Moving Toward Inclusion: Access to Care Models for Uninsured Immigrant Children.

Policy Points Models for access to care for uninsured immigrant children that mitigate structural and sociopolitical barriers to inclusive health care include funding structures (e.g., state-sponsored coverage) and care delivery systems (e.g., federally qualified health centers,). Although the quintessential model of access to care necessitates health coverage for all children regardless of immigration status or date of United States entry, incremental policy change may more realistically and efficiently advance equitable access to high-quality health care. Intentional advocacy efforts should prioritize achievable goals that are grounded in data, are attentive to the sociopolitical milieu, are inclusive of diverse perspectives, and would meaningfully impact health care access and outcomes.

Legal Relief for Children in Immigrant Families: A Mixed-Methods Study.

OBJECTIVE: Immigration status is a known social driver of health. Little research exists on addressing concerns about immigration status in primary care. The objective of this study is to understand the experiences of immigrant families that received a clinical-community intervention to address immigration-related concerns. METHODS: We conducted a mixed-methods study: an embedded experimental design study. We implemented an immigration-focused legal needs screening tool and referral intervention at one academic primary care clinic in January 2018. Caregivers who screened positive for immigration-related concerns and were referred to a local immigration law firm were invited to participate in a semi-structured interview. Interviews were recorded, de-identified, transcribed, and systematically coded using an inductive content analysis approach. A modified constant comparative method was used to iteratively review codes, identify emerging themes, and resolve differences through consensus. RESULTS: Nineteen caregivers reported immigration-related legal concerns, seven of whom were interviewed. Most (84.2%) were mothers, identified as Hispanic (94.7%), were from Mexico (52.6%), and reported persecution and fear of returning to their country of origin (57.9%). In interviews, we identified three major themes: (1) families were motivated to immigrate due to mental health trauma and persecution; (2) families sought legal services for several immigration-related concerns; and (3) families experienced challenges in navigating the legal system, with which clinics may assist. CONCLUSION: This study demonstrates the need for immigration-related services in primary care settings and the feasibility and potential benefits of implementing a legal screening and referral intervention.

State Preemption of Municipal Laws and Policies that Protect Immigrant Communities: Impact on Latine Health and Well-Being in North Carolina.

BACKGROUND: Some U.S. municipalities have proclaimed themselves "sanctuary cities" and/or adopted laws and policies limiting local involvement in enforcement of federal immigration policies. Several states, however, have adopted laws that preempt municipal laws and policies designed to protect immigrants. We explored the consequences of House Bill (H.B.) 318, one such preemption law in North Carolina (NC), on the health and well-being of Latine immigrants. METHODS: We conducted focus groups with Latine immigrants (n=49) and in-depth interviews with representatives from health, social service, and immigrant-serving organizations and local government (including law enforcement) (n=21) in NC municipalities that, before HB 318, adopted laws and policies supporting immigrants. Data were analyzed using constant comparison. RESULTS: Twelve themes emerged, including the positive impacts of municipal sanctuary laws and policies are limited by preemption and other state and federal actions; laws and policies like HB 318 are confusing, have a chilling effect on health services use, and make life harder overall for Latine communities; intensified federal immigration enforcement has increased fear among Latine communities; Trump administration policies worsened anti-immigrant climates; and use of community identification cards and greater information dissemination and inter-organization coordination can lessen the consequences of preemption and other restrictive laws and policies. CONCLUSION: State preemption of protective municipal laws and policies negatively and profoundly affects immigrant health and well-being. However, creative strategies have been implemented to respond to preemption. These findings provide critical data for decision-makers and community leaders regarding the detrimental impacts of preemption laws and mitigation of these impacts.

The Health of Children in Immigrant Families: Key Drivers and Research Gaps Through an Equity Lens.

