Duration of US Residence And Resource Needs In Immigrant Families With Young Children

Abstract

To mitigate the negative impact of resource needs on child health, practices serving low-income immigrant families have implemented screening programs to connect families to community resources. Little is known about how duration of US residence relates to patterns of resource needs and indicators of acculturation such as community resource knowledge/experience or self-efficacy. We conducted a cross-sectional analysis of a convenience sample of immigrant families with young children at an urban primary care clinic. These families were seen 5/2018–1/2020 for well child care, screening positive for ≥1 social need using a tool derived from Health Leads. Analysis of 114 families found that newly arrived families with a shorter duration of US residence (≤5 years) were more likely to report immediate material hardships like food insecurity and need for essential child supplies. Newly arrived families were also less likely to have access to technology resources such as a computer or smartphone. Long-term families with a longer duration of US residence (≥15 years) were more likely to report chronic needs like poor housing conditions, but also reported increased community resource knowledge/experience and increased self-efficacy. Primary care pediatric practices should assess immigration contextual factors to identify subgroups such as newly arrived families with young children to target resources (e.g., increase screening frequency) or enhance services (e.g., patient navigators) to relieve resource needs.

Introduction

The social drivers of health, or the social circumstances in which children live and grow, are particularly important in the early years of life, a critical period of cognitive, socio-emotional, and behavioral development (Cusick & Georgieff, 2016). Since about 20% of US children live in poverty, research has emerged about poverty-related social drivers of health including associations between food insecurity and obesogenic feeding styles (Gross et al., 2012), housing disrepair with infant and toddler sleep practices (Duh-Leong et al., 2020), and unreliable internet access with educational outcomes (Masonbrink & Hurley, 2020). To mitigate disparities due to social drivers of health, primary care practices are implementing screening and community referral programs to address resource needs such as food insecurity and housing disrepair (Chung et al., 2016; Fierman et al., 2016). When compared to children of families native to the United States (US), young children of immigrant families have been found to have lower iron status (Saunders et al., 2016), lower rates of health insurance coverage (Jarlenski et al., 2016), and overall poorer health (McGee & Claudio, 2018). While we know that children of immigrant families are likely to experience health disparities, there is a gap in understanding how immigration contextual factors, or the circumstances of immigration, may shape family resource needs that contribute to poorer health outcomes in children (Castañeda et al., 2015).

Immigration contextual factors (e.g., region of origin, circumstances of departure, family resources and skills) shape outcomes in immigrant families with children (Bornstein, 2019). Duration of US residence, or the number of years that has elapsed since a family immigrated, is an accessible immigration contextual factor that has been found to contribute to health outcomes in other populations. Prior studies have identified associations between duration of US residence and health outcomes such as obesity (Afable et al., 2016; Goel et al., 2004), cortisol stress response (Novak et al., 2017), and length of pregnancy gestation (Elsayed et al., 2019). Newly arrived immigrant families with shorter duration of US residence may face challenges related to acculturation, or the adaptation or integration of a new society, which may exacerbate poverty-related social drivers of health and increase resource needs. For example, previous evidence has shown that newly arrived immigrant mothers with young children are at highest risk for food insecurity (Chilton et al., 2009). Given this evidence, understanding how duration of US residence relates to the extent and pattern of multiple resource needs may inform how to begin to operationalize immigration contextual factors to deliver health and community services to immigrant families with young children.

In order to tailor programs for immigrant families, understanding how duration of U.S. residence may affect patterns of acculturation can motivate program enhancements (e.g., patient navigators) to optimize screening and referral outcomes for subgroups that need support. Prior work has found that duration of US residence contributes to the acculturation process (Ro, 2014), and that acculturation occurs on the individual (e.g., psychological) level as well as the societal (e.g., integration of societal knowledge) level (Bornstein, 2019). In the context of meeting resource needs, individual acculturation is closely associated with self-efficacy, a modifiable optimistic self-belief that one can cope with adversity (Jerusalem and Schwarzer (1995)). Decreased self-efficacy has also been associated with decreased help-seeking behaviors (Harpaz & Grinshtain, 2020), which may interfere with addressing resource needs. Assessing community resource experience and knowledge, a reflection of societal level acculturation, may identify populations who can benefit from program supports that increase community resource familiarity. Prior evidence has shown that while immigrant families were at highest risk of being lost to follow-up, they were also most likely to utilize community resources if engaged (Uwemedimo & May, 2018). Understanding relationships between duration of US residence, individual and societal acculturation factors may prompt the development of program enhancements such as patient navigators or sustained community partnerships to optimize referral processes for immigrant families.

