Partnering with immigrant patients and families to move beyond cultural competence: A role for clinicians and healthcare organizations

Abstract

The delivery of culturally competent healthcare is recognized as critical to providing quality, equitable care for marginalized groups. This includes immigrant patients and families who experience significant barriers to healthcare and poor health outcomes. However, operationalization of cultural competence challenges healthcare delivery. Complementary concepts have also emerged such as cultural humility, cultural safety, and structural competence, recognizing the need for multi-level approaches involving patients, families, clinicians, healthcare organizations, the larger community, and policymakers. In this review, we define cultural competency and related frameworks and their applicability to immigrant patients and families. The evolution in terminology reflects an increasingly more comprehensive approach to understanding culture as multidimensional and shaped by social and structural factors. We then highlight strategies at each level, focusing on clinicians and organizations to leverage loci of control most directly within clinicians’ reach. Community-level strategies include community engagement (i.e., vis-à-vis community health workers or community advisory boards) for clinical and research practice. Organization-level strategies include “immigrant-friendly,” or “immigration-informed” policies aimed at reducing immigration-related stressors, like limiting cooperation with immigration enforcement agencies or developing medical-legal partnerships to assist with patients’ legal needs. Lastly, policy-level strategies seek to change local and federal policies to address needs beyond healthcare (e.g., education, housing, other social services), taking a “Health in All” policies approach that articulates health considerations into policymaking across sectors. Finally, we conclude with suggestions for future directions that center the experiences of immigrants, with the ultimate goal of sustainably meeting the complex needs of immigrant patients and families.

Effective medical care requires navigating patients’ and families’ unique perspectives, cultural belief systems, interpersonal relationships, and power structures. However, the socioeconomic, racial, ethnic, and linguistic diversity of the healthcare workforce continues to lag behind that of the general population, increasing the likelihood that clinicians’ lived experiences may differ from those they serve. This divergence is particularly pronounced for immigrant patients and families, who must also navigate numerous structural barriers to care. When healthcare is offered, incongruity with a patient’s belief systems can intimidate, undermine trust, and adversely impact treatment participation, even deterring care-seeking altogether. Continual efforts to bridge gaps in understanding and create welcoming, safe clinical spaces are thus critical to promoting health. In this review, we outline frameworks for conceptualizing and providing health care that centers the experiences of immigrant patients and families.

Definitions and Distinctions

Facilitating access and providing effective medical care for immigrant families requires clinicians and systems to engage patients with openness, curiosity, and respect. It also requires a basic understanding of the migration nomenclature, with the recognition that these labels do not reflect whole identities. We identify some common terms and definitions related to migration in Table 1. “Immigrant” refers broadly to individuals who have crossed international borders into a new country, with “refugee,” “asylum seeker/asylee,” “lawful permanent resident,” “undocumented/unauthorized immigrant,” and “Deferred Action for Childhood Arrivals (DACA) recipient” representing particular subsets of the immigrant population.¹

Table 1:

Common Terms and Definitions Related to Migration¹

Term	Definition/Description
Refugee	Person who has been forced to leave or flee native country because of war, persecution or violence Defined by the 1951 United Nations Refugee Convention and its accompanying 1967 Protocol as fleeing a specific kind of persecution based on “race, religion, nationality, membership of a particular social group or political opinion”
Asylum Seeker	A person seeking refuge due to persecution faced in their native country, but their claim has not yet been determined by the country in which they are seeking asylum In the U.S., asylum seekers are physically present in the U.S. or at a U.S. border and seeking permission to remain in the U.S., compared to refugees whose status has been determined prior to traveling to the U.S.
Asylee	Person who has been granted relief of asylum
Lawful Permanent Resident (LPR)	In the U.S., also known as “green card” holder Non-citizen who is lawfully authorized to live permanently within the U.S.
Undocumented or unauthorized immigrant	Foreign-born person who doesn’t have a legal right to be or remain in the country they have crossed into Another term used in the media is “illegal” immigrant, although the use of this term is contested on both legal and moral grounds. For example, it connotes criminality, despite presence in the U.S. without documentation being considered a civil rather than criminal offense
Deferred Action for Childhood Arrivals (DACA) recipient	Available to certain people who came to the United States as children and meet several guidelines Neither in lawful status nor fully undocumented, having been given protection from deportation for a period of 2 years, subject to renewal

Alongside terminology related to migration is terminology relating to “cultural competence” and related concepts. However, clinicians’ understanding of how to meet the needs of diverse populations such as immigrants has evolved over time since “cultural competency” was initially proposed as a framework in the 1980s.² Alternative frameworks proposed later include “cultural humility,” “cultural safety,” “culturally effective care,” “structural competence,” and “structural humility” (Table 2). Complementary concepts proposed later include “cultural humility,” “cultural safety,” “culturally effective care,” “structural competence,” and “structural humility” (Table 2).

