competent health care delivery services to facilitate adherence to treatment regimens.
  • The need for collaboration with community based organizations for effective delivery of services.
  •  

    The Monroe County Health Department serves the City of Rochester, New York and the surrounding county.  Rochester is one of the nationally designated refugee relocation centers.  Located in upstate New York, infectious disease morbidity and mortality in Monroe County tends to replicate NYC trends on a smaller scale after a three to five year delay.  During the period 1992 through 1994, 120 individuals were diagnosed with active TB disease in Monroe County with thirty three percent of the cases occurred in foreign-born individuals.  In 1995, 41 individuals in Monroe County were diagnosed with active TB disease.  Consistent with previous years' experience, 22% of these cases occurred in foreign-born individuals.  Due to precipitous increases in the number of individuals immigrating to the Rochester area and the increased number and scope of community screening programs run in cooperation with the TB Clinic, the number of individuals started on INH preventive medication for LTBI rose from 299 in 1991, to 446 in 1994.  A record number of 525 individuals were offered and accepted INH prophylaxis in 1995 and a full 65.1% were foreign-born, the majority of whom were assumed to have acquired LTBI in their respective countries of origin.  The most common countries and regions of origin for clients screened in 1995 included:  Vietnam, Cuba, Bosnia, the Ukraine, the Caribbean, Sudan, Puerto Rico, and Russia.   

     

    As mandated by the US Public Health Service, all legal immigrants and refugees must undergo health screening prior to leaving their country of origin or country of first asylum.  CDC guidelines require a history and physical exam including a mental status examination; chest x-ray, VDRL and HIV testing if 15 years of age or older; and documentation of initiation of catch-up on age appropriate immunizations.  The primary intent of the screening exam is to identify individuals with excludable conditions including communicable disease of public health significance (defined as infectious TB, HIV infection, Syphilis or other STD, Hansen’s disease).  Following protocol, the Immigration and Naturalization Service (INS) forwards an Overseas Health Screening Form on each refugee relocated to Monroe County.  Screening within 30 days of arrival is mandatory for individuals with class A conditions (including infectious TB disease).  Other individuals are requested to complete new arrival screening within 3 months.[55] 

     

    Due to the increasing numbers of immigrants and refugees relocating to Rochester, the TB Clinic assigns an Outreach Worker and a Community Health Nurse to serve as refugee coordinators and has also established special screening programs targeting the refugee and immigrant community.  Often the proper forms are not received or individuals assigned to Rochester leave for more desirable locations before they can be contacted.  Because of the MCHD TB Control program’s mission, the assigned Outreach Worker and CHN attempt to contact every newly arrived individual (regardless of class) arranging an appointment at the clinic for initial screening within thirty days of arrival in Monroe County.  First priority is given to individuals with class A (active infectious TB) or classes B1 (active non-infectious TB) and B2 (inactive TB).[56]  In order to locate all individuals and facilitate transportation to the clinic and the provision of interpreting services, the TB control program relies heavily on the cooperation and participation of three local refugee resettlement organizations.  In addition, TB screening is available at the Bullshead Plaza Outreach Center, conveniently located blocks away from the Adult Learning Center (ALC), a local adult day school which provides English as a Second Language (ESL) and other basic courses and community supports for newly arrived refugees.  Monthly Medication Refill Clinics staffed by the TB Clinic CHN serving as refugee coordinator are held on site at the Adult Learning Center in order to facilitate completion of therapy for LTBI in the newly arrived refugee and immigrant population.

     

    Overcoming language barriers to appropriate care is a difficult task and unfortunately all too often in Monroe County family or other community members are relied upon for interpretive services.  Formal interpretive services provided to clients included use of TB Clinic staff (one bilingual CHN—Spanish language), interpreters sent with a patient to the TB Clinic by a Refugee Resettlement Organization, and frequent use of AT&T Interpretive Services provided by trained telephone operators.  In order to improve understanding of latent TB infection, the importance of treatment, and facilitate communication of risks and benefits associated with medications the TB clinic has a library of patient information handouts translated into a variety of languages including Spanish, Vietnamese, and Laotian.  TB Clinic personnel also assist refugee families with referrals to the Monroe County Immunization Program and STD Clinic for confidential HIV testing as warranted. 

     

    One potential barrier to acceptance of the need for preventive therapy among immigrants and other foreign-born individuals is the use of the BCG vaccine.  CDC and American Thoracic Society (ATS) guidelines acknowledge that the BCG may prevent dissemination of TB among infected children but maintain that this vaccine loses efficacy within 5 years of administration.  Because of the low prevalence of active TB disease in the US today, the BCG administration is not recommended. Keeping with these guidelines, the MCHD does not consider BCG an effective preventive measure.  However, world wide, the BCG is commonly believed to provide lifelong protection to immunized individuals from the acquisition of TB disease.  Many individuals receiving the vaccine in their country of origin believe that the vaccine causes a lifelong false positive result on a PPD skin test.  Following CDC and ATS guidelines, positive skin tests in any individual who has received the BCG are considered secondary to TB infection, and not a vaccine conferred delayed type hypersensitivity immune response.  Therefore MCHD TB Clinic policy is to regard individuals with a history of BCG administration and a significant Mantoux PPD Skin Test as any other individual with a significant skin test and latent TB infection.  This policy frequently causes confusion among immunization recipients who attribute a positive skin test at the time of screening to a presumed effective BCG vaccine received in their country of origin.

