paradox” • Current predicted longevity per country – Females Japan #1 (82.9yrs) : USA # 19 (78.9yrs) – Males Japan #1 (76.4yrs) : USA # 25 (72.5yrs) • Some immigrants enjoy superior health based upon certain genetic determined tendencies and healthy cultural behaviors • Over time “acculturation” occurs and eventually immigrant health status tends to converge with general USA population (www.healthypeople.gov & Kandula, 2004, Ann Rev Pub Health, p. 357-8 & Mendoza, 2009, Pediatrics, p. 5188)
Slide 9: #8- Immigrant Health Care Delivery DisparitiesFactors • Lack of health insurance is the most powerful predictor of poor health outcomes • Lack of health insurance is NOT the only factor: Census of Immigrant Children in 2004 – – – 14.5 % : Privately Insured 31.9 % : Publically Insured 53.7 % : Uninsured In addition, undocumented immigrants face low income, overcrowding, poor sanitation, alienation, poor diets, high stress • Concept: vast majority of undocumented immigrants eventually STAY in USA so there exist “prudential” reasons to optimize their overall health • Concept: issue of “entitlement” or “moral obligation” • (Pati, 2008, Am J Pub Health, p. 2007 & Viadeck, 2007, Health Affairs, p. 1233 & Guttmacher, 1984, Health Polit Policy Law, p. 506 & Bloche, 2007, Health Affiars, p.1317 & Nickel, 1986, Hastings Center Rep, 20 & Villaurrel, 2004, Ann Rev Nurs Res, p. 1233)
Slide 10: #9-Contributing Factors or Barriers to Immigrant Health Care Delivery • Patient-related “needs” component: influenced primarily by the acute heath care Need/Disease/Illness • 90% undocumented immigrant health care delivery is for an acute emergency – – Emergency Department Visits Hospitalizations • De-emphasis upon community health priorities of prevention, screening, early detection, sanitation (Smith, 2001, J of Community Health Nursing, p. 55)
Slide 11: #10-Barriers to Immigrant Health Care Delivery: Patient Variables • General: demographics; socioeconomic; preferences individual or cultural; knowledge of resources, awareness of needs; cultural beliefs and values; language barriers; distrust of western medicine; reliance upon “underground” care providers; money; lack of social support network • Undocumented immigrants: fear of discovery and deportation (Kuo, 2001, Research of Aging, p. 15 & Kullgren, 2003, Am J Pub Health, p. 1630)
Slide 12: #11- Barriers to Immigrant Health Care Delivery: Provider and Systems  Provider variables: racism; discrimination; stereotyping; biases; cultural incompetency, especially language; lack of monetary gain; inadequate education and preparation; lack of sensitivity  Systems variables: proximity; availability; facilities; resources; equipment; equity (Ibrahim, 2003, Am J Pub Health, p. 1619)
Slide 13: #12-Professional Organizations Position Statements • HealthyPeople 2010 and 2020: 1) Increase life expectancy and 2) eliminating health disparities by reducing the disease burden in groups with unfavorable rates • American Nursing Association: strong supporter and advocate for health policy that includes “Right to Access Quality Health Care By All Persons” • Institutes of Medicine: “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” • Nursing Code of Ethics: “the nurse in all professional relationships practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by consideration of social or economic status, personal attributes, or the nature of health problem.” www.nursingworld.org/ethics/ecode.htm (www.healthypeople.gov & Smith, 2001, J Comm Health Nurs, p. 61 & Villaurruel, 2004, Ann Rev Nurs Res, p. 2)
Slide 14: #13- Benefits of Resolving Immigrant Health Care Delivery Disparities • To immigrant individuals: increasing longevity and reducing morbidity of our neighbors, employees, employers, tax payers, property owners, parents who have integrated into our society • To society and public welfare: more appropriate and less expensive utilization of medical resources; limit spread of communicable diseases; enable greater productivity and contribution to general good; guarantee the health of their children (the next generation) • Poor health in one sector of society threatens the whole of society (Ibraham, 2003, Am J Public Health, P. 1619)
Slide 15: #14- Controversies In Equitable health Delivery to Undocumented Immigrants • California Proposition 187, 1994: Voter approved restriction on services to illegal newcomers including funded health care • Federal Welfare Reform; Personal Responsibility and Work Opportunity Act (PRWORA)- Public Law 99-272, 1996: barred public assistance with federal funds including Medicaid for noncitizen newcomers • Federal Medicaid eligibility requirement of 5 years legal residence before receiving public funds • DO NOT APPLY TO CHILDREN (Smith, 2001, J Commun Health Nurs, p. 55 & Kullgren, 2003, Am J Pub Health: p. 1630)
Slide 16: #15- General Strategy to Eliminate Health Care Delivery Disparities  “Center of gravity for public policy initiatives intended to improve health status of the most vulnerable has remained fixed on “Improving Access to Care”---far less attention has been directed to upstream factors such as socioeconomic status, education, and life style changes”. (Mechanic, 2007, Health Affairs, p. 1219)