The purpose of this study was to describe relationships among duration of US residence, resource needs, and acculturation factors (e.g., self-efficacy, and community resource experience/knowledge) in immigrant families with young children at a federally qualified health center. We hypothesized that: (1) newly arrived families would report more total as well as more basic material needs, and (2) long-term families would have higher likelihood of resource knowledge/experience and higher levels of self-efficacy.

Methods

Study Design

This was a cross-sectional analysis of a convenience sample of families with young children seen for well child care between May 2018 and January 2020.

Study Population and Sample

This federally qualified health center serves the Sunset Park community in Brooklyn, New York, where 47% of the population are foreign born and 49% self-identify as having limited English proficiency (NYC Community District Profiles, 2020). The practice conducts ~50,000 pediatric primary care visits annually. As part of routine care, families who bring young children for well child visits are screened for resource needs using a self-administered paper screen asking about both material (e.g., food insecurity, housing disrepair) and non-material (e.g., adult education, legal) needs.

The screening tool (Fig. 1) was adapted from the Health Leads resource needs screening toolkit (Social Needs Screening Toolkit, 2016). From the Health Leads essential domains, we included food insecurity, housing (rent instability and disrepair), financial resource strain (essential child supplies and public benefits), as well as exposure to domestic violence. From the Health Leads optional domains, we included childcare, adult education, and child behavior issues. In addition to the recommended domains, we included a screen for legal needs. An internal focus group of bilingual providers (physicians, resource navigators, and child developmental psychologists) adapted domains and questions based on perceived needs of the patient population based on clinical experience and neighborhood availability of resources. Given that there were no neighborhood resources to assist with technology resources at the time, the screening tool did not include technology resource needs. The research team developed a separate assessment, which is described below. The questions were translated and back-translated into Spanish, then reviewed by the same committee for cultural adaptation. Families that screened positive were referred to community resources.

Fig. 1.

Screening Tool in English and Spanish

Trained research assistants obtained informed consent and enrolled a convenience sample of parents in the waiting room. Subject enrollment occurred when volunteer research assistants (native Spanish-speaking local college students) were available (usually 1 day a week). Inclusion criteria were that the parent be fluent in either English or Spanish, be at least 18 years old, and have a child under 6 years of age receiving primary care at the clinic. Parents were excluded if they endorsed no needs on the screener or could not provide contact information. For this analysis, we excluded parents who were born in the US. During the study period, 236 parents were approached in the waiting room. Of these families, 81 (34%) did not endorse any needs on the screener, 23 (15%) declined to participate in the study, 5 (4%) refused to provide contact information, and 13 (10%) were native born in the United States. Overall, of 142 who were eligible to participate, 114 (80%) agreed to participate. Study procedures were approved by our institutional review board.

Study Measures

Duration of US residence

Our independent variable was duration of US residence. We assessed duration of US residence by subtracting the year that the primary caretaker moved to the US from the year that the primary caretaker completed the baseline questionnaire. We treated duration of US residence as a continuous variable but also categorized the families by lowest quartile (newly arrived, ≤5 yr), 2nd and 3rd quartiles (more established, >5, <15 yr) and highest quartile (long-term, ≥15 yr).

Resource needs

Total resource needs, the sum of identified needs on the clinic screening tool, was coded as a continuous variable (1–10). The questions assessing each individual need are shown in Fig. 1. Food insecurity was assessed using the validated 2-question Hunger Vital Sign, where a “yes” response to either question has a sensitivity of 97% and specificity of 83% for food insecurity (Hager et al., 2010). An affirmative answer to either question was coded as a positive result (Hager et al., 2010). Each of the remaining resource needs was coded based on a “yes” or “no” response.

