Social Determinants of Health
and Health Disparities Among
Immigrants and their Children
Cindy D. Chang, MD
In 2017, the United States (U.S.) foreign-born population was
estimated to be 44.5 million, the highest share since 1910. It is
unclear how many undocumented immigrants live in the U.S.,
but estimates in 2014 determined that there were at least
12.1 million. The immigrant population, particularly undocu-
mented immigrants, has consistently been affected negatively
by social determinants of health such as poverty, food and
housing insecurity, lack of educational attainment, and
he immigrant population in the United States
T (U.S.), particularly undocumented immi-
grants, is one of the most affected in terms of
poverty and health disparities. This vulnerable popula-
tion tends to be a difficult one to study, particularly
those who lack legal status given that it is difficult to
account for this particular demographic. Undocu-
mented immigrants originate from countries with
long-term war or civil unrest, or in some cases they
migrate for economic, cultural, social, and political
reasons.1 This group is at increased risk for poor phys-
ical and psychological health given the lack of eco-
nomic opportunities and societal resources, poor
health care access, and stigma.
Demographics of the U.S. immigrant
population
Given the rising immigrant population, it is impor-
tant to understand their demographics and migratory
patterns in order to address the social factors that
affect their health. The U.S. Census Bureau sends out
an annual nationwide survey known as the American
Community Survey (ACS) to make estimates of the
U.S. population in regards to their demographics,
From the Department of Emergency Medicine Los Angeles County, Har-
bor-UCLA Medical Center 1000 West Carson St, Torrance, CA 90509,
United States.
E-mail: CindyChang@dhs.lacounty.gov
Curr Probl Pediatr Adolesc Health Care 2019;49:23 30
1538-5442/$ - see front matter
Published by Elsevier Inc.
https://doi.org/10.1016/j.cppeds.2018.11.009
Curr Probl Pediatr Adolesc Health Care, January 2019
challenges with health care access. Additionally, they face
stigma and marginalization, difficulties with acculturation, and
fear of deportation. Given these challenges that immigrants
and their children face, physicians have a responsibility of
assessing these social determinants of health and providing
comprehensive care for this population.
Curr Probl Pediatr Adolesc Health Care 2019; 49:23 30
social, economic, and educational characteristics. The
ACS survey does not ask about legal status, but it
does make an estimate on the foreign-born population
(naturalized citizens, lawful permanent residents, refu-
gees and asylees, persons on temporary visas, and
undocumented immigrants). In 2017, the U.S. foreign-
born population was estimated to be 44.5 million,
comprising 13.7% of the total U.S. population (325
million) and the highest share since 1910. Of the for-
eign-born population, 22.5 million are not U.S. citi-
zens with 1.9 million being less than 18 years of age.2
As of 2014, the U.S. Department of Homeland Secu-
rity estimated that there were roughly 12.1 million
undocumented immigrants living in the U.S, mainly
in California, Texas, Florida, New York, New Jersey,
and Illinois.3 5
Millions of immigrant families are known as “mixed-
status” families, which include at least one citizen or
legal immigrant child and at least one parent who is an
undocumented immigrant. It is estimated that 18.1 mil-
lion children live with at least one immigrant parent and
88% of these children are U.S. born. Around 5.1 million
children currently live with at least one undocumented
immigrant parent.6,7 Due to the limitations of educational
and economic opportunities that undocumented immi-
grants face, it is not surprising that their children struggle
with early disadvantages in development, social margin-
alization, and fear of deportation.
