The United States is home to approximately 44.5 million immigrants and refugees, and these numbers continue to grow. To ensure a healthy immigrant and refugee population, it is important to address the unique health needs of these communities. Migrant women face many obstacles in obtaining women’s health services, including language and cultural barriers, difficulty finding childcare to attend medical appointments, and transportation difficulties. These factors are compounded by systemic difficulties in receiving health insurance coverage. Published literature describes women’s health in immigrant and refugee women living in the United States, but much of this literature either focuses on specific cultural or religious groups rather than looking at overall trends in women’s health care or does not differentiate between women’s and men’s health services in immigrant and refugee populations. Through reviewing published studies, the aim of this paper is to analyze general trends about the accessibility of women’s health services to immigrant and refugee women living in the United States. This paper will also look at specific examples of cultural and religious groups in the United States to examine the variation in women’s health preferences and issues among immigrant women of different backgrounds. Finally, this paper will explore potential ways to improve women’s health services available to immigrant and refugee women living in the United States.

HEALTH RISKS, NUTRITION ASSESSMENT AND DISEASE PREVALENCE AMONG AFRICAN IMMIGRANT GROUPS IN ATLANTA GEORGIA Background: Though past studies have suggested immigrants are generally healthier than the native population, the immigrant acquisition of chronic diseases, such as obesity, hypertension and diabetes, over time, is poorly understood among African immigrants. Objective: The objective of this study was to evaluate the health status, health risks chronic disease prevalence, and acculturation among immigrants from Ghana, Kenya and Nigeria. Participants/setting: 130 adult African immigrants living in Atlanta and attending any of four church health fairs. Participants completed anthropometric, health status assessments and a Home Environment Family connections Survey. Main outcome measures: BMI, waist circumference, blood glucose, blood pressure, fruit consumption frequency, availability of sugared sweetened drinks and physical activity were assessed and compared among African immigrant groups. Statistical analysis: Prevalence was calculated. Independent sample t-test, one-way ANOVA, and Pearson correlation coefficients were used to compare anthropometrics while demographic and categorical survey data was compared using chi-squared tests. Results: There was a statistically significant difference in the mean BMIs of African Immigrants (Nigeria and Ghana) (p=0.013) but not in the waist circumferences (p>0.05). High blood pressure prevalence in Ghanaian, Nigerian and Kenyan immigrants was 42.6 %, 36.8 %, and 25.8 % respectively. The prevalence of diabetes in Ghanaian, Nigeria and Kenyan immigrants was 18.8 %, 11.8 %, and 4.9 % respectively. Obesity prevalence in Nigerian, Kenyan and Ghanaian immigrants was 52.6 %, 45.8 %, and 31.1 % respectively. There were no statistically significant associations between the Years of Stay status and disease prevalence (p>0.05). There were no statistically significant associations between the BMI status and the availability of sugared sweetened drinks in the household, fruit consumption frequency, or the physical activity of African immigrants. Conclusion: African immigrants appear to have a slightly lower prevalence of diabetes, but a higher prevalence of hypertension and obesity than the United States population. Acculturation did not play a strong role in determining the health trajectories of African immigrants. Grouping immigrants by their country of origin does provide another important dimension in understanding the variation in immigrant health as each group had significant differences in the prevalence of diseases.

The claim of some policymakers that education is the great equalizer of socioeconomic disparities in health (Low et al. 2005) has come under question in recent years. Higher education is related to better health for both immigrants and the Canadian-born. However, immigrants experience weaker health returns to their education than the native-born (Kennedy et al. 2006). Despite the importance of this issue, the reasons for this gap are not fully understood. This dissertation integrates the immigrant health, social stress, and immigrant integration literatures to better understand this issue, using Cycles 17 and 22 of the Statistics Canada collected General Social Survey (GSS). The analyses reveal that education has a diminished effect on the self-rated health (although not stress) of immigrants, the functional limitations of established immigrants, and the happiness of recent immigrants. The reasons for this gap vary depending on the health measure. The weaker relationship between education and the functional ability of established immigrants and the happiness of recent immigrants is explained by immigrants’ lower work-related returns (employment type, occupational skill, personal income) to education. For self-rated health, the nativity status differential in the effect of education on self-rated health is rooted in immigrants’ lower work-related and psychosocial returns (mastery and trust, although not social support) to education. Since work-related and psychosocial resources are integrally linked to health, immigrants experience lower health returns to their education than the native-born. These findings make three major contributions. First, they extend the traditional understanding of the relationship between education and health (Low et al. 2005), underscoring that immigrants do not experience the same level of health benefits to their education as the native-born. Second, they augment knowledge about why immigrants experience weaker health returns to their education than the native-born: because they receive diminished employment types, occupational levels, income, mastery, and trust relative to their levels of education. Third, the results highlight that foreign education is not linked to as high mastery and trust as that of the native-born – a new finding that underscores that foreign education is not just linked to diminished work-related resources and health, but psychosocial resources as well.