Table 2:

Definition of Cultural Competence and Related Terminology

Concept/Framework	Definition	Examples relating to immigrant patients and families
Cultural competence	“a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations”2	Reading about customs from a particular region or cultural group prior to meeting with a patient
Cultural humility	“a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of her/his own beliefs and cultural identities”3	Asking a patient about their beliefs regarding their illness and what might help, then working with the patient to jointly craft a treatment plan that incorporates those beliefs
Cultural safety	“[C]ultural safety encompasses a critical consciousness where healthcare professionals and healthcare organisations engage in ongoing self-reflection and self-awareness and hold themselves accountable for providing culturally safe care, as defined by the patient and their communities, and as measured through progress towards achieving health equity”4	Critically reexamining use of terms such as “nonadherent” or “noncompliant,” and instead actively exploring with individual patients the barriers they face to participating in treatment plans and working collaboratively to overcome them
Culturally effective care	“the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions leading to optimal health outcomes”5	Demonstrating improvement in patient outcomes by providing appropriately translated educational materials that incorporate a cultural group’s commonly held beliefs or customs
Structural competence	“ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking, medication “non-compliance,” trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health”6	Leveraging a health care organization’s political clout to advocate for legislation that increases immigrant patients’ access to health insurance or nutrition benefits, regardless of immigration status
Structural humility	“the trained ability to recognize the limitations of structural competency”6	Seeking guidance from immigrantled community-based organizations to identify and prioritize public health challenges and develop and implement solutions

The cultural competency framework is individually focused. It suggests that clinicians can provide better care for patients from marginalized groups by increasing their knowledge about patients’ culturally specific beliefs and behaviors. This framework is critiqued because it can denote arrival at a fixed endpoint rather than engagement in a continual process, as well as perpetuate cultural stereotypes by reducing groups to a collective ‘they,’ failing to acknowledge culture as heterogeneous, nuanced, dynamic, and flexible. Further, cultural competence does not invite curiosity or reflection, and risks obscuring upstream sources of health inequities such systemic racism.

By contrast, cultural humility deconstructs traditional power dynamics within the clinician-patient relationship and encourages clinicians to explore how their own identities, rather than just the patients’, influence and inform clinical interactions.³ The core tenets of cultural humility call for lifelong learning, self-reflection, and mitigating interpersonal power imbalances with appreciation of patients’ knowledge and agency. Cultural safety is similar in foregrounding power dynamics and empowers patients to determine whether a clinical setting or encounter is safe.⁴ Empowerment within the healthcare space is particularly important for immigrant patients and families who may have experienced violence, loss, discrimination, and/or other hardships along their migration journeys.

Culturally effective care, a component of the American Academy of Pediatrics’ patient-centered medical home criteria, expands the scope of responsibility for cultural competence to the level of the healthcare system by emphasizing measurable improvement in health care outcomes.⁵ Finally, structural competence and structural humility are system-level corollaries that call for awareness of social policies and conditions that underlie health inequities, coupled with advocacy for collaborative solutions that center the voices of affected populations.⁶ Providing culturally appropriate therapeutic interactions therefore requires change not only by individual clinicians and healthcare teams but also at organization and policy levels.

Moving toward Multi-level Interventions

Addressing health inequities demands multilevel, collaborative interventions between patients, families, clinicians, healthcare systems, communities, and lawmakers to rectify socioeconomic, environmental, and system-level factors that undermine health for marginalized populations. To date, interventions aiming to improve health disparities have traditionally focused on individual patients or clinicians, albeit such interventions neglecting the contextual interplay of communities, organizations, and policies in fostering health. A social ecological conceptual framework better frames the many factors contributing to the health of immigrant patients and families (Figure 1)⁷, and thereby better informs target interventions, emphasizing that these levels are interrelated and embedded within one another. For example, Community Health Workers (CHWs, also called promotores or lay health workers) operate at the individual interpersonal level (i.e., between the CHW and the patient), at the community level (i.e., CHWs representing community members who share cultural, linguistic and life experiences with patients), at the organizational level (i.e., organizations committing person power and resources to using CHWs at various care touch points), and at the policy level (i.e., Medicaid or other payers reimbursing services provided by CHWs). Importantly, system-level interventions include disease-agnostic interventions to alter the root causes and contexts that yield social inequities and health disparities. We highlight some strategies at each of these levels, focusing on clinicians and healthcare organizations to leverage loci of control most directly within the health profession’s reach.