Undocumented children in particular suffer from
many stressors including relationship conflicts with
sponsors or household members, school enrollment,
educational challenges, food and housing insecurity,
23
financial strains, and acculturation.8 All these stressors
follow them throughout childhood development and
into adulthood placing them at risk for continued pov-
erty, physical and mental health problems, and home-
lessness. In recent years, there has been a rise of
undocumented children crossing into the U.S. through
the southern border.9 Most of these unaccompanied
children are coming from Central America countries
such as Guatemala, El Salvador, and Honduras that
face violence, economic instability, and increased pov-
erty.10,11 Many of these children suffer from traumatic
events from their experience in their home country.12
When children are apprehended by immigration author-
ities, they are referred to the Office of Refugee and
Resettlement (ORR), a division of the U.S. Department
of Health and Human services. While these children
wait to be claimed, they are placed in shelters for the
duration of their immigration cases. In 2017, there
were 40,810 children referrals to the ORR a dramatic
rise in comparison to 13,625 children in 2012.13
Social determinants of health in the
immigrant population
Social determinants of health refer to non-medical fac-
tors determined by social and economic systems and
inequalities that have important effects on health. They
are the conditions in which people are born, grow, live,
work, and age and are mostly responsible for health
inequities.14,15 Immigrants in particular are at a great risk
of suffering from health disparities due to social factors
like poverty that impact their lives.
Immigrants as a group are often known to benefit from
what is known to be the “healthy immigrant effect”16,17,
given that they tend to have less chronic health problems
when compared to native residents upon early arrival
from their home countries. According to a study on
homeless immigrants in Toronto, Canada, these individ-
uals tend to be mentally and physically healthier, and
suffer less from chronic conditions and substance abuse
problems than native-born homeless individuals. How-
ever, the prevalence of mental health problems is still
quite high and immigrants who have lived more than ten
years in their new country end up having similar health
problems as the native population.18
Undocumented immigrants have also often suffered
through migration stressful events, including impris-
onment, rape, ethnic cleansing, physical violence, eco-
nomic distress, and torture that impact both their
24
physical and mental health.1 All these factors in addi-
tion to the social, educational, and economical disad-
vantages they face in their new home country
contribute to the decline of the initial immigrant
health advantage. The following are several social
determinants of health that affect immigrants:
Health care system
Health care access is one of the major barriers that con-
tribute to health disparities in the immigrant population,
particularly the undocumented who are ineligible for
federal government programs such as Medicaid or the
Children’s Health Insurance Program (CHIP). In 2010,
the Patient Protection and Affordable Care Act (ACA)
was signed into law and provided insurance to millions
of people, but explicitly excluded undocumented immi-
grants from enrolling into coverage through the health
exchanges. They are also not allowed to buy Market-
place health coverage, receive premium tax credits, or
obtain other savings on Marketplace plans.19 Without
subsidies, buying insurance becomes cost prohibitive for
immigrants that are largely affected by poverty.
As of 2017, there were still over 28 million people in
the U.S. without health insurance. Of these, 3.9 million
of them were children younger than 18 years of age.20
The Kaiser Family Foundation estimated that noneld-
erly undocumented immigrant adults were four times
more likely to lack health care coverage compared to
citizens and the uninsured rate for undocumented immi-
grant children was nearly five times greater than for cit-
izen children. Legal immigrants were also two times
more likely than natives to lack health care coverage.21
Health care may be available for many children in
immigrant families; however they currently represent
nearly half of the uninsured child population.22 They are
known to have lower access to care, even after control-
ling for health status and insurance coverage.23,24 Low-
income immigrant families have difficulties obtaining
health insurance coverage for their children due to lack
of family experience with health insurance programs,
distrust of the health care system, or uncertainty regard-
ing their child’s eligibility for Medicaid or CHIP cover-
age.25 27 Such obstacles demonstrate that despite access
being available to many children, non-medical factors
negatively affect access to health care.
Given the difficulties of obtaining public health
insurance, many immigrants rely on employer-based
insurance or go to community health clinics, free clin-
ics, and emergency departments to access medical
Curr Probl Pediatr Adolesc Health Care, January 2019
care. In cases of needing emergent medical care, immigration enforcement and mistrust of health serv-
undocumented immigrants can apply for Emergency ices.26 Among Hispanic children, the prevalence of poor
Medicaid coverage if they are in a Medicaid-eligible health, obesity, and physical inactivity remains high.37
category such as children, pregnant women, families Immigrant children have lower rates of immunization,
with dependent children, and elderly or disabled indi- are less likely to be prescribed recommended preventive
viduals. Federal guidelines define emergency services medications for asthma, and have a higher incidence of
as either labor and delivery or treatment after sudden suffering from diseases such as tuberculosis and Hepati-
onset of an acute illness that requires immediate medi- tis A compared to native-born children.38 40
28
cal attention to prevent serious complications. Mental health disparities are also highly prevalent.