The claim of some policymakers that education is the great equalizer of socioeconomic disparities in health (Low et al. 2005) has come under question in recent years. Higher education is related to better health for both immigrants and the Canadian-born. However, immigrants experience weaker health returns to their education than the native-born (Kennedy et al. 2006). Despite the importance of this issue, the reasons for this gap are not fully understood. This dissertation integrates the immigrant health, social stress, and immigrant integration literatures to better understand this issue, using Cycles 17 and 22 of the Statistics Canada collected General Social Survey (GSS). The analyses reveal that education has a diminished effect on the self-rated health (although not stress) of immigrants, the functional limitations of established immigrants, and the happiness of recent immigrants. The reasons for this gap vary depending on the health measure. The weaker relationship between education and the functional ability of established immigrants and the happiness of recent immigrants is explained by immigrants’ lower work-related returns (employment type, occupational skill, personal income) to education. For self-rated health, the nativity status differential in the effect of education on self-rated health is rooted in immigrants’ lower work-related and psychosocial returns (mastery and trust, although not social support) to education. Since work-related and psychosocial resources are integrally linked to health, immigrants experience lower health returns to their education than the native-born. These findings make three major contributions. First, they extend the traditional understanding of the relationship between education and health (Low et al. 2005), underscoring that immigrants do not experience the same level of health benefits to their education as the native-born. Second, they augment knowledge about why immigrants experience weaker health returns to their education than the native-born: because they receive diminished employment types, occupational levels, income, mastery, and trust relative to their levels of education. Third, the results highlight that foreign education is not linked to as high mastery and trust as that of the native-born – a new finding that underscores that foreign education is not just linked to diminished work-related resources and health, but psychosocial resources as well.

Childhood obesity (CO) is a significant public health issue in the United States, including the immigrant populations. Obese children and adolescents are at increased risk for multiple preventable comorbidities that affect their physical health and psychological well-being. The perception exists that the immigrant child population may possess protection against CO, but this group also experienced an increased prevalence of CO. Acculturation, or the adaptation to American culture and lifestyles, has been shown to be associated with the increased obesity rate among immigrant children and adolescents. Understanding the association between acculturation factors and CO is necessary to effectively combat obesity among children and adolescents in immigrant populations. The purpose of this literature review is to analyze the association of acculturation factors on the prevalence of CO among U.S. immigrant children and adolescents. Only articles that examined CO and at least one aspect of acculturation were included in this review. Twelve articles meeting the criteria were retrieved from CINAHL, Medline, PsychInfo, Academic Search Premier, and ERIC. The review identified the following acculturation factors to be associated with CO: parental immigration factors, child immigration factors, country of birth, generational status and primary home language, parental level of acculturation, and CO related lifestyle practices. There is modest evidence to suggest that a combination of acculturation factors is associated with increasing CO rate in immigrant populations. This review enhances the knowledge and awareness of public and pediatric healthcare professionals to develop targeted interventions that promote healthy weight in immigrant children and adolescents at increased risk for obesity.

African immigrant women and refugee women face disproportionate reproductive health risks and adverse outcomes compared with the Canadian population. The diversity of African women and complexity of the migration process suggest the need for contextualized knowledge to better understand these challenges. I sought such knowledge through the use of the theoretical frameworks of place and intersectionality. These frameworks draw attention to the multi-level mixture of social relations in given contexts and how they create opportunities and oppression. The specific purpose of this research was to: a) explore how the reproductive health experiences of African immigrant and refugee women were shaped by the unique context of given places; b) consider how these women actively negotiated and constructed place in their search for reproductive health information, services, and support. A multiple case study was used to explore the reproductive health experiences of African immigrant and refugee women in three different areas of Ottawa, Ontario. These areas provided different local contexts (e.g., history, socioeconomic profile, proximity to downtown). In each area, data was collected through interviews with African immigrant and refugee women, interviews and focus groups with reproductive health service providers, and mapping of available services. In total, 19 immigrant and refugee women and 23 service providers participated in this study. The findings showed that African immigrant and refugee women’s reproductive health experiences were much more complicated than simple interaction with neighbourhood services. Their varied social positions in Canadian society were highly relevant. In addition, social networks based in places outside of the system (e.g., private homes, religious institutions) were environments in which they were comfortable and sought support for their reproductive health needs. Recommendations based on these findings include the need to engage communities and explore the delivery of information and services outside of the traditional places employed by the Canadian health care system.

