Assessment of Perspectives on Health Care System Efforts to Mitigate Perceived Risks Among Immigrants in the United States A Qualitative Study

IMPORTANCE Increases in the enforcement of immigration policies, deportations, and rhetoric critical of immigration during and after the 2016 US presidential election have been associated with a decrease in health-seeking behaviors and an increase in adverse health outcomes among immigrants. Efforts to address the health care needs of immigrants after the 2016 presidential election have centered on individual-level patient-practitioner strategies or federaland state-level policy changes. However, these approaches have not captured the role of health care systems and the range of health care facilities encompassed within them. OBJECTIVE To characterize policies and actions implemented by health care facilities to address immigration status–related stressors. DESIGN, SETTING, AND PARTICIPANTS This exploratory qualitative study involved semistructured interviews in a purposive sample of health care facilities across 5 states (California, Texas, New York, Florida, and Illinois) with the largest populations of individuals with undocumented immigration status. Data from media sources and informational interviews with local immigration advocacy leaders were used to identify health care facilities that had implemented welcoming policies and strategies. Stakeholders, including administrators, frontline clinicians involved in policy implementation, and senior executive leaders, were interviewed. Interviews were conducted between May 1 and August 9, 2018, and were recorded, transcribed, and coded using constant comparative analysis. Data analysis was performed from June 29, 2018, to February 5, 2019. MAIN OUTCOMES AND MEASURES Stakeholder perspectives on the range, scope and content of policies and actions implemented to address immigration-related stressors at health care facilities. RESULTS A total of 38 in-depth interviews were conducted spanning 25 health care facilities in 5 states; these facilities included 13 federally qualified health centers, 7 academic or private hospitals, and 5 public institutions. Interviewees described policies and actions that mitigated one or more of the following perceived risks: (1) risk of exposure to immigration enforcement personnel at or near facilities, (2) risk of immigration status–related information disclosure, (3) risk associated with patient-level stressors, (4) risk associated with practitioner-level stressors, and (5) coordination of risk mitigation. Most personnel at health care facilities emphasized that their policies and actions fit within a larger mission and history of addressing the social needs of diverse patients and mitigating risks for patients. CONCLUSIONS AND RELEVANCE Health care facilities can implement both active and reactive measures to address perceived immigration-associated risks among patients and practitioners. Population health and immigration policies are at the forefront of current policy debates. An (continued) Key Points Question How have health care facilities in 5 states with the largest populations of individuals with undocumented immigration status responded to enforcement of immigration policies after the 2016 US presidential election? Findings In this qualitative study involving 38 interviews across 25 health care facilities, such facilities were found to have implemented institutional policies and actions to mitigate perceived risks among patients who are immigrants and health care practitioners. Patients and practitioners identified risks related to exposure to immigration enforcement personnel at or near facilities and of immigration status disclosure; these risks were associated with patient-level stressors, with practitioner-level stressors, and with coordination of risk mitigation. Meaning This study suggests that understanding the ways in which health care facilities address risks to their patients and employees may help to optimize care for patients who are immigrants and health care


Introduction
Studies have suggested that increased enforcement of immigration policies, deportations, and rhetoric critical of immigration during and after the 2016 US presidential election have reduced the willingness of immigrants to access health and social services [1][2][3] and have been associated with adverse health outcomes, such as decreases in birth weights and increases in mental health disorders. 4,5 Similar consequences have been documented after the increased enforcement of state immigration policies [6][7][8] and the occurrence of immigration enforcement actions in the workplace. 9,10 The consequences may extend to the physical and mental health of US-born ethnic minority populations who are perceived to be immigrants. 11,12 Children born in the United States in families with mixed immigration status may also experience consequences. For instance, 1 in 4 American children with Latino ancestry belong to families with mixed immigration status 13 ; such families appear to have lower than expected rates of participation in federally funded health and social programs, such as Medicaid; the Special Supplemental Nutrition Program for Women, Infants, and Children; and the Supplemental Nutrition Assistance Program. 14,15 As a consequence, some health care facilities, such as hospitals and clinics, are adopting policies and actions to welcome immigrants, address immigration status-related stressors, and mitigate fears associated with accessing health care services. These efforts are embedded within a larger social and political landscape that includes media reports of immigration enforcement actions at or near health care facilities 16 and state or city sanctuary policies limiting the involvement of local law enforcement agencies with federal immigration enforcement agencies. 16 The ways in which health care facilities are responding to the increased enforcement of immigration policies has been discussed in media and medical literature editorials but has not been empirically studied. This study offers a systematic multistate exploration of institutional policies and actions undertaken to mitigate perceived risks among patients who are immigrants and health care practitioners.