Within the health care sys- Immigrants report increased feel-
tem, it is important for physi- ings of sadness, depression, and
cians to provide immigrants Within the health care system, it loneliness after several years of
with culturally competent and is important for physicians to living in a new country compared
linguistically appropriate care. provide immigrants with cultur- to when they initially arrived.16
Immigrant families may have ally competent and linguistically They face challenges such as
different culture, religion, or lower income, acculturation and
social class that affects their
appropriate care. ethnic identity, and discrimina-
interactions with the provider tion. Stigma and denial of mental
and the health care system.29 Over half of the undocu- illness have been previously identified as major barriers
mented immigrants in the U.S. are from Mexico and to treatment41, especially when accounting for the differ-
since 2004 there has been a rise of immigrants from ent cultural and religious beliefs. Elderly immigrants
Central America (El Salvador, Guatemala, Honduras), also have poorer physical and mental health outcomes
Asia, and Sub-Saharan Africa.4 Compared to the gen- compared to non-immigrant elderly including higher lev-
eral population, racial and ethnic minority groups els of depression and more difficulties with instrumental
have poorer health outcomes from preventable and activities of daily living.42
treatable diseases, such as cardiovascular disease, can-
cer, asthma, prenatal care, obesity among children,
and human immunodeficiency virus (HIV).30,31 Poverty
Immigrants receive suboptimal care when it comes Undocumented immigrants experience disproportion-
to obtaining preventive health care services, managing ately high rates of poverty over half of them reported
their chronic health conditions, living below the federal poverty
and accessing mental health
services. They have dispropor-
Immigrants receive suboptimal line compared to a third of legal
immigrants and only 11% of U.
tionately low breast, cervical, care when it comes to obtaining S.-born and naturalized citizens.40
and colorectal cancer screening preventive health care services, Foreign-born workers are more
rates compared to the native pop- managing their chronic health likely than natives to receive low
ulation.32 34 Undocumented
Latinos are less likely to receive
conditions, and accessing men- wages and less likely to receive
employer-provided benefits, such
blood pressure and cholesterol tal health services. as health insurance.43 Despite
level checks compared to the high rates of employment, many
native population.35 In Califor- immigrant parents are unable to
nia, they were reported to be less provide for their families’ needs.
likely to have a usual source of It is difficult for immigrant It is difficult for immigrant
care other than the emergency parents to address both their parents to address both their
department and least likely to
have visited a doctor when com-
health necessities and those of health necessities and those of
their children when there are
pared to the native population.36 their children when there are unmet fundamental needs such
Hispanic or Latina mothers have unmet fundamental needs such as food and housing. Pediatric
also received both late and inade- as food and housing. practices implementing social
quate prenatal care due to fear of determinants of health screening

Curr Probl Pediatr Adolesc Health Care, January 2019 25

have revealed rates as high as 75% of patients reporting York Immigration Coalition noted that 61% of legal
food insecurity and housing deprivation.44,45 service providers reported at least one immigrant cli-
Poverty is a strong determinant of child well-being ent living in a homeless shelter, with 20% reporting
and is very common among immigrant children. It is having at least 50 of them in shelters. Over half of sur-
closely linked to negative physical, developmental, vey respondents noted that 90-100% of their immi-
and mental-health related outcomes.46 Between grant clients lived below the poverty line.52
2009-2013, three-quarters of children with an undocu-
mented immigrant parent lived in families with
Education
incomes below 185 percent of the federal poverty
level. By contrast, 51% of children of immigrants Health literacy, defined by the U.S. Department of
overall and 40% of all U.S. children lived in familiesHealth and & Human Services, is the ability to “obtain,
with incomes below this threshold.7 process, and understand basic health information and
Immigrant families face unexpected financial hard- services to make appropriate health decisions.”53 In
ship when an undocumented immigrant parent is 2003, the U.S. Department of Education reported that
apprehended and deported. The sudden loss of income over 75% of adults with less than a high school degree,