Aisha Kamilah O. Lofters Cervical Cancer Screening Among Ontario’s Urban Immigrants Doctor of Philosophy, 2012 Institute of Health Policy, Management and Evaluation University of Toronto Background: The majority of cervical cancers can be prevented because of the highly effective screening tool, the Papanicolaou (Pap) test. Relevant guidelines recommend routine screening for nearly all adult women. However, inequities in screening exist in Ontario. This dissertation, consisting of three studies, uses administrative data to advance knowledge on barriers to cervical cancer screening for Ontario’s urban immigrant population. Methods: First, we developed and validated a billing code-based algorithm for cervical cancer screening. We then implemented this algorithm to examine screening rates in Ontario among women with various sociodemographic characteristics for 2003-2005. Second, we compared the prevalence of appropriate cervical cancer screening in Ontario in 2006-2008 among immigrant women from all major geographic regions of the world and Canadian-born women. Third, we used a stratified multivariate analysis to determine if the independent effects of various factors that could serve as screening barriers were modified by region of origin for immigrant women for 2006-2008. Results: Our first study showed that our algorithm was 99.5% sensitive and 85.7% specific, and that screening inequities in Ontario’s urban areas are largest among women 50 years and older, living in the lowest-income neighbourhoods and new to the province. In our second study, we determined that immigrant women had significantly lower screening rates than their peers, with the most pronounced differences seen for South Asian women aged 50 years and above. In the final study, we demonstrated that living in the lowest-income neighbourhoods, being younger than 35 years or older than 49 years, not being enrolled in a primary care enrolment model, having a male provider, and having a provider from the same region of the world each significantly influenced screening for immigrant women regardless of region of origin. Conclusion: These results add to the literature on health equity in cancer screening. Our findings demonstrate that Ontario’s urban immigrant women experience significant inequities in cervical cancer screening, and may offer guidance toward targeted patient and physician interventions to decrease screening gaps.

Aisha Kamilah O. Lofters Cervical Cancer Screening Among Ontario’s Urban Immigrants Doctor of Philosophy, 2012 Institute of Health Policy, Management and Evaluation University of Toronto Background: The majority of cervical cancers can be prevented because of the highly effective screening tool, the Papanicolaou (Pap) test. Relevant guidelines recommend routine screening for nearly all adult women. However, inequities in screening exist in Ontario. This dissertation, consisting of three studies, uses administrative data to advance knowledge on barriers to cervical cancer screening for Ontario’s urban immigrant population. Methods: First, we developed and validated a billing code-based algorithm for cervical cancer screening. We then implemented this algorithm to examine screening rates in Ontario among women with various sociodemographic characteristics for 2003-2005. Second, we compared the prevalence of appropriate cervical cancer screening in Ontario in 2006-2008 among immigrant women from all major geographic regions of the world and Canadian-born women. Third, we used a stratified multivariate analysis to determine if the independent effects of various factors that could serve as screening barriers were modified by region of origin for immigrant women for 2006-2008. Results: Our first study showed that our algorithm was 99.5% sensitive and 85.7% specific, and that screening inequities in Ontario’s urban areas are largest among women 50 years and older, living in the lowest-income neighbourhoods and new to the province. In our second study, we determined that immigrant women had significantly lower screening rates than their peers, with the most pronounced differences seen for South Asian women aged 50 years and above. In the final study, we demonstrated that living in the lowest-income neighbourhoods, being younger than 35 years or older than 49 years, not being enrolled in a primary care enrolment model, having a male provider, and having a provider from the same region of the world each significantly influenced screening for immigrant women regardless of region of origin. Conclusion: These results add to the literature on health equity in cancer screening. Our findings demonstrate that Ontario’s urban immigrant women experience significant inequities in cervical cancer screening, and may offer guidance toward targeted patient and physician interventions to decrease screening gaps.

During the last decade, immigration operations have drastically increased in the United States. Between 2009 and 2015, the Obama administration deported a record high of 2.4 million unauthorized immigrants (Homeland Security, 2016). Due to the amplified number of migrants being deported, the number of individuals in U.S. Immigration and Customs Enforcement (ICE) detention centers has also increased. Consequently, this phenomenon has raised concerns regarding undocumented migrants’ access to medical services in these facilities. This research project was conducted in order to assess the quality of medical and health care services in ICE detention centers in the state of Arizona. It also examined whether the ICE operational manuals and detention standards on medical care were being followed and were consistent with the Universal Declaration of Human Rights. The findings indicated that ICE was not compliant with a major portion of their Performance-Based National Detention Standards on medical care and thus, were violating the basic human rights of undocumented immigrants in detention centers as stated in the Universal Declaration of Human Rights.

Local context should be considered a significant social determinant of health for immigrant communities, particularly those with precarious legal status. In this thesis I use a study done by Lilia Cervantes, MD and collegeaues of undocumented immigrants with end-stage renal disease attempting to access healthcare in three different US states to expand on my argument. Due to the lack of comprehensive federal immigration reform since 1986, many immigrants depend on the Emergency Medical and Active Labor Treatment Act (EMTALA) to access healthcare, which provides emergency-only care. Without federal mandates, further healthcare for this population is dependent on local laws and/or safety-net services. As a result, this local context impacts their medical outcomes, healthcare utilization and economic costs and acts as a potential moral hazard to family, patients and providers of and serving immigrant communities. / Urban Bioethics