We assessed technology resource access using the study questionnaire by asking, “Which of the following, if any, do you have in your household?” We assessed whether families had: “a laptop or desktop computer,” “high-speed internet access (cable, wireless, or DSL),” “an iPad or similar tablet device.” We assessed cell phone access parents had by asking, “What type of cell phone, if any, do you have?” Parents could answer “a ‘smartphone’” (in other words, you can send email, watch videos, or access the Internet on it),” “a regular cell phone (just for talking or texting),” or “I don’t have a cell phone.” We coded this question as “yes” if the parent reported having “a smartphone”.

Self-efficacy

We assessed self-efficacy using the 10-item General Self-Efficacy Scale, a multiculturally validated scale which predicts coping with daily challenges and adaptation in the setting of stressful life events (Jerusalem and Schwarzer (1995)). Each item is an optimistic belief statement assessed from 1 to 4, (1 = Not at all true; 2 = Hardly true; 3 = Moderately true; 4 = Exactly true). Total score (10–40) was assessed continuously.

Community resource knowledge/experience

We assessed community resource knowledge/experience with the following prompt, “I’d like to ask you about your experience obtaining help and services for your family.” Community resources available in Sunset Park, Brooklyn were listed for the parent to select from the following responses, “I have used this service in the past year,” “I have used this service in the past, but not this year,” “I know about this service, but haven’t used it,” or “I don’t know anything about this service.” We coded “I don’t know anything about this service” as “no”, vs. all others as “yes,” considering knowledge or past service use as knowledge/experience. The following community resources were assessed: the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Supplemental Nutrition Assistance Plan (SNAP), Graduate Equivalency Degree (GED) or English classes, Head Start early education program, city daycare subsidies, housing disrepair assistance, the Housing Choice Voucher program (Section 8), New York City Housing Authority (NYCHA), Legal Aid assistance, Early Intervention services.

Family characteristics

Baseline demographic information included child age and sex, maternal age and education level, family size (number of children), parent marital status, employment status, and parent occupations.

Statistical Analysis

Statistical analyses were performed using Stata/SE version 15 (Stata Corp, College Station, TX). We used descriptive statistics to summarize variables. For adjusted analyses, we controlled for child-, maternal-, and family-level demographics selected a priori: infant age and sex, maternal age and education level, marital status and number of children living in the home.

To investigate associations between duration of US residence and total number of needs, we used adjusted linear regression to assess the difference in total number of needs for newly arrived families compared to all other immigrant families. To investigate associations between duration of US residence with specific resource needs, we performed chi-square with Fisher exact tests to compare the prevalence of each specific social need across the three categories, then performed pairwise comparisons between all the groups.

We then performed separate adjusted logistic regressions to identify associations between duration of US residence (newly arrived vs. all others and long-term vs. all others) and each specific need. We conducted similar analyses to assess associations between duration of US residence and technology resource access as well as between duration of US residence and community resource knowledge/experience.

To assess whether duration of US residence is associated with differences in self-efficacy, we performed an adjusted linear regression to examine the association between duration of US residence as a continuous variable and total self-efficacy score. We also created dummy variables for each category (newly arrived, more established, and long-term). Using adjusted linear regressions, we used newly arrived families as the reference group and examined differences in mean self-efficacy scores in more established and long-term families.

Results

Descriptive Sociodemographics

Sample characteristics are summarized in Table 1. Almost half of the parents came from Mexico (48.2%), with most of the remainder from Central America (Guatemala, Dominican Republic, Ecuador, among others). The mean duration of US residence was about 10 years. The most commonly endorsed needs were adult education (73.7%), child care (40.4%), and food insecurity (35.1%). The most common job held by working mothers was providing cleaning services (52.6% of working mothers). For fathers, the most common jobs were construction (34.3% of working fathers) and food service (30.3% of working fathers).

Table 1.