Figure 1.

Social Ecological Model and The Needs of Immigrant Patients and Families, adapted from Suárez-Orozco et al (2018).

1. Individual level strategies

A. Increasing cultural knowledge and practicing cultural curiosity

Clinicians working with immigrant patients and families should continually seek knowledge about patients’ and families’ cultures (e.g., gender norms, religious beliefs, use of names) alongside historical and political context of patients’ home countries as these affect their health beliefs and experiences.⁸ The cultural formulation interview included most recently within the DSM-V is one example of a tool to facilitate integration of patients’ backgrounds and beliefs into care provision.⁹ Building upon Kleinman et al.’s early work¹⁰, it facilitates better understanding of how patients make meaning of their problem (e.g., “Why do you think this is happening to you?”). Further, the tool includes example questions geared toward immigrants that incorporate pre- and post-migration stressors that could affect health and help-seeking behaviors (e.g., “Is there anything about your migration experience or current status in this country that has made a difference to your [problem]?”).¹¹ Other elements of a patient-based approach to cross-cultural care include being attentive to differences in styles of communication, family dynamics, traditions, customs and spirituality, gender issues.¹²

Understanding and integrating patients’ and families’ cultural beliefs around disease and healing supports tailored care. However, cultural and contextual histories must be explored sensitively to prevent re-traumatization for immigrants who have experienced discrimination or whose migration was precipitated or affected by violence or persecution.¹³ This necessitates using a trauma-informed approach that includes careful framing of, and asking permission to discuss, potentially difficult topics (e.g., family history for those who have experienced loss or separation) and practicing a strengths-based approach to care.¹⁴ Familias Reunidas and Family Reunification and Resiliency Training (FUERTE) are two model community-based programs that incorporated these principles to meet the needs of recently immigrated children whose parent(s) immigrated years before them.¹⁵ In the clinical context, time constraints necessitate that cultural/contextual exploration should focus on topics relevant to immediate care needs, while ensuring provision of adequate resources to process traumas, including psychological support.

B. Attending to intersectional identities.

It is imperative that providers recognize the limitations of broad brushstroke understandings of patients and families and their cultural backgrounds. Kimberlé Crenshaw coined the term “intersectionality” to illustrate how overlapping identities lead people to navigate the world differently (e.g., Black women navigating discrimination based on multiple marginalized identities of race and gender).¹⁶ Likewise, immigrants may experience discrimination based on several marginalized identities including but not limited to class, race, immigration status, sexual orientation and gender identity, and migration generation.

A scoping review of existing cultural competency related interventions in service settings noted limited attention to intersectional identities and intergenerational cultural differences, representing a poignant gap for this population in particular.¹⁷ This is especially relevant for immigrant youth, or children of immigrant adults, for whom parent-child conflicts, family cohesion or lack thereof, acculturative stress and acculturation gaps portend psychological distress and poor mental health outcomes.^18,19 For example, immigrant children and youth can experience “adultification” as their linguistic abilities and cultural assimilation outpace that of their parents (the “acculturation gap”), which can be a source of stress.²⁰ Ultimately, recognizing intersectional marginalization allows for provision of better care by allowing clinicians to consider and address multiple factors that could be contributing to a patient’s health.

C. Clinician self-awareness and cultural identity.

Clinicians should engage in continual reflection around how their personal identities and biases affect interactions with and care of immigrant patients and families. White et al. developed a 14-session didactic and experiential training program for medical students and clinicians to increase critical awareness of one’s own culture, beliefs, and positionality (i.e., the social and political context that shapes one’s identity) and how these influence interactions with patients.²¹ Such programs, that move beyond traditional cultural competence training to strengthen providers’ skills in identifying and addressing power imbalances, are crucial for optimizing health outcomes in marginalized immigrant communities.