leaves many immigrant families struggling with food 53% of uninsured adults, and up to 60% of Medicaid or
insecurity and experiencing homelessness. This leads Medicare recipients had a below basic or basic level of
health literacy.54 This is concerning given that there are
to increased stress, anxiety, and depression seen in the
remaining parent and children. Older children in thesecurrently 25.2 million people having less than a high
families also struggle more with school, with many of school degree in the U.S.20
them deciding to get a job to support their family Given the disparities that exist, immigrants suffer from
instead of pursuing a college degree.47 poorer health literacy when compared to the native pop-
ulation. More than half of undocumented immigrant
adults do not have a high school diploma, in contrast to
Housing insecurity and homelessness
6.4% of U.S. natives. Older children of undocumented
Housing insecurity has been linked to poor health immigrants complete significantly fewer years of formal
outcomes for both adults and children and is more education than those with legal immigrant parents.55
common among the impover- Depending on how many years
ished. It is associated with food of schooling they receive many
insecurity and negatively Immigrants with low health liter- undocumented immigrants likely
impacts a child’s growth and acy and limited English profi- struggle with reading and writing
development.48 Crowding in ciency are known to have and may not understand written
homes and multiple moves also 56 medical instructions.
poorer health outcomes.
affects children’s mental health, Immigrants with low health
ability to cope with stress, and literacy and limited English
sleep. Both adults and children living in crowded proficiency are known to have poorer health out-
households are less likely to access health care and comes.56 A 2018 survey given out to Hmong Ameri-
seek out preventive services than are those in non- cans showed that half of them reported not
crowded households.49,50 understanding health information well, including hav-
Undocumented immigrants are a vulnerable popula- ing difficulties with functional aspects of health liter-
tion at risk for housing insecurity and homelessness. acy such as medication management.57 Even among
Immigrants face high rates of poverty and tend to Asian Americans, the level of health literacy among
have low-wage jobs that are unable to meet the rising subgroups is variable with Chinese, Korean, and Viet-
housing costs, especially in places such as Los namese groups reported to have the lowest levels of
Angeles and New York City, where there are high health literacy.58 Another study reported that among
concentrations of both immigrants and homeless pop- those with limited-English proficiency, Chinese
ulations.4,51 Not much is known regarding the inci- respondents had the highest prevalence of low health
dence and prevalence of homelessness among literacy (68.3%), followed by Latinos (45.3%), Kore-
immigrants; however a significant number of them ans (35.6%), Vietnamese (29.7%), and Whites
reside at homeless shelters. A survey by the New (18.8%).56

26 Curr Probl Pediatr Adolesc Health Care, January 2019

 Language barriers and limited-English proficiency
place immigrants at a higher risk of mismanagement
of their medical conditions and is a concern for patient
safety. Adverse medication reactions occur frequently
when patients receive instructions in a language they
don’t speak or read fluently.59 Over 74% of undocu-
mented immigrants report not speaking English well
at all, compared to half of documented immigrants
and a quarter of naturalized citizens.40 Non-English
speaking or limited-English speaking parents fre-
quently have problems interacting with the health care
system, thereby increasing their children’s risk of
having poor health outcomes.60
Immigration policies and laws
Tight immigration policies can affect the health
and well-being of undocumented immigrants. A
systematic review of the impact of immigration
policies on the health status among undocumented
immigrants found that immigration laws and poli-
cies explicitly provided or restricted access to
health services. Several immigration laws using the
word “undocumented” excluded immigrants from
federally funded prenatal care and from receiving
vital services such as treatment for HIV and other
sexually transmitted infections.1
According to the Personal Responsibility and Work
Opportunity Reconciliation Act (PRWORA), undocu-
mented immigrants are ineligible for publicly funded
federal services such as health care, food stamps,
housing subsidies, or disability benefits. Legal immi-
grants are ineligible until after their first five years of
residence in the U.S. However, according to a joint
letter written by the U.S. Department of Housing and