Sample characteristics (n = 114)^a

Sociodemographics
Child characteristics
Age Range (years)	0–5
Median Age, IQR (months)	9, 1–26
Female Sex	46 (40.4%)
Caregiver characteristicsb
Median Age of Mother, IQR (years)	30, 25–34
Maternal Education Beyond 6th Grade	39 (34.2%)
Mother Spanish-Speaking Only	104 (91.2%)
Mother Works for Pay	19 (16.7%)
Father Works for Pay (N = 107)	99 (92.5%)
Family characteristics
Median Number of Children, IQR	2, 1–3
Married/Living with partner	85 (74.6%)
Immigration information
Mean Years in US (SD)	10.1 (6.5)
Country of origin
Mexico	55 (48.2%)
Guatemala	22 (19.3%)
Dominican Republic	10 (8.8%)
Other Central America (Colombia, El Salvador, Honduras)	17 (14.9%)
Ecuador	8 (7.0%)
Other (Tajikistan, Trinidad and Tobago)	2 (1.8%)
Resource needs
Median # of Needs, IQR	2, 1–3
Adult Education	84 (73.7%)
Child Care	46 (40.4%)
Food Insecurity	40 (35.1%)
Essential Child Supplies	37 (32.5%)
Public Benefits	28 (24.6%)
Legal Needs	16 (14.0%)
Housing Instability	15 (13.2%)
Housing Disrepair	12 (10.5%)
Behavior Issues	9 (7.9%)
Domestic Violence	1 (0.9%)
Technology resource needs
Smartphone	102 (89.5%)
High Speed Internet	56 (49.1%)
Computer at Home (Desktop or Laptop)	47 (41.2%)
Tablet	43 (37.7%)
Community resource knowledge/experience
Women Infants Children or Supplemental Nutritional Assistance Program	100 (87.7%)
Graduate Equivalency Degree/English Classes	64 (56.1%)
Head Start/daycare subsidies	54 (47.4%)
Housing Disrepair assistance	41 (36.0%)
Section 8 Housing	41 (36.0%)
Early Intervention	39 (34.2%)
Food Pantries	36 (31.6%)
Legal Aid	6 (5.3%)
Self-Efficacy (Score range 10–40)
Median score, IQR	32, 29–36

^aUnless otherwise indicated, numbers shown in N(%)

^bIn this sample, 110 of the respondents (>96%) identified as the child’s mother. Maternal characteristics were collected and are reported here for all children. The survey assessed employment information for additional caregivers, and 107 identified a father as a second caregiver

Association of Duration of US Residence with Resource Needs and Resource Access

In adjusted linear regression, being newly arrived was associated with having an increased total number of needs compared to all other immigrant families. (B = 0.98 needs, 95% CI: 0.02, 1.93). We found that each year increase in duration of US residence was associated with a decrease in total number of needs (B = −0.02, 95% CI: −0.04, −0.003).

Variations in frequency of specific needs by duration of US residence are shown in Fig. 2. We found that newly arrived families were significantly more likely to endorse immediate material needs like food insecurity (58.3% vs. 28.9%, p < 0.01) and essential child supplies (54.2% vs. 26.7%, p < 0.05) compared to all other immigrant families. We also found that long-term families were significantly more likely to endorse housing disrepair (25.0% vs. 5.8%, p < 0.01) compared to all other immigrant families. Compared to other immigrant families, newly arrived families also had lower odds of technology resource access (computer and smart phone) and long-term families had higher odds of high-speed internet access. These associations remained significant after adjustment (Table 2).

Fig. 2.

Prevalence of Specific Needs Endorsed by Immigrant Families by Duration of US Residence

*p<0.05; Overall Chi-Square or Fisher’s Exact

^p<0.05, ^^p<0.01; Different from all others within comparison group; Fisher’s Exact

¹Newly Arrived (n=28); More Established (n=62); Long-Term (n=24)

Table 2.

