Immigrant Adolescents and Young Adults

Carol Lewis

IMMIGRANT AND REFUGEE HEALTH

International migration has become increasingly fluid, diverse, and common. Immigrants and refugees have health burdens that are often uniquely global and confront barriers to care, including linguistic, cultural, and legal issues as well as those that accompany poverty. In spite of this, many providers do not feel adequately equipped to provide the needed cross-cultural care.¹,²

Worldwide, the migrant population has increased dramatically to more than 3% of the world’s population.³ The US became home to over 1 million newly arrived immigrants in 2012, representing a marked increase in immigration over the last century (www.migrationinformation.org/datahub/charts/final.fb.shtml),⁴ and the US leads in countries welcoming foreign-born individuals (http://esa.un.org/unmigration/documents/The_number_of_inter-national_migrants.pdf).³ It is estimated that over 41 million US residents are foreign-born, representing just over 13% of the entire US population and more than half have noncitizen status⁵ (http://www.pewhispanic.org/2013/01/29/statistical-portrait-of-the-foreign-born-population-in-the-united-states-2011/). Fifty-eight percent of new legalized immigrants reside in five states: California (19.4%), New York (13.5%), Florida (10.4%), Texas (9.4%), and New Jersey (5.4%).

Of particular interest is the increasing number of foreign-born adolescents and young adults (AYAs) who reside in the US, which is estimated to be over 4 million (aged 15 to 24).⁶ In addition, 76% of Unaccompanied Alien Children (UAC, US Customs term) are between the ages of 14 and 18.⁷

Cultural Competency

A provider should:

Acquire knowledge and information about the particular group(s) one is working with and/or develop a relationship with the medical interpreter or community health worker and utilize their knowledge for cultural and linguistic interpretation.
Use a medical interpreter for all encounters with limited English proficient (LEP) patients.
Approach each encounter with humility and respect, recognizing that each medical provider also has a cultural perspective from which the world is seen and may affect the perception of other cultures.
Develop a comfort with differences that exist between one’s own personal culture and the cultural values and beliefs of others.
Remember that most immigrant AYAs are forgiving of cultural “mistakes” as long as the provider conveys a genuine sense of caring and respect.

Interpretation

Poor communication can be potentially devastating for patients seeking health care and also decreases access to health care.⁸,⁹ LEP patients are at increased risk for medical errors. The US federal law mandates “linguistic accessibility to health care” under Title VI of the Civil Rights Act. Health care providers who receive federal funding are required to provide language access to LEP individuals who cannot communicate with their provider, but as might be expected, interpreters are often underutilized.¹⁰,¹¹ Useful tips for the use of medical interpreters can be found in Table 79.1 ¹² (www.health.state.mn.us/divs/idepc/refugee/guide/11interpreters.html).

In the event that an interpreter is not available, the use of a telephone interpreter service may be an option. It is important to provide information to the telephone interpreter regarding the setting prior to initiating the interview.

Legal Status

The legal status of migrants often complicates or influences an immigrant’s ability to obtain medical insurance and their comfort to
seek medical care. It is useful to understand the different classifications of foreign-born individuals to better appreciate barriers and their medical needs.

TABLE 79.1
Guidelines for Using Medical Interpreters

Use qualified interpreters trained in medical interpretation.
Do not depend on children or other relatives and friends to interpret.
Have a brief preinterview meeting with the interpreter.
Address yourself to the interviewee, not to the interpreter. Maintain eye contact with the interviewee.
Avoid jargon and technical terms.
Keep your utterances short, pausing to permit the interpretation.

From the Minnesota Department of Health Refugee Provider Guide.

Refugees are designated by the United Nations High Commissioner for Refugees because they are forced to leave their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion and are living outside the country of nationality.¹³ These individuals are recognized as refugees prior to arrival and typically are from countries experiencing significant violence and conflict. Refugees may apply for legal permanent resident (LPR) status after living in the US for 1 year.
LPRs are individuals who come to the US and are legally accorded the privilege of residing permanently.
Unauthorized immigrants arrive but do not have LPR status and face potential deportation and separation of families.
Asylees meet the definition of refugees, but are already in the US and are seeking admission at a port of entry.

Legal status has implication for access to health insurance. Refugees are provided with increased services through the US State Department in partnership with local Volunteer Resettlement Agencies (VOLAG). In addition to initial reception and placement, they are provided with medical assistance in the first 8 months after arrival in the US. Application for change in legal status to LPR necessitates a specific medical examination as required by the US Citizen and Immigration Service (USCIS). Unauthorized immigrants do not have access to health insurance and often do not seek medical attention for fear of deportation. Unauthorized immigrants are not eligible for change in legal status to LPR under the US federal law. Young adult immigrants (aged 16 to 26) are more likely to be unauthorized as compared to immigrants as a whole. In fact, nearly half of young adult immigrants are unauthorized. They are unique as compared to other marginalized young adults in that they are categorically excluded from programs, benefits, and services offered to other young adult groups.¹⁴

Health Screenings

Overseas Medical Screening

Overseas medical screening is required for all immigrants and refugees before entering the US. The purpose of this examination is to identify individuals with any disease of public health concern that renders the individual inadmissible. The evaluation is performed by panel physicians designated by the local US Embassy overseas. Guidelines for panel physicians are determined by the Centers for Disease Control and Prevention (CDC) Immigrant and Refugee Health.¹⁵

Excludable conditions of public health significance are Class A conditions and include the following:

Active tuberculosis (TB)
Syphilis
Chancroid
Gonorrhea
Granuloma inguinale
Lymphogranuloma inguinale
Hansen disease (leprosy)
Mental health disorder with associated harmful behaviors
Substance-related disorder with associated harmful behaviors

The US Medical Screening

This is recommended by the CDC for all refugees and immigrants within 30 to 60 days upon arrival and aims to identify public health disease, promote and improve the health of the refugee/immigrant, and prevent disease and familiarize refugees with the US healthcare system.¹⁶

The health burden of refugees has been well documented,¹⁷,¹⁸ and evidence-based recommendations for screening for refugee and immigrant AYAs include the following:

A complete history (including detailed travel history)
Review of all predeparture overseas documents including chest x-ray or predeparture presumptive treatment for malaria, schistosomiasis, or strongyloides

Complete physical examination should include the following: