In the last few years, US immigration policy has received increasing attention from the media, political candidates, and citizens. Within the medical community, there has been a slower but burgeoning realization that immigration policy has consequences for the practice of medicine as well as the delivery of health services. Regardless of political ideology or one’s opinion about ideal immigration policies, there is increasing data indicating that immigration status is associated with health and should be considered a factor in achieving the goal of optimal health for patients and communities.1 For example, sentiments critical of undocumented immigration and fear of deportation have been associated with changes in health-seeking behaviors2 and adverse physiological effects.3 Given this context, health care practitioners and health systems have the opportunity to identify, address, and mitigate the negative consequences that immigration policy and sentiments critical of undocumented immigration may have on the health and well-being of immigrants.
Some health systems have responded to recent changes in immigration policy through the use of institutional policies and strategies to safeguard health care delivery to immigrants. However, there is a dearth of information about the development, implementation, and effectiveness of such health system interventions. The work of Saadi and colleagues4 represents an innovative contribution to our knowledge and provides invaluable insights into institutional policies that were developed to mitigate the unique risks that affect immigrants.4 Using a qualitative approach, they conducted in-depth interviews with stakeholders at health care facilities across 5 states that have large populations of immigrants with undocumented status to identify how these facilities were responding to national and local policies characterized as harmful to individuals with undocumented immigration status. Specifically, the focus of the stakeholder interviews was to identify interventions and strategies that were aimed at reducing immigration status–related risks and associated stressors among patients and health care practitioners.
The research approach undertaken by Saadi and colleagues is noteworthy. First, their purposive sampling strategy identified stakeholders at health care facilities in major metropolitan areas in specific states that have large numbers of individuals with undocumented immigration status.5 This research approach could be used by stakeholders at other health care systems who would like to understand the extent of immigration status–related risks and stressors for their patients and practitioners. Another unique aspect of the study is its focus on health care practitioners, given practitioners’ unique experiences in caring for immigrants.
We are pediatric physicians with a commitment to serving all immigrant populations, and we have experience with the emotional consequences of immigration policies for our patients and the way in which immigration policies influence care-seeking behaviors. In our professional roles, we have provided medical documentation for immigration hearings when deportation would have had an adverse effect on the health of pediatric patients. We have also weighed the risk of recommending a needed social program to parents, such as public health insurance, when there is a concern that receiving the benefit could jeopardize the parents’ immigration status in light of the new public charge rule. As physicians, we recognize the potential consequences of immigration policies for our patients' health and well-being and the challenges associated with trying to provide the best clinical care. Our own health care systems have developed policies and procedures, including specific procedures to handle the presence of immigration enforcement agents on the medical center campus; however, the work of Saadi et al4 highlights the need for further systematic study, evaluation, and policy development.
The study by Saadi and colleagues4 is also important because it exemplifies the ways in which one might begin to incorporate community voices in research. Immigration policies have potential consequences for the overall health of communities in which large numbers of immigrants with undocumented status reside. As such, this area of research requires the community’s input to truly understand the consequences of immigration policies for health and health care delivery. This study was designed to identify trusted local stakeholders at health care facilities “that had implemented welcoming policies and strategies.”4 The authors describe the ways in which they used lay media sources and interviews with local immigrant advocacy leaders to identify and conduct qualitative interviews with such community stakeholders. Qualitative interviews can serve as a critical first step in the process for many research methodologies, including quality improvement studies, community-based participatory research,6 and dissemination and implementation science.7 Thus, the work of Saadi et al4 provides a starting point to evaluate areas worthy of study, including efforts to mitigate the risks of exposure to immigration enforcement personnel or immigration status–related information disclosure among research participants.
However, to build on the implementation science framework that Saadi et al4 used, future work should include questions about how health care facilities engaged in the process of designing these policies. Institutional policy development should elicit community concerns (eg, needs assessment) and engage those who are most likely to experience the consequences of the implementation of these policies (ie, immigrants and frontline health care practitioners) in designing solutions. In short, eliciting community voices is an initial step in authentic community-based scholarship. Involving community stakeholders as co-researchers requires that scientists engage partners in knowledge-sharing and transfer, not just a one-way gathering of information. For researchers, this approach includes actively relaying research findings back to participants to assist stakeholders with evaluation of their strategies. Both community-based participatory research and dissemination and implementation science emphasize such iterative processes of information- and power-sharing.
Despite many strengths, the article by Saadi et al4 did not provide detailed information about the ways in which health care systems identified the potential challenges experienced by their immigrant communities nor the process by which they designed possible solutions. Future studies should include an evaluation of the effectiveness of the strategies and policies implemented at participating health care facilities. The authors recognized this important limitation and noted that some strategies that were intended to mitigate risk could result in unintended negative consequences. For health care administrators who read the article by Saadi et al4 and are motivated to address similar concerns within their immigrant communities, the study could serve as the starting point for policy development and implementation.
Overall, the work of Saadi et al4 provides data indicating that health care systems can, and perhaps should, be change agents for improving health among immigrants. The article reminds us that policies that may mitigate risk among immigrants with undocumented status must be examined in other contexts. For instance, children may experience unique stressors, threats, and risks, and health care systems may need to develop specific strategies for health care settings that serve pediatric patients. Children who live in mixed–immigration status households may be particularly susceptible to the broad consequences of immigration policy that are associated, in part, with the unique vulnerability of parents and caregivers with undocumented immigration status.8 Similarly, health systems that recruit patients for research studies may need to consider specific policies to protect the rights of participants with undocumented immigration status, a group that has been largely understudied. What strategies will ensure safety and protection for research participants who have undocumented immigration status when there are evolving concerns associated with the privacy of research data sets?
Ultimately, we need a rigorous literature base to inform best practices associated with health care delivery and research in the area of immigrant health. The nature and effectiveness of policies intended to address the adverse effects associated with social factors, such as rhetoric critical of undocumented immigration or increased immigration enforcement, should be studied as rigorously as the effectiveness of new drug regimens or clinical protocols. In the same vein, policies related to the health of immigrants should be subject to the iterative evaluative processes that characterize quality improvement programs. By grounding this body of work through research partnerships with community stakeholders, health policy and health services researchers can be prepared to respond to rapidly changing policies.
Published: April 17, 2020. doi:10.1001/jamanetworkopen.2020.3022
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Montoya-Williams D et al. JAMA Network Open.
Corresponding Author: Diana Montoya-Williams, MD, Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19146 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Montoya-Williams D, Fuentes-Afflick E, Wallis K. The Case for Research-Informed Immigrant Health Policies Within Health Care Systems. JAMA Netw Open. 2020;3(4):e203022. doi:10.1001/jamanetworkopen.2020.3022
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