Likelihood of resource needs for newly arrived and long-term immigrant families

	Newly arrived (≤ 5 years) v. all others aOR (95% CI)a	Long-term (≥15 years) v. all others aOR (95% CI)a
Resource needs
Food insecurity	3.07 (1.04–9.10)*	0.58 (0.23–1.47)
Essential child supplies	6.74 (1.92–23.65)**	0.77 (0.30–1.95)
Housing disrepair	0.57 (0.06–5.77)	6.11 (1.55–24.02)*
Adult education	1.80 (0.50–6.46)	0.36 (0.14–0.91)*
Technology resource needs
Smartphone	0.12 (0.02–0.65)*	2.27 (0.33–15.50)
Computer at home	0.21 (0.06–0.75)*	1.50 (0.54–4.16)
High speed internet	0.35 (0.11–1.12)	5.55 (1.67–18.41)**
Community resource knowledge/experience
GED/English classes	0.57 (0.19–1.64)	3.42 (1.07–10.95)*
Head Start/Daycare subsidies	0.25 (0.08–0.81)*	4.70 (1.53–14.43)**
Housing disrepair assistance	0.07 (0.009–0.62)*	1.49 (0.52–4.23)
Section 8/NYCHA	0.21 (0.05–0.85)*	2.15 (0.76–6.09)
Legal aid	0.90 (0.29–2.74)	1.14 (0.39–3.34)
Early intervention	0.29 (0.06–1.48)	3.86 (1.27–11.77)*

^*p < 0.05;

^**p < 0.01

^aLogistic Regression adjusted for infant age, child sex, maternal education, maternal age, number of children, marital status

Table 2 summarizes significant associations between being a long-term family and community resource knowledge/experience (GED/English classes, Head Start/daycare subsidies, Early Intervention). Being newly arrived was inversely associated with community resource knowledge/experience (Head Start/Daycare subsidies, Housing disrepair assistance, Section 8/NYCHA housing). There were no other significant associations between duration of US residence and resource needs, technology resource access, or community resource knowledge/experience.

Associations Between Duration of US Residence and Self-Efficacy

In adjusted linear regression, we found that each year increase in duration of US residence was associated with an increase in self-efficacy score (B = 0.25 points, 95% CI: 0.06–0.44). Adjusted mean scores (SD) increased with each category: newly arrived 30.7 (2.3), more established 32.4 (1.4), and long-term 34.5 (2.1).

Discussion

In this sample of immigrant families with young children at a federally qualified health center in an urban setting, we found that newly arrived status was associated with increased total needs, increased likelihood of basic material needs, and decreased likelihood of computer or smartphone access. We also found an association between long-term status with higher levels of indicators of individual and societal acculturation such as self-efficacy scores and community resource knowledge/experience.

Prior evidence has identified higher rates of poverty in immigrant populations: a third of legal immigrants and over half of undocumented immigrants report living below the federal poverty line compared to 11% of US-born and naturalized citizens (Wallace et al., 2012). This study extends these findings by being the first study to our knowledge that shows that newly arrived families with young children are at risk for higher total number of resource needs in the first 5 years of arrival compared to those with longer lengths of US duration. While the difference in total needs was approximately 1 additional need, this significant difference suggests that families with young children may be contending with the effects of poverty more acutely when they first arrive in the country.

The presence of material hardships, or the inability to meet basic needs, have been associated with poorer health outcomes in young children in domains such as sleep practices (Duh-Leong et al., 2020) as well as infant and toddler wellness (Frank et al., 2010). Our study found that families who were newly arrived were more likely to endorse material hardships like food insecurity and essential child supplies. This reinforces prior findings that families with young children are at highest risk for food insecurity when they are newly arrived to the US (Chilton et al., 2009). We also found that long-term families were more likely to report housing disrepair, an issue that may be less urgent to a family than food insecurity-related hunger. While this may mean that newly arrived families are less likely to experience housing disrepair, what may be more likely is that this screening method is not sensitive enough to identify housing disrepair in families that are prioritizing immediate basic needs.

Prior evidence in low-income urban families with young children have found that 17% of families in a screening program were referred to adult education resources (Garg et al., 2015). In contrast, our low-income urban immigrant families with needs identified a higher prevalence (74%) of adult educational needs. This may be because our population was predominantly Spanish speaking operating in an English dominant country and almost a third (31%) had less than a high school education. Still, long-term families were significantly less likely to endorse needs for adult education and more likely to report knowledge/experience with GED/English classes compared to all others. This suggests that long-term families may have already engaged with adult education resources or have been able to survive with their current skillset.

