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    Original Investigation
    Public Health
    April 17, 2020

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

    Author Affiliations
    • 1Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
    • 2Dominican University, River Forest, Illinois
    • 3David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
    • 4Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles
    • 5Health Systems Science Department, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
    JAMA Netw Open. 2020;3(4):e203028. doi:10.1001/jamanetworkopen.2020.3028
    Key Points español 中文 (chinese)

    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 practitioners.


    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 federal- and 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 understanding of the ways in which health care facilities can serve to mitigate perceived risks among their patients and employees can be one step toward optimizing health care for immigrants.