Data Collection
We developed a 45-to 60-minute semistructured interview guide based on input from the literature and community organizations. 18 Drawing from the Consolidated Framework for Implementation Research, 19 the interview protocol included questions about potential barriers and facilitators to the implementation of risk-reduction strategies (Box).
Two of us (A.S. and A.F.V.) conducted interviews between May 1 and August 9, 2018. We conducted most of the interviews in person, with the remainder conducted by telephone.
Interviewees provided verbal informed consent for audio recording and transcription in all but one instance, in which extensive notes were taken instead. Most of the interview refusal reasons were nonspecific because the individuals did not respond. Two individuals who declined to participate implied that the bureaucratic requirements at their institutions were too difficult to overcome to allow for an interview. Interviews continued until we reached thematic saturation (ie, until no new thematic information could be obtained). 20

Data Analysis
Interviewers took notes and discussed emerging themes as the interviews progressed so that thematic saturation could be assessed. We analyzed the data using constant comparative analysis, 21 an iterative procedure in which codes and themes evolve as a result of the comparison of new data with previous data. We identified the range of policies and actions considered and/or implemented at participating health care facilities. An initial codebook was used to categorize interventions at the levels of the institution, practitioner, and patient. To manage the data, we used Dedoose qualitative data analysis software, version 8.0.42 (SocioCultural Research Consultants). We focused this article on the range of policies and actions implemented at participating facilities. Data analysis was performed from June 29, 2018, to February 5, 2019.

Results
We conducted 38 in-depth interviews (26 conducted face to face and 12 conducted by telephone).
Although we had originally asked about institution-level, practitioner-level, or patient-level interventions, our analyses found that interviewees described policies and actions that mitigated one or more of the following perceived risks: (1) risk of exposure to immigration enforcement personnel at or near facilities, (2) risk of immigration status-related information disclosure, (3) risk associated with patient-level stressors, (4) risk associated with practitioner-level stressors, and (5) coordination of risk mitigation. The Table lists subcomponents of these categories that emerged from the interviews.
Interviewees at all facilities reported that they addressed at least one of these risk categories. documenting enforcement officers' actions with photographs or video; training an internal team to respond; and determining if and when to notify patients. The personnel at one facility had practiced these protocols as "a drill [because] you never know" and reported that, as part of a training exercise, they had "pulled out a patient and had them be the person that's being detained." They informed patients in advance that this was a training simulation to avoid the spread of fear. Other facilities shared the protocols with personnel but not with patients.
Administrators of health care facilities reported preparing their personnel to recognize and distinguish between administrative warrants, judicial warrants, and subpoenas. At most facilities with a training protocol, personnel had focused on preparing a core response team-stating that "our directive was that you should call senior management"-to reduce the burden on health care practitioners who "were terrified this was going to be all on them" in terms of engaging immigration enforcement personnel. Interviewees at a few facilities reported developing a response protocol that was integrated with a larger rapid response team that included attorneys, community leaders, and city officials.
At some health care facilities, staff members delineated differences between public and private spaces on the premises because law enforcement personnel are legally permitted to enter only public, but not private, spaces without a judicial warrant or permission from the facility. 22 Specific policies included performing an internal review and environmental scan of current signage, posting clear signage in areas requiring further clarity, and sharing information with staff. Interviewees from several facilities noted that the physical layout of the facility constrained their choices. A seniorlevel executive at an FQHC in California explained that "at our main sites, you can't get into the waiting area without going through security. In our smaller sites, you walk straight into the waiting area, which is a public space. We should have thought of that." One facility used a table as a room divider to create a public waiting area for all patients and a second waiting area for patients who had already signed in. A practitioner at an academic medical center in New York expressed concern about people being "afraid because, at a lot of hospitals, they ask for IDs at the front desk," highlighting the potential for unintended consequences at facilities that had not established community trust.
To address the risk of exposure to immigration enforcement personnel who were en route to a

Immigration Status-Related Information Disclosure
Interviewees at health care facilities noted that asking about and documenting immigration status could stigmatize patients, discourage them from seeking care, and expose them to unnecessary risk should immigration enforcement officers gain access to medical records. Staff members at some facilities reviewed intake forms and clinical assessment and documentation practices to ensure this information was not being requested or recorded. This policy became formal at some facilities, informal at others, or was practiced only by select health care practitioners at others. One county administrator in Florida described their facility's policy as a "don't ask, don't tell" attitude among practitioners and patients, while another practitioner reported telling patients, "I just need to know the parts where I can help you. I don't need to know your whole story." Several interviewees, however, noted that the effort to avoid eliciting patients' immigration information was counter to a broader effort to assess the social factors associated with patients' health.