OBJECTIVE: The United States benefits economically and socially from the diverse skill-set and innovative contributions of immigrants. By applying a socioecological framework with an equity lens, we aim to provide an overview of the health of children in immigrant families (CIF) in the United States, identify gaps in related research, and suggest future areas of focus to advance health equity. METHODS: The literature review consisted of identifying academic and gray literature using a MeSH Database, Clinical Queries, and relevant keywords in 3 electronic databases (PubMed, Web of Science, and BrowZine). Search terms were selected with goals of: 1) conceptualizing a model of key drivers of health for CIF; 2) describing and classifying key drivers of health for CIF; and 3) identifying knowledge gaps. RESULTS: The initial search produced 1120 results which were screened for relevance using a meta-narrative approach. Of these, 224 papers were selected, categorized by topic, and reviewed in collaboration with the authors. Key topic areas included patient and family outcomes, institutional and community environments, the impact of public policy, and opportunities for research. Key inequities were identified in health outcomes; access to quality health care, housing, education, employment opportunities; immigration policies; and inclusion in and funding for research. Important resiliency factors for CIF included strong family connections and social networks. CONCLUSIONS: Broad structural inequities contribute to poor health outcomes among immigrant families. While resiliency factors exist, research on the impact of certain important drivers of health, such as structural and cultural racism, is missing regarding this population. More work is needed to inform the development and optimization of programs and policies aimed at improving outcomes for CIF. However, research should incorporate expertise from within immigrant communities. Finally, interventions to improve outcomes for CIF should be considered in the context of the socioecological model which informs the upstream and downstream drivers of health outcomes.

Children in Immigrant Families: Advocacy Within and Beyond the Pediatric Emergency Department.

In the United States, 1 in 4 children lives in an immigrant family. State and national policies have historically precluded equitable access to health care among children in immigrant families. More recently, increasingly restrictive policies, political rhetoric, and xenophobic stances have made immigrant families less able to access health care and less comfortable in attempting to do so, thus increasing the likelihood that patients will present to the emergency department. Once in the emergency department, language, cultural, and health literacy barriers make providing high-quality care potentially challenging for some families. Emergency care professionals can therefore glean critical insight regarding inequities from clinical work to inform advocacy and policy changes at institutional, community, regional, and national levels.

Providing Care for Children in Immigrant Families.

Children in immigrant families (CIF), who represent 1 in 4 children in the United States, represent a growing and ever more diverse US demographic that pediatric medical providers nationwide will increasingly encounter in clinical care. Immigrant children are those born outside the United States to non-US citizen parents, and CIF are defined as those who are either foreign born or have at least 1 parent who is foreign born. Some families immigrate for economic or educational reasons, and others come fleeing persecution and seeking safe haven. Some US-born children with a foreign-born parent may share vulnerabilities with children who themselves are foreign born, particularly regarding access to care and other social determinants of health. Therefore, the larger umbrella term of CIF is used in this statement. CIF, like all children, have diverse experiences that interact with their biopsychosocial development. CIF may face inequities that can threaten their health and well-being, and CIF also offer strengths and embody resilience that can surpass challenges experienced before and during integration. This policy statement describes the evolving population of CIF in the United States, briefly introduces core competencies to enhance care within a framework of cultural humility and safety, and discusses barriers and opportunities at the practice and systems levels. Practice-level recommendations describe how pediatricians can promote health equity for CIF through careful attention to core competencies in clinical care, thoughtful community engagement, and system-level support. Advocacy and policy recommendations offer ways pediatricians can advocate for policies that promote health equity for CIF.

Clinical Tools Working at Home with Immigrants and Refugees.

At a time of evolving demographics and turbulent policy changes, pediatric providers have a critical role in the care of all children, regardless of where the child or parent was born. Pediatric providers can facilitate access to high-quality care and critical community-based resources for immigrant children and families. In this article, we delineate the primary domains for clinical care and offer clinical tools to achieve the provision of accessible, comprehensive, high-quality care within a family-centered medical home.

Advocating for Immigration Policies that Promote Children's Health.

Immigration laws and policies, as well as related media and public discourse, have a direct and significant effect on the health and well-being of children and families. The purpose of this article is to identify the impact of family immigration status and immigration laws on children's health, to understand the legal system that immigrant children face, and to describe opportunities for health care professionals to engage in advocacy at the systems level, from the local community to Capitol Hill.