2. Community level strategies

A. Community engagement in clinical practice.

Healthcare organizations can improve representation by hiring from the communities they serve and by recruiting and retaining diverse, multilingual representation on patient/family advisory councils. For example, The Johns Hopkins University Centro SOL’s Latino Family Advisory Board provides compensation and interpretation services for community members from multiple Latin American countries of origin to share feedback for improving immigrant health programs and initiatives.²²

Community engagement can lead to improvements that are both inward-facing, within an organization, as well as outward-facing, within the broader community. This can include engaging with multicultural/multilingual media outlets and producing health materials and communications in as many languages as possible. But engagement must be continuous, and improvement iterative. For example, a study with Latinx immigrants in Cincinnati, Ohio found that Guatemalans were experiencing greater healthcare navigation difficulties than Mexicans. Many Guatemalans in the study primarily spoke indigenous languages, but were only offered hospital materials available in Spanish.²³ Therefore, although the healthcare organization was offering materials in another language, there remained gaps that were only identified with continued engagement with the immigrant community.

Another strategy to increase immigrant involvement in formal healthcare settings includes incorporating culturally-concordant CHWs into the healthcare team, which facilitates respectful and responsive community engagement while empowering patients within clinical spaces. CHW models have been shown to improve management of chronic conditions in community-based settings and to reduce hospitalizations by “meeting patients where they are” – i.e., removing barriers like transportation or mistrust that deter vulnerable populations from engaging in formal healthcare settings.²⁴

B. Partnerships with communities in research efforts.

CHWs and Community Advisory Boards have also been employed in research settings to facilitate better identification of communities’ health needs and inherent strengths to leverage for health interventions.²⁵ Community-based participatory research (CBPR) is one research approach that can center immigrant communities’ experiences and expertise, producing results that lead to more tangible action items.²⁶ The CBPR framework includes not only building relationships with community partners but cultivating their capacity and incorporating their input across the spectrum of the research process, from formulating the research question to conducting the study and disseminating results. Further, CBPR lends itself to powerful qualitative methods, such as photovoice, which allows participants to illustrate their experiences through self-captured images like those in “DACAmented Voices in Healthcare.” This project examined the intersection between restrictive immigration policies and health care among immigrant youth in Arizona.²⁷ Such strategies allow for research that is more relevant, translatable, and sustainable, thereby improving the possibility of reducing health inequities.

3. Organization-level strategies

Creating “immigration-informed” and “immigrant-friendly” health systems that center physical and psychological safety for immigrants requires organization-level strategies with adaptations to local contexts.^28,29 Implementing systematic and sustainable organizational change necessitates engaged leadership willing to commit financial and human resources to change efforts; integrated organizational structures to transcend internal silos; commitment to quality improvement efforts to ensure continual progress toward health equity; and consistent stakeholder communication, engagement and collaboration.

“Immigrant-friendly” health systems strive to mitigate immigration-related stressors among immigrant patients, families, and healthcare staff, above and beyond strategies required to promote health equity for all populations like addressing health literacy barriers. This expansive approach recognizes that many immigrants, including a significant proportion of health system employees, are part of mixed immigration status households and experience spillover, “chilling” effects of immigration stressors. Such health system practices include limiting cooperation with immigration enforcement on facility premises; not documenting immigration status in medical records; and establishing medical-legal partnerships to provide an avenue for addressing legal needs (further detailed in Table 3).

Table 3.

“Immigrant Friend” Healthcare Organization Interventions Aiming to Address Immigration-Related Stressors

Intervention Target	Sample Policies and Actions
Risk of immigration enforcement at or near facilities	Limiting cooperation with immigration enforcement Designating public vs. private spaces where patient care is directly provided Initiating alternative models for delivering health care services (i.e., telehealth)
Risk of disclosure of patient immigration status	Limiting the collection and documentation of immigration status in medical records Ensuring protection and confidentiality of medical records Providing alternative payment methods (i.e., out-of-pocket payment options)
Risks associated with patient-level stressors
(e.g.,. fear of deportation, fear of jeopardizing immigration status, internalized feelings of shame, deservingness and disempowerment regarding to immigration status)
Legal stressors	Seeking medical-legal collaborations to meet the legal needs of immigrants, including establishing medical-legal partnerships Educating patients regarding their legal rights Combining deportation preparedness within larger emergency preparedness
Patient resiliency	Affirming care messages Seeking avenues to nurture empowerment and engagement among immigrants (i.e., advocacy skills workshops, media and story-telling skill-building programs, voter registration)
Practitioner-level stressors (e.g.,. direct impact from immigration policies, uncertainty about response to immigrant patients’ needs)	Providing supportive services for employees who are immigrants Training clinicians on providing health care to immigrants
Coordination of interventions	Appointing an immigration point person or task force

