“No one left behind”: A social determinant of health lens to the wellbeing of undocumented immigrants

Abstract

Undocumented and mixed-status families, in which some, but not all members have an undocumented immigration legal status, often face multiple and chronic stressors that influence their health. Compounded by trauma and limited opportunities, the aforementioned stressors negatively impact the physical and mental health of the undocumented and mixed-status population. This article uses a social determinants of health (SDOH) framework, examining five key domains––economic stability, education, healthcare, the social and community context, and the neighborhood and built environment. Undocumented immigrants face challenging living, social and work environments, have less economic stability, and have restricted access to opportunities. The aforesaid challenges place undocumented and mixed-status families at risk. Strategies are discussed to improve the health outcomes of this vulnerable population.

Introduction

Undocumented immigration has become an increasingly debated topic in the United States (U.S.). Recently, anti-immigrant rhetoric and actions have fostered a hostile environment for undocumented immigrants and mixed-status families, in which some members but not all have an undocumented immigration legal status. Yet, undocumented immigrants comprise a considerable proportion of the U.S. population. As of 2019, 45 million immigrants reside in the U.S., comprising 13.7% of the total U.S. population [1]. Of these, an estimated 11 million have an undocumented immigration legal status, with many of these immigrants living in mixed-status families [1]. Indeed, approximately 5.3 million children under the age of 18 live in a household with at least one undocumented parent [1]. Importantly, over 60% of undocumented immigrants have been living in the U.S. for more than 10 years, and nearly half (46%) do not speak English well or cannot speak it at all [1,2]. The longer undocumented immigrants remain in the U.S., the worse their health outcomes become [2,3].

Significant health and social disparities uniquely affect the wellbeing of undocumented immigrants and mixed-status families [4–6], and result in worse mental and physical health outcomes when compared to their documented counterparts and the general U.S. population [7–10]. The aforesaid deteriorating health outcomes arise from a confluence of social and economic factors encountered in the U.S., including xenophobic attitudes towards immigrants and limited economic opportunities, which over time give rise to chronic stress [9,10], unhealthy living environments [7], and reduced access to healthcare [10]. Given that undocumented immigrants comprise a substantial portion of U.S. society, it is imperative to consider the structural limitations they face in achieving and maintaining adequate health and wellbeing. By identifying structural catalysts for disease and implementing targeted solutions, health inequities faced by undocumented immigrants can be alleviated.

Framework

Social determinants of health (SDOH) frameworks are helpful to understand and address health disparities and inequalities with the goal of improving community health [11]. SDOH refers to the environments, conditions, and societal structures to which individuals are exposed, and which affect their health outcomes [12]. Five key SDOH domains include economic stability, education, healthcare, the social and community context, and the neighborhood and built environment [13,14]. Health outcomes are the result of reciprocal interactions between individuals and the aforesaid SDOH over time. Given existing structural and systemic barriers imposed by the cultural, social, and political environment, undocumented immigrants experience compounded chronic stressors across all aforesaid SDOH [14]. Although there is widespread use of SDOH frameworks in public health, there is a need to incorporate a SDOH lens to the study of health among undocumented immigrants to identify, understand, and address systemic and structural risk and protective factors more accurately. In the next sections, we will briefly discuss how undocumented legal status impacts each of the different SDOH to increase health risk in this vulnerable, yet resilient population, along with providing practical recommendations for intervention and change.

Undocumented legal status and economic stability

Once established in the U.S., many undocumented immigrants face economic instability that negatively impacts their long-term health. As a result of unauthorized legal status, undocumented immigrants often have to take low-paying jobs that are exploitative and hazardous, without legal protections and with limited financial remuneration [7,15]. Also, a primary contributor to economic instability among undocumented immigrants is their lack or limited access to mainstream financial services such as bank account ownership or lack of credit history that restricts their economic opportunities [16,17]. Instead, undocumented immigrants often rely on alternative financial services such as check-cashers, exchange bureaus, remittance transfer services, or payday loans that charge them high fees for needed services [16,17]. Additional factors contributing to economic hardship among undocumented immigrants include the need to provide remittances to assist their families abroad [18]. The financial barriers faced by undocumented immigrants limit their ability to escalate the social ladder, contribute to significant distress, strain family and interpersonal relationships, and increase vulnerability to disease given their inability to afford health services when needed [19].

Undocumented legal status and education

Access to educational opportunities and the associated benefits are limited for many undocumented immigrants. Undocumented immigrants must weigh the competing demands of low paying, work-intensive jobs that demand the majority of their time and a chance to pursue educational opportunities, including becoming English proficient, while also risking deportation [15,20,21]. Limited English proficiency is a significant educational stressor for many undocumented and mixed-status families, and is associated with less opportunities for social mobility and occupational advancement, low health literacy, and difficulty navigating legal and healthcare systems [6,22,23]. Educational hurdles persist for undocumented immigrants which in combination with economic struggles further diminish health outcomes.

Undocumented status and healthcare

Undocumented immigrants underutilize the U.S. healthcare system and often delay the use of health services due to existing personal, interpersonal, and structural barriers [24,25]. Financial difficulties are also significant barriers limiting healthcare access for this population. Despite many working in industries classified as essential and of high health risk, undocumented immigrants have little to no financial or health protections [26,27]. Compounded with the aforesaid barriers are fears that their personal information may be mishandled, leading to legal implications, including risk of detention, deportation, and/or family separation [28]. Access to health services that are linguistically, culturally, and contextually attuned to the needs and experiences of undocumented immigrants are limited [29–31]. The detrimental health consequences of lacking access to healthcare are well documented in the literature including greater risk for morbidity and mortality [32].