Community Engagement and Equitable Policy: Promoting Resilience and Stability for Children in Immigrant Families in North Carolina.

Immigrant families in North Carolina, despite multidimensional challenges in the context of national, state, and local policies, enrich our communities. Over the last 18 months, a small group of North Carolina Pediatric Society (NCPS) physicians with concerns about the health and emotional well-being of children in immigrant families have come together to address the challenges facing this vulnerable population. Our goal, as the newly formed NCPS Committee on Immigration, is to advance policy to support immigrant families in obtaining equitable health, educational, and economic opportunities in our state. We are in the process of building a task force to bring together those who work closely with the North Carolina immigrant population to promote resilience and stability through legislative and policy advocacy.

Introducing the Concepts of Advocacy and Social Determinants of Health Within the Pediatric Clerkship.

Introduction: Although advocacy and social determinants of health (SDH) are fundamental components of pediatrics and other areas of health care, medical education often lacks formal training about these topics and the role of health care professionals as advocates. SDH are common targets of advocacy initiatives; however, little is known about optimal ways to incorporate this content into medical education curricula. Methods: We developed a lecture and assessment for third-year medical students that included interactive discussion of advocacy, SDH issues specific to children, and opportunities for learners to engage in advocacy. Learners attended the lecture during the pediatric clerkship. Over the course of a year, questionnaires assessing knowledge of advocacy, SDH, and incorporation of advocacy into practice were administered to 75 students before the lecture and as the clerkship ended. We used chi-square and Fisher's exact tests to compare knowledge before and after the lecture. Results: Students showed significant improvement on most individual questions and overall passing rates. Learners provided positive feedback on the quality of the lecture material and demonstrated interest in engaging in current advocacy projects to address SDH. Discussion: As recognition of the importance of advocacy and SDH increases, the development of educational tools for teaching this information is critical. Our lecture produced significant improvement in knowledge of these topics and was well received by students. Early introduction to advocacy and SDH during relevant clinical rotations emphasizes the importance of these topics and may establish a foundation of advocacy as fundamental to health care.

Connecting Refugees to Medical Homes Through Multi-Sector Collaboration.

As increasing numbers of refugees have resettled globally, an interdisciplinary group of stakeholders in Forsyth, North Carolina, recognized obstacles preventing coordinated medical care, which inspired the development of our Refugee Health Collaborative. This study assessed the Collaborative's impact on access to coordinated care within patient-centered medical homes (PCMH). A Collaborative-developed novel algorithm guided the process by which refugees establish care in PCMHs. All refugees who established medical care in the two primary health systems in our county (n = 285) were included. Logistic non-linear mixed models were used to estimate the differences between three time frames: pre-algorithm, algorithm implementation and refinement, and ongoing algorithm implementation. After algorithm implementation, there has been a significant decrease in the time required to establish care in PCMHs, increased provider acknowledgment of refugee status, and decreased emergency department (ED) visits. Multi-disciplinary, organized collaboration can facilitate enhanced access to care for refugee families at the population level.

Building Community Support Using a Modified World Café Method for Pregnant and Parenting Teenagers in Forsyth County, North Carolina.

STUDY OBJECTIVE: To identify community priorities, foster awareness of existing supports, and recognize barriers and opportunities to enhance support services for pregnant and parenting teens (PPTs). DESIGN AND SETTING: A modified World Café event incorporated parallel, rotating focus groups with semistructured, case-based discussions of salient issues. The event was organized and took place in Forsyth County, North Carolina. PARTICIPANTS: Seventy-eight local health and social service professionals and 15 PPT representatives. INTERVENTIONS AND MAIN OUTCOME MEASURES: Qualitative coding was used to thematically analyze transcript data. Quantitative data pre-/post-event comparisons were made using Fisher exact test. RESULTS: Key community-based support services for PPTs were identified. Qualitative analysis yielded 10 key codes regarding barriers and opportunities to enhance community-based support services, resulting in 4 themes. Themes included maximizing access and efficient delivery of high-quality health care, engaging a 3-generation approach to meet the current and future needs of at-risk families, focusing efforts to meet the unique needs of each teen and his/her family, and emphasizing teen self-advocacy. Pre/post survey responses were overwhelmingly positive regarding use of the modified World Café format for discussion and network building. CONCLUSION: The modified World Café Method offered a platform to collaboratively identify challenges and opportunities and to develop networks to improve health and well-being of PPTs. Engaging multiple stakeholders in meaningful dialogue might foster multidisciplinary, cross-sector collaboration that mitigates risk and enhances resilience among PPTs and their children.