Patient-Level Stressors Legal Stressors
Risks associated with patient-level legal stressors were addressed in several ways. First, administrators and employees at health care facilities recognized that many patients struggled with daily fears and legal issues associated with their immigration status. In response, some facilities expanded or initiated new medical-legal partnerships focused on providing legal immigration assistance. Other facilities included legal partners in local resource fairs or resource guides, or they coordinated efforts to have practitioners contribute to patients' legal cases (eg, provide medical evaluations for asylum cases or letters of support to prevent the deportation of family members). Texas recommended that her patients speak to an attorney rather than offering advice herself.

One administrator at an FQHC in
Third, personnel at health care facilities also prepared patients for the risk of deportation, which was sometimes incorporated within broader emergency preparedness plans. Deportation preparedness involved "who do you leave your children to, where are their birth certificates, who's going to handle your bank account should you be deported. It becomes a full kit so that everybody knows exactly what to do in the time of emergency."

Promotion of Resiliency
Administrators and staff at some health care facilities promoted resiliency among patients and their families, seeking to respond both reactively and actively to perceived risks. One common active action was the provision of affirming care messages, such as "you are welcome here." The form of dissemination and the language used to communicate this message varied based on the local facility's context within the larger community. A county administrator in Florida noted that they had to consider negative feelings about immigration in the local community before taking action, stating, "We don't want a red target on the organization." Most interviewees reported that they avoided using the word sanctuary because it was falsely reassuring, too politically charged, too ambiguous (ie, did not have a definitive meaning), or did not translate well in the languages spoken by their patients. In the words of an administrator at an FQHC in California, "There is a connotation around sanctuary where people believe they can stay there, [that] they can lock themselves in the clinic, be bathed, clothed, and given food and shelter. [But] no. This is a community health center. We cannot do that." A senior-level executive at an FQHC in Illinois

JAMA Network Open | Public Health
Health Care System Efforts to Mitigate Risks Among US Immigrants stated, "We can't promise people something we can't be. We cannot harbor patients. We cannot hold someone longer than needed for clinical care." Some interviewees emphasized the importance of providing accurate messages in multiple languages.
Several interviewees reported using patient-empowerment strategies, such as (1) the development of community advisory boards with representation from immigrants; (2) the creation of targeted programming, such as summer youth programs, story-telling events, or media advocacy skill-building programs; (3) outward engagement and policy engagement opportunities, such as visits to local or state legislators; and (4) voter registration efforts to encourage civic participation.
One administrator in Texas explained, "We've been taking on multiple initiatives on registering people to vote, empowering them to say this is why it's so important that you go out and vote." Interviewees underscored the importance of "partnerships with community-based organizations and legal help organizations [that] are strong" so that "they are eyes and ears on the

Practitioner-Level Stressors
Another identified theme was the consequence of stressors among health care practitioners.
Administrators of health care facilities responded by bolstering their legal services and increasing behavioral health support for their personnel. One senior level administrator in Illinois explained, "Many of our staff are from the communities we serve, so this was personal for [them]." Some interviewees at facilities reported hearing biased and demeaning remarks from patients, such as, "Now that Trump's elected, you can't speak Spanish here. They're going to kick you back." Interviewees at several facilities emphasized the importance of discussing patients' anxiety and fears among clinic personnel, addressing sources of burnout, brainstorming ideas, or sharing best practices. These facilities hosted town hall events or dedicated staff meetings to discussing immigration status-related concerns.
Furthermore, interviewees at health care facilities described practitioner education as a crucial component in assisting patients who are immigrants, particularly because practitioners have different levels of experience, training, and comfort in navigating these patients' concerns. A number of interviewees reported addressing practitioner misconceptions, such as the belief that only non-English speakers are immigrants. Health care facilities that offered education for clinicians focused on reviewing the changes to local and federal government immigration policies; providing guidance for communicating with patients who have immigration status-related questions, including whether and how to ask patients about their immigration status without eliciting fear or stigma; and explaining the ways in which immigration status is associated with health. Interviewees noted that conversations about immigration status were especially delicate, saying, "it's like you're in a forest, it hasn't rained in a year, and anything can just start a fire." In addition, several senior executive leaders emphasized the limits to clinicians' knowledge about immigration issues because "they're doctors, not lawyers, and this is a very changing environment."