Undocumented status and the neighborhood/built environment

Most undocumented families are forced to make decisions about their living environment based on constraints imposed by their financial and legal statuses [33,34]. Financial instability and limited access to financial loans that facilitate homeownership lead many undocumented families to settle in low-income and less-desirable neighborhoods with high crime, low safety, lower quality housing (e.g., structural deficiencies in housing units), and limited access to public services and recreational facilities [34,35]. High housing costs often lead many undocumented families to reside in crowded and multigenerational homes, which complicates family dynamics and adds compounded stress [27,33]. Undocumented status families must often make trade-offs between quality living and risk detention or deportation, along with cascading detrimental health consequences.

Undocumented status and the social and community context

Harsh anti-immigrant rhetoric and actions contribute to toxic social environments that are harmful to the health, wellbeing, and social networks of undocumented immigrants [36,37]. Over the past decade, undocumented immigrants have been portrayed as dangerous and a burden to American society [38,39]. The results of these harmful stereotypes have led to the prejudice, discrimination, and marginalization of undocumented communities, which is associated with stress and diminished mental health [40]. The high prevalence of discrimination leads to isolation, feelings of rejection and a sense of lack of belonging, even years after arriving to the U.S [10]. The detrimental effects of discrimination and marginalization are passed on to birth right citizen children through “multigenerational punishment” so that all members of the family share the experiences of hardship from being a mixed-status family [41].

Recommendations

In addition to facilitating an understanding of the many structural barriers that undermine the health and wellbeing of undocumented communities, a SDOH lens is helpful to outline and identify avenues for change. Below, we briefly outline practical recommendations salient to different SDOH in hope of motivating intervention aimed to reduce risk and prevent further harm.

Facilitating economic stability

Undocumented immigrants constitute an important part of the labor market and make important contributions to the U.S. economy [16]. The regularization of employment opportunities and the economic integration of undocumented immigrants into formal financial services could help decrease economic instability among undocumented families; a primary source of stress and health vulnerability in this population [16]. For instance, access to low-cost, convenient, and efficient financial services is needed to prevent undocumented immigrants from falling prey to financial scams and avoid the high fees for needed services (e.g., sending remittances, cashing paychecks). Also important is to grant work permits for undocumented immigrants that are based on employer and market needs, which would increase economic stability for undocumented families, highlight their contributions to the U.S. economy, and provide compensation in case of work-related injury or retirement [16,42].

Facilitating educational opportunities

Increasing opportunities for undocumented families to access affordable quality education can help undocumented families advance the social ladder, increase economic stability, reduce stress, and develop literacy that can help these families navigate complex legal and healthcare systems [23]. English proficiency has been identified as a protective factor to the wellbeing of undocumented families [23]; thus, the provision of free and accessible English-as-Second Language (ESL) classes is important. Achieving English proficiency among undocumented adults is important to bridge intergenerational gaps within undocumented families and to significantly reduce the health burden of cultural brokering among undocumented youth and U.S.-born children in mixed-status families [23]. Providing informational support and mentoring for undocumented families to learn about available educational opportunities within safe environments can go a long way in improving access to education for this immigrant population [43–45].

Facilitating healthcare access

Given the high un-insurance rates among undocumented immigrants (52%) [16], creating avenues to facilitate access to health insurance for undocumented families is of paramount importance. Allowing undocumented immigrants to purchase health insurance in the public marketplace could have important economic and health implications, including preventing the delay of needed services [46]. The provision of health resources and the incorporation of health navigators that can assist undocumented families can increase trust, prevent miscommunication, increase compliance with medical recommendations, and improve health outcomes in this population [47]. In addition, advocacy efforts to support expansion of safety net providers and the building of collaborative efforts with non-traditional sources of service delivery (e.g., faith-based and community organizations) could foster safe environments for immigrants [48,49]. Also, important to emphasize is the need for access to mental health services and resources that are linguistically, culturally, and contextually sensitive to the needs of undocumented immigrants. Building a robust and competent workforce that can adequately address the complex physical and mental health needs of undocumented families requires advocacy, funding, and an investment in training, dissemination, and sustainability efforts [11,50].

Building safer living environments

Efforts in urban planning and public policy can improve the living environments in ethnic enclaves where undocumented families reside. For instance, urban planning in targeted areas should focus on reviving neglected neighborhoods by enforcing building codes and facilitating reporting of unscrupulous landlords [51]. To increase neighborhood safety, support for sanctuary policies and “safe reporting” aimed at ensuring that immigrant victims and witnesses report crime without fear or penalization can help reduce victimization, trauma, and fear in immigrant communities, while also protecting local public security [52].

Building safe social environments

Condemning and countering anti-immigrant rhetoric and actions is imperative to reduce incidences of discrimination and marginalization that are detrimental to the well-being of undocumented immigrants [53]. To build safe social environments, immigration policy should focus on individual protections from exposure to traumatic events, including discrimination, stigmatization, and racism. Along with the aforesaid efforts, efforts to implement and disseminate trauma-informed practices and trauma-informed policing that enhance an understanding of trauma and its effects can reduce risk for re-traumatization, build community trust, and promote early intervention by connecting immigrants in need with appropriate community services and support [54].

Conclusion

Undocumented immigrants face undue systemic barriers that range from economic instability to living in toxic environments, which is detrimental to their physical and mental wellbeing. Despite their resilient spirit, the significant health and social disparities faced by undocumented immigrants place them at-risk and keep them at a disadvantage. Approaching the aforesaid disparities through a social determinants of health lens is needed to highlight the compounded challenges that undocumented immigrants face, and most importantly to identify a plan for comprehensive action and change. Nonetheless, for any solution to come to fruition it is important to treat immigration legal status as a health determinant itself.

Data availability

No data was used for the research described in the article.