This is the first study to our knowledge to describe technology resource access in immigrant families with young children. While the majority of families reported having smartphones, less than half of the families reported having high speed internet, computer, or tablet access. Newly arrived families were less likely than other immigrant families to have smartphone or computer access at home and long-term families were more likely to have high speed internet access. These findings have crucial implications for virtual access to medical, educational, and community resources that impact the ability of young children to grow and thrive in a world navigating remote learning and virtual resources.

Prior studies have identified lower levels of parental self-efficacy during periods of high stress while orienting to a new country (Boruszak-Kiziukiewicz & Kmita, 2020). Our findings that self-efficacy scores increase with duration of US residence extend these findings to suggest that duration of US residence, a proxy for the integration process, is associated with increased self-efficacy. Self-efficacy may increase with time due to increased knowledge of support resources or language fluency, reduced stress because of acculturation. In our study, our sample may have also excluded those with low self-efficacy who eventually returned to origin countries. Self-efficacy has also been associated with the ability to communicate about and seek needed care (Umubyeyi et al., 2016). Referral programs should study whether higher intensity referral strategies (e.g., resource navigators) may better accommodate newly arrived families with potentially lower levels of self-efficacy.

Overall, these results represent a framework to study how immigration contextual factors like duration of US residence may indicate resource needs in immigrant families with young children. Our study broadens the evidence base by showing that we are able to detect with a relatively modest sample size that there are significant differences in family resource needs based on duration of US residence. Stakeholders in programs and policies to prevent disparities in early child outcomes in immigrant families should consider using duration of US residence to begin to understand the broader immigration contextual factors that contribute to material hardship. As primary care practices develop models of care to mitigate social risk factors by meeting resource needs, practical implications include identification of potentially vulnerable subgroups such as newly arrived families with young children so that clinics may target resources (e.g., increase screening frequency) or enhance services (e.g., patient navigators) to better serve these families.

Limitations of this study include the cross-sectional design as well as unmeasured immigration contextual factors. Since this study is cross sectional, we can draw no inferences about causality. Migration patterns, refugee status, and sociopolitical drivers of immigration shift with time, so critical immigration contextual factors of the long-term families may be different (e.g., educational, economic, safety) than the newly arrived families, limiting our interpretation of the results. Future studies should incorporate a robust qualitative component to assess relevant immigration contextual factors to frame assessment for psychological, emotional, and/or physical trauma, which prior work has found complicates the ability to acculturate in a new country (Bornstein, 2019). In addition, this study took place during a time period (May 2018–January 2020) when the Department of Homeland Security announced a “public charge” rule that legal immigrants who received public benefits beyond a period of time may be ineligible for permanent residency (Final Rule on Public Charge Ground of Inadmissibility, 2020). The potential that immigrant families may be facing a racist, anti-immigrant political climate would have unmeasured impacts on perceived access to community resources. However, our findings contribute to an urgently needed knowledge base for future studies to examine resource need patterns and develop strategies to support acculturation and resilience in immigrant families with young children.

Conclusion

Immigrant families with young children and a shorter duration of US residence may be more likely to experience material hardships and have lower self-efficacy. Primary care pediatric practices may consider adapting existing resource needs screening strategies and programs to accommodate immigrant families with consideration to their varying lengths of duration of US residence. Practitioners who work with young children in immigrant families (e.g., medical professionals, educators) may consider using duration of US residence to begin to understand the broader immigration contextual factors that also contribute to resource needs. Future studies should follow young children in immigrant families over time to understand causal pathways between immigration contextual factors, resource needs, and child health outcomes.

Highlights.

• This was a study of immigrant families with young children at a federally qualified health center with a social resource screening program.

• Newly arrived immigrant families were more likely to report material hardships like food insecurity, essential child supplies, and technology needs (e.g., computer, smart phone).

• Given society’s increased reliance on virtual services, screening tools should incorporate technology resources (e.g., computers, high speed internet).

• Intervention strategies should identify subgroups such as newly arrived families with young children to target resources (e.g., increase screening frequency) or enhance services (e.g., patient navigators) to relieve resource needs.