Coordination of Risk Mitigation
Interviewees at a number of health care facilities reported that, given the pace of change in immigration policy, they had assigned a point person or team designated to stay abreast of policy changes and ensure clinicians and executive leadership were updated about best practices. The process of identifying and connecting with key stakeholders may have otherwise been delayed, which may have hindered the facility's ability to respond effectively. Team representatives commonly

Discussion
This exploratory multistate qualitative study identified several main areas of response by health care facilities to perceived immigration-associated risks among patients and practitioners, thereby creating an environment that was both physically and psychologically safe. The range of policies and actions described in this study highlights the ways in which health care facilities can implement both active and reactive measures that address risks to the health of immigrants. Previously discussed efforts to improve the health of these patients after the 2016 presidential election have focused on individual patient-practitioner communication 23 or policy changes at the federal or state level.
However, these approaches did not capture the role of health care facilities and the health systems in which they are embedded. The description of these policies and actions is an essential first step in building an evidence base for health system approaches that optimize health care among immigrants. An understanding of these policies and actions may also serve as a guide to personnel at other health care facilities who seek to address the needs of all their patients, regardless of immigration status.
Among most of the facility personnel we interviewed, these policies and actions fit within a larger patient-centered or health equity mission and did not represent controversial actions.
Historical and current parallels exist regarding such immigration status-related policies and actions, as health care facilities have responded to nonmedical perceived risks to emphasize their commitment to patients regardless of the political or legal landscape. For example, in war zones, hospitals use distinctive emblems, such as large flags or red crosses on white roofs, to underscore their independent status. 24 Furthermore, although immigration violations are civil and not criminal, parallels can be drawn with patients with substance use disorders who have committed illegal acts but have continued to have their clinical care prioritized. In addition, personnel at health care facilities have sought to reduce the risks associated with the disclosure of sensitive information in patients' medical records. This approach was used when HIV infection and AIDS first emerged; during this period, clinicians were hesitant to record the HIV status of patients because of the potential for stigma and discrimination. In the past, practitioners were also reluctant to share patients' DNA pedigrees and other genetic information that could be used by insurance companies or employers to target asymptomatic patients based on their genetic susceptibilities. 25 Personnel at health care facilities have also tried to make their environments welcoming, trusting, and supportive by addressing patient and practitioner stressors in other contexts. The connection of patients with legal resources, for example, is akin to the prescription of fruits and vegetables for patients with food insecurity. 26 Deportation preparedness or planning is similar to advanced care planning. Another example is the fostering of lesbian, gay, bisexual, transgender, and queer (LGBTQ)-friendly health care services. 27 The Human Rights Campaign, one of the largest civil organizations working to achieve LGBTQ equality, publishes an annual Healthcare Equality Index, 28 a benchmarking tool that evaluates health care facilities' policies and practices for the equity and inclusion of patients and employees with LGBTQ identification. Some of the criteria used in the benchmarking tool mirrors the policies and actions that we found had been implemented by health care facilities to serve immigration status-related needs, such as staff training, welcoming signs, and Policies and actions implemented in the immigration context are similar to those that health care facilities have been performing across the disease and policy spectrum for many years, such as reducing risks to their patients, responding to the physical and mental health needs of their patients and employees, and fulfilling their mission for care equity. Coincident with a mission for care equity, these policies and actions were implemented alongside other efforts that addressed common barriers to care, such as language, transportation, or insurance barriers.

Limitations
Our study had several limitations. The study did not evaluate the policies and actions reported by interviewees. Future studies can assess the efficacy of these interventions and evaluate which variations are most effective. Although this study was not statistically representative, it was purposefully designed to identify a range of perspectives from facilities in regions with large populations of immigrants but with potentially different political pressures and health care delivery challenges. The results suggest that institutions of various sizes and structures across states with different political leanings could potentially apply these policies and actions. Other studies have suggested that the prevalence of fear of deportation is not associated with the use of medical care at FQHCs, in particular, 30 so the variations across health care facility types require further exploration.

Conclusions
Population health and immigration policies are at the forefront of current policy debates. An understanding of the ways in which health care facilities serve to mitigate risks to their patients and employees can be one step toward optimizing care for immigrants and health care practitioners.
Health care facilities can, in changing policy environments, consider and implement processes to adapt to and address evolving patient and practitioner concerns.