The Health Impact of Experiences of Discrimination, Violence, and Immigration Enforcement Among Latino Men in a New Settlement State.

Among Latinos in the United States, particularly in new settlement states, racial/ethnic discrimination, violence, and immigration enforcement contribute to health disparities. These types of experiences were explored among Latino men in North Carolina through quantitative assessment data ( n = 247). Qualitative in-depth interviews were also conducted with a subsample of Latino men who completed the assessment ( n = 20) to contextualize quantitative findings. Participants reported high rates of unfair treatment, discrimination or violence, and questioning about their immigration status. Having been questioned about one's immigration status was significantly associated with increased drug use (adjusted odds ratio [AOR] = 2.16; 95% confidence interval [CI] [1.07, 4.38]) and increased depressive symptoms (AOR = 2.87; 95% CI [1.07, 7.67]). Qualitative themes included: reports of frequent discrimination based on immigration status, race/ethnicity, and language; workplaces and police interactions as settings where reported discrimination is most common and challenging; frequent violent victimization; psychological consequences of experiences of discrimination and violence and concerns related to immigration enforcement for Latino men and their families; inter- and intra-community tensions; health-care services as safe spaces; use of coping strategies; and system-level approaches for reducing discrimination and violent victimization of Latinos. Findings point to the need to address underlying causes of discrimination and violence toward Latinos, particularly those related to immigration enforcement, to support health and well-being.

Integrating Parenting Support Within and Beyond the Pediatric Medical Home.

Positive parenting programs, developmental support services, and evidence-based home visiting programs can effectively provide parenting support and improve health and developmental outcomes for at-risk children. Few models, however, have integrated referrals for on-site support and home visiting programs into the provision of routine pediatric care within a medical home. This article describes an innovative approach, through partnership with a community-based organization, to deliver on-site and home visiting support services for children and families within and beyond the medical home. Our model offers a system of on-site services, including parenting, behavior, and/or development support, with optional intensive home visiting services. Assessment included description of the population served, delineation of services provided, and qualitative identification of key themes of the impact of services, illustrated by case examples. This replicable model describes untapped potential of the pediatric medical home as a springboard to mitigate risk and optimize children's health and development.

Discrimination against Mixed-Status Families and its Health Impact on Latino Children.

BACKGROUND AND OBJECTIVE: Restrictive immigration policies and discrimination are associated with negative health outcomes for immigrant and Latino families. Mixed-status families represent a unique subpopulation of Latinos affected by restrictive immigration policies. This qualitative study explored discrimination against mixed-status families and its potential health impact on Latino children from the perspective of Latina mothers. METHODS: In 2017, twenty in-depth interviews with Latina mothers of mixed-status families living in northwestern North Carolina were conducted, transcribed, and analyzed. Constant comparison, an approach to grounded theory development, was used. RESULTS: Nine themes emerged that reflected experiences with discrimination and its negative impact on children. Themes included more frequent and severe discrimination during and after the 2016 US presidential election, determination to stay together and remain in the US, experiences of discrimination in multiple settings, the impact of discrimination on child health and well-being, the impact of fear and stress on meeting the needs of children, the burdening role of children as liaisons between families and services, the inability of citizenship to protect against the effects of discrimination, positive and hopeful responses to discrimination, and the potential role of education in building a foundation for reducing discrimination (and thus promoting the health and well-being of Latino children) in the future. CONCLUSIONS: Discrimination against mixed-status, Latino families constitutes a critical threat to the health and well-being of Latino children. Further research should inform immigration policies that support (rather than threaten) the health, well-being, and health care practices that mitigate the stresses experienced by Latino children.