Slide 17: #16-Role of Nursing Advocacy: Research and Education • Research and Education – Inclusion of minority contributions and coalitions – Explore differences in curricular content between different levels of nursing education and impact upon levels of perception and discrimination – Develop new paradigm that enhances the understanding of barriers to equal service – Critically examine underlying attitudes and values that pervade discriminatory health care – Stress importance of communication (Porter, 2004, Ann Rev Nurs Res, p.54 & Bolton, 2004, Ann Rev Nurs Res, p. 40)
Slide 18: #17-Nursing Advocacy: Action • Develop a needs assessment plan • Gather accurate census data • Develop and distribute questionnaires • Research best practice approaches • Develop an action plan – – – – Proposed needs Proposed services Proposed collaborations Projected expenses • Distribute plan for multiple reviews in both the private and public sector (Cameron, 2005, Health Progress, p. 27)
Slide 19: #18-Exemplar: Richmond,VA Immigrant Needs Plan • Key health care areas – Prenatal and Ob/Gyn care – Behavioral health care – Dental care – Health screenings – Urgent care • Key healthcare personnel – Bilingual professionals or translators • Key health care services – Mobile clinics or transportation to services – Evening or weekend hours – Neighborhood or employment based delivery – Low cost or free services (Cameron, 2005, Health Progress, p. 29)
Slide 20: #19-Conclusion • Health care disparities exist as a major issue affecting the • • • • morbidity and mortality of population groups within the USA including immigrants Responsibility for the disparity is shared by multiple groups and organizations, not limited to the medical community Responsibility for resolving the disparity must be shared by multiple groups and organizations, But the entire medical community must be the leader There are moral, ethical, professional and humanitarian obligations Advanced practice nurses are qualified to take an active role
Slide 21: References  Bloche, M.G. (2007). Consumer-directed health care and the disadvantaged. Health Affairs, 26(5): 1315-1327.  Bolton, L.B., Giger, J.N., & Georges, C.A. (2004). Structural and racial barriers to health care. Annual Review of Nursing Research, 22: 39-58.  Cameron, K. & Hansen, E. (2005). Health planning for immigrants. Health Progress, 86(1), 26-29.  Dwyer, J. (2004). Illegal; immigrants, health care, and social responsibility. Hastings Center Report, 34(1), 34-41.  Ferguson, C.C. (2007). Barriers to serving the vulnerable: thoughts from a former public official. Health Affairs, 5: 1358-1365
Slide 22: References  Guttmacher, S. (1984). Immigrant workers: health, law, and public policy. Journal of Health Political Policy Law, 9(3), 503-514. Kandula, N.R., Kersey, M. & Lurie, N. (2004). Assuring the health of immigrants: what the leading health indicators tell mus. Annual Review Public Health, 25, 357-376. Kullgren, J.T. (2003). Restrictions on undocumented immigrants’ access to health services: the public health implications of welfare reform. American Journal of Public Health, 93(10), 1630-1633. Kuo, T. & Torres-Gil, F.M. (2001). Factors affecting utilization of health services and home- and community-based care programs by older Taiwanese in the United States. Research on Aging, 23(1), 14-36. Mechanic, D. & Tanner, J. (2007). Vulnerable people, groups, and populations: Societal view. Health Affairs, 26(5), 1220-1230    
Slide 23: References  Mendoza, F.S. (2009). Health disparities and children in immigrant families: A research agenda. Pediatrics, 124, S187-S195.  Messias, D.K.H. & Rubio, M. (2004). Immigration and health. Annual Review of Nursing Research, 22: 101-134.  Nickel, J.W. (1986). Should undocumented aliens be entitled to health care? Hastings Center Report, 16(6), 19-23.  Pati, S. & Danagoulian, S. (2008). Immigrant children’s reliance on public health insurance in the wake of immigrant reform. American Journal of Public Health, 98(11), 2004-2010.  Pauly, M.V. & Pagan, J.A. (2007). Spillovers and vulnerability: the case of community uninsurance. Health Affairs, 26(5), 1304-1314.
Slide 24: References  Porter, C.P. & Barbee, E. (2004). Race and racism in nursing research: past, present, and future. Annual Review of Nursing Research, 22: 9-37.  Smith, L.S. (2001). Health of America’s newcomers. Journal of Community Health Nursing, 18(1), 53-68.  Viadeck, B.C. (2007). How useful in “vulnerable” as a concept? Health Affairs, 26(5), 1231-1234.  Villarruel, A.M. (2004). Introduction: Eliminating health disparities among racial and ethnic minorities in the United States. Annual Review of Nursing Research, 22: 1-8.  Yeo, S.A. (2004). Language barriers and access to care. Annual Review of Nursing Research, 22: 59-73.
Slide 25: Online Citations  http://www.nytimes.com/2009/09/06/health/policy/0  http://online.wsj.com/article/SB125027261061432585.h