Importantly, all these efforts are bolstered when affected community stakeholders are involved in design and implementation, efforts are seen as ongoing rather than discrete, one-time efforts, and there are iterative monitoring and evaluation benchmarks in place that involve transparent reporting and stakeholder input. For example, affirming care messages may include not only multilingual and multicultural signage and educational materials but art and music by community members. Electronic health records may begin by first seeking to accurately capture a patient’s naming conventions and linguistic preferences and then evolve to include important real-world nuances (e.g., parents prefer Spanish and the child prefers English in a pediatric chart, or a patient has different linguistic preferences for spoken versus written communication or may have low literacy or illiteracy). Training for healthcare staff would entail regular updates regarding evolving local, state, and federal policies.

Further, just as studies have enumerated the benefits of racial and ethnic diversity among healthcare workforces, employees with personal exposure to the impact of immigration policies have been found to significantly contribute to the design and implementation of interventions mitigating immigration-related stressors³⁰. In this way, a diverse healthcare workforce inclusive of immigrants should be heeded as an important ingredient in facilitating organizational change to meet the needs of immigrant communities. This includes a commitment to recruitment and retention of culturally and linguistically diverse staff reflective of communities served, including attention to supportive policies and equitable compensation.

There are several freely available resources and toolkits available to ensure that diverse communities are welcomed in clinical settings, some of which we highlight in Table 4. While we are aware of only one toolkit highlighting targeted efforts to address concerns of immigrants^28,31, these resources represent broader interventions to promote health equity that can be tailored for the needs of immigrant families.^32–34 Notably, implementing new policies or actions must occur in addition to an organizational-level self-assessment, where existing policies are interrogated with an equity lens to see if they could be discriminatory or biased against immigrants. For example, asking for a social security number to register for routine services like obtaining vaccination might dissuade undocumented family members without a social security number from obtaining those services.

Table 4.

Organizational Tools to Promote Cultural and Structural Competence and Related Concepts

Model/Tool	Description	Sample Questions/Components or Assessment Considerations
Health Resources and Services Administration (HRSA) Organizational Cultural Competence Assessment Profile33	Describes a framework for indicators of cultural competence in health care delivery organizations across the following domains: Organizational Values, Governance, Planning and Monitoring/Evaluation, Communication, Staff Development, Organizational Infrastructure; Services/Interventions; Outlines observable indicators of structures, processes, and outputs that reflect cultural competence in healthcare delivery organizations.	Sample indicators for Governance (Focus area of Community Involvement and Accountability) Structure: Diverse governing body or policy influencing group, with representatives from groups served; Community advisory committee(s), representative of groups served Process: Community participants are provided financial and other supports for their involvement on governing board and advisory committees Outputs: Percentage and retention of community members on governing body and advisory committees; Reports to stakeholders on cultural competence activities/issues
Joint Commission Health Care Equity and Accreditation Resource center32	Outlines Joint Commission’s Health Care Equity Standards, provides examples of specific interventions and synopses of organizational efforts designed to prepare organizations to meet Joint Commission’s Health Care Equity Standards	Elements of performance: The organization designates an individual(s) to lead activities to reduce health care disparities for the organization’s patients. The organization assesses the patient’s health-related social needs and provides information about community resources and support services. The organization identifies health care disparities in its patient population by stratifying quality and safety data using the sociodemographic characteristics of the organization’s patients. The organization develops a written action plan that describes how it will address at least one of the health care disparities identified in its patient population. The organization acts when it does not achieve or sustain the goal(s) in its action plan to reduce health care disparities. At least annually, the organization informs key stakeholders, including leaders, licensed practitioners, and staff, about its progress to reduce identified health care disparities.
National Center for Cultural Competence Cultural and Linguistic Competence Policy Assessment34	Organizational self-assessment, examines dimensions of values, policy, structures, and practice. Intended to support organizations to (1) improve health care access/utilization; (2) improve quality of services; (3) promote cultural and linguistic competence as essential approaches in addressing health disparities	Sample questions (all have follow-up question about whether there is a supporting policy) Is your agency able to identify the culturally diverse communities in your service area? Is your agency able to describe the social strengths (e.g., support networks, family ties, spiritual leadership, etc.) of diverse cultural groups in your service area? Does your agency systematically review procedures to ensure that they are relevant to delivery of culturally competent services?