Urban Development, the U.S. Department of Health
and Human Services, and the U.S. Department of Jus-
tice, housing and service providers that receive federal
financial assistance must not turn away homeless
immigrants or immigrants who are victims of domes-
tic abuse or human trafficking based on their immigra-
tion status.61 This letter was written to clarify that
PRWORA restricts immigrant access to certain fed-
eral public benefits, but does not restrict access to
services that protect life or provide safety. Many
immigrant parents fear that accessing services for their
eligible children will lead them to be considered a
public charge, someone who is dependent on the gov-
ernment for subsistence62, and worry how that may
impact their immigration status and prospects. There
Curr Probl Pediatr Adolesc Health Care, January 2019
is also fear that agencies offering assistance will share
information with immigration agencies.63
In 2012, the Deferred Action for Childhood Arrivals
(DACA) became one of the largest immigration poli-
cies to affect undocumented immigrants in the U.S. by
providing temporary work permits and freedom from
deportation to undocumented youth who arrived to the
U.S. as children. While undocumented youth have the
right to K-12 public education, their illegal residency
status as they become adults previously prevented
them from working legally and obtaining higher edu-
cation.64 Of the estimated 1.7 million of eligible
undocumented youth, more than 820,000 applications
were approved for DACA as of 2018.65,66 Studies
have shown that since DACA implementation, these
undocumented youth have had improved social deter-
minants of health such as increased educational attain-
ment, economic stability, and health care access.67
DACA recipients have had increased sense of well-
being and improved mental health due to the removal
of constant stressors involving deportation and finan-
cial insecurity.68 These findings suggest that laws do
have an impact on the social determinants of health of
immigrants.
Discussion
With the growing immigrant population in the U.S.,
it is important to address the social determinants of
health that lead to health disparities, particularly
among the undocumented. Issues such as lack of
health care access, low socioeconomic status, food
and housing insecurity, and transportation barriers
negatively impacts immigrants.
The lack of diversity and cultural competence in the
health care field also impact the care provided to
undocumented immigrants who tend to already have
very low levels of health literacy.69 Physicians should
assess for health literacy and provide culturally com-
petent and linguistically appropriate care. In order to
address these issues in medicine, several medical
schools across the country have implemented courses
that teach cultural competence.70,71 There has also
been an increased effort to recruit underrepresented
minorities into the medical field that reflect the
increasingly diverse U.S. population.72,73
Given the current immigration laws and recent dis-
crimination acts that have raised fear among undocu-
mented immigrants, it is likely that they will continue
to face health disparities. The current state of
27
immigration enforcement has become a public health
concern, with foreign-born individuals being at
increased risk of having active tuberculosis and HIV
positive immigrants receiving delayed care.74 Undoc-
umented immigrants who need health care may be
afraid to seek it for fear of arrest or deportation. In
recent years, there have been increased reports of per-
secution from the U.S. Immigration and Customs
Enforcement (ICE), including agents arresting undoc-
umented immigrants outside a church homeless shel-
ter and targeting individuals with Latino-sounding
names inside a commercial hotel.75 78 Currently, ICE
has a policy of not taking enforcement actions at
“sensitive locations” such as schools, hospitals,
churches, or public demonstrations unless they have
exigent circumstances.79 Homeless shelters, food
banks, courthouses, or locations providing disaster
relief are not considered sensitive locations. With
recent discrimination acts, it is not surprising that
undocumented immigrants may be hesitant to access
services available to them.
Health care providers have the responsibility of
addressing the social determinants of health that affect
the physical and mental health of this vulnerable pop-
ulation. Without new federal health reform or a path-
way to citizenship, undocumented immigrants will
continue to face health disparities. Health care pro-
viders at community health centers, clinics, and public
hospitals will have to continue building creative strat-
egies to provide necessary comprehensive care for
undocumented patients.
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