Organizational change can also integrate a commitment to facilitating policy change, such as lending institutional statements of support or lobbying power to legislation that would facilitate healthcare for immigrants and their families. For example, Mass General Brigham leveraged its status as the largest employer in Massachusetts to endorse the Work and Family Mobility Act, which allows qualified Massachusetts residents, regardless of immigration status, to apply for a standard driver’s license. Other institutions have supported “sanctuary” policies or disengagement with 287(g) agreements that allow for local law enforcement to carry out federal immigration enforcement or have spoken out against exclusionary immigration policies like the Trump administration’s “Muslim Ban.”

Implementing organizational change is not without challenges. A recent study highlighted several barriers³⁰, including perceptions of legal complexity (particularly in areas with less welcoming local immigration policies), heterogeneity of immigrant communities meriting distinct interventions and approaches, and limited time and resources available to evaluate proposed interventions. Conversely, implementation was facilitated by including multiple staff role groups in efforts; encouraging open and safe communication among healthcare personnel; identifying institutional champions; cultivating a shared sense of mission around health equity within the organization; and leveraging existing community partnerships with immigrant rights and service organizations. Recognizing these barriers and facilitators will allow clinician and administrator champions, within and outside formal leadership roles, to promote effective and sustainable organizational change responsive to changing social and political contexts.

4. Policy-level strategies

Local, state, and federal policies involving multiple sectors beyond the healthcare system, (e.g., education, transportation, housing, criminal justice, other social services) influence immigrant families’ health outcomes. For example, state policies allowing all residents, irrespective of immigration status, to obtain a driver’s license influence health care access and outcomes by allowing immigrants to drive to health care facilities without fear of arrest and deportation, reduce reliance on public transportation during pandemics, and install children’s car seats properly in a family vehicle rather than haphazardly (if at all) in a taxi. Similarly, paid sick leave may fall within the purview of the labor sector but facilitates optimal health for immigrants by allowing adequate time for quarantine and recovery, as highlighted during the COVID-19 pandemic when immigrants disproportionately served in “essential worker” roles that increased their risk of viral exposure. Of course, healthcare sector policies such as insurance reimbursement for medical interpretation and CHW services are also critical to promoting equity for immigrant families, but this “health in all policies” approach allows for the centering of common public health goals irrespective of the sector involved.³⁵

Finally, it is important to recognize that clinicians, within their healthcare organizations or as individuals, can play important roles in promoting policy-level changes, whether by contacting legislators, writing opinion pieces, or joining grassroots advocacy efforts.

Opportunities for Next Steps

Interventions must shift to address social and environmental contexts and increasingly incorporate immigrant patient and family perspectives in clinical and research processes, both approaches which are currently lacking relative to clinician-driven individual and interpersonal interventions.¹⁷ Existing medical and continuing professional education must also be updated to reflect the importance of structural competence and community engagement. As an example, Castillo et al proposed a reconsideration of the competency of Systems-Based Practice towards medical education that advances trainees’ structural competence and humility and develops what they call ‘structural action’, including skills to intervene on structural and social determinants of health, participate in community partnerships and advocacy, and identify and intervene upon institutional practices that contribute to inequities in care.³⁶

Within the walls of healthcare organizations, it is time to fully integrate equity into quality improvement efforts that often by nature target healthcare organization-level factors. Quality improvement efforts have the potential to either exacerbate or decrease inequities in healthcare access and outcomes, and represent an important locus for inclusivity efforts. For example, healthcare systems can invite family participation in co-development and implementation of processes designed to more actively involve linguistically diverse families in pediatric hospital adverse event reporting.³⁷

Regardless of the target of a proposed intervention (e.g., whether the intervention targets individuals, organizations or policies), strengthening processes to seek out and incorporate perspectives of immigrant patients and families, fostering partnerships with community organizations, and supporting the ongoing evaluation of these efforts is critical to success. Such processes will increase the likelihood that clinicians and organizations remain nimble and responsive towards the evolving patient and policy landscape to optimize care for children and youth in immigrant families.