     

    Results from the 1995 study directly applicable to the provision of services to an immigrant population include:

     

    It is difficult to adhere to a preventive medication for six to nine months when there are no tangible symptoms to treat and when there is no sign of improvement related to taking the medication as is the case with the treatment of LTBI.  This appears to be an even more difficult endeavor for immigrants and refugees relocated to the greater Rochester area.  This study could not analyze the impact of socio-cultural factors on adherence as it was conducted retrospectively and by chart review.  It is easy to attribute irregular clinic attendance and poor adherence to medication among immigrants to low levels of formal education, language barriers, the difficult costs of transportation in the city of Rochester, the lack of personal funds available for individuals to access health care and the consequences of lost income secondary to lost labor during clinic visits.  Despite a cultural or religious disinclination toward medication, a recently arrived refugee may acquiesce under physician pressure and agree to begin INH therapy only to discontinue after returning home and facing community pressure or re-examining his personal beliefs.  This study does not elicit these factors and cannot determine for which socio-demographic groups or cultures they were important.  Further investigation is necessary to elucidate how individuals from different cultural groups use their knowledge to assess and interpret symptoms at the time they seek medical attention and how their decision to access the health care system is influenced by other considerations or experiences.

     

    The limitations of the described study combined with the great potential for programmatic improvements indicate the need for further evaluation of the effectiveness of health care delivery programs involving the immigrant population on a local, state, and national level.  For example, some of the efforts of the MCHD TB Control program may be misguided, revealing the need to start with the basic building blocks of cultural competency—a cultural assessment of the current clinic population.  Use of interpreters in individuals with language barriers did not improve adherence to therapy.  This may be the result of study methodology but more likely reflects the need for a larger number of independent interpreters and more frequent use of the ATT interpretation service as mandated under the provisions of Title VI. 

     

    In order to effectively address the prevention and elimination of TB on a national basis, the CDC must address the increasing proportion of active disease and burden of latent TB infection within the US immigrant community.  According to the CDC’s 1998 Recommendations for Prevention and Control of Tuberculosis Among Foreign-Born Persons, successful control and eventual elimination of TB in the US will require intensive collaboration between the CDC, state and local health departments, and other national and international public health organizations.  Essential programmatic goals must include:  improvement of overseas screening for TB and development of an evaluation tool to assess the effectiveness of the overseas screening process; computerization or other improvement of the system used to alert local health departments of foreign-born individuals with suspected TB requiring immediate evaluation and possible treatment; coordination of TB control activities at the Mexican border to ensure individuals crossing adhere to a full course of treatment; and implementation of an aggressive national system to universally test immigrants from high-incidence countries for latent TB infection and ensure adherence to appropriate therapeutic regimen.[57]

     

    Conclusions:

    The health of immigrants impacts the health status of the national and international community.  As the ease of transportation facilitates migration and renders national borders more and more obsolete, surveillance systems and health interventions will be increasingly necessary to reduce the public health risk to the international community from the travel related spread of infectious disease.  Goals for future public health planning must address the need for sound health care policy decisions to be based on a thorough analysis of public health considerations.

     

    Bibliography:

    Aleinikoff, TA, Century Foundation.  Immigration Reform, The Basics:  A Century Foundation Guide to the Issues.  New York City:  Century Foundation Press, 2000.  www.tcf.org/Publications/Basics/Immigration

     

    American Academy of Pediatrics Committee on Community Health Services, 1996-1997.  Health Care for Children of Immigrant Families (RE9724) [Policy Statement].  Pediatrics  1997;100(1).  www.aap.org/policy/970702.html

     

    Benjamin AE, Wallace S, Villa V, and McCarthy K.  UCLA Center for Health Policy Research.  California Immigrants Have Mostly Lower Rates of Disability and Use of Disability Services than State’s U.S.-born Residents.  [Policy Brief]  July, 2000.  www.healthpolicy.ucla.edu

     

    Berk M and Shur C.  The Effect of Fear on Access to Care Among Undocumented Latino Immigrants.  Journal of Immigrant Health  2001;3(3):151-156.

     

    Berk M, Schur C, Chavez L, and Frankel M.  Health Care Use Among Undocumented Latino Immigrants: Is free health care the main reason why Latinos come to the United States?  A unique look at the facts.  Health Affairs  2000;19(4):51-64.

     

    Borjas, G.  National Bureau of Economic Research.  Immigration and Welfare Magnets.  NBER Working Paper 6813.  Cambridge, 1998.  www.nber.org/papers/w6813

     

    Brown ER, Wyn R, Ojeda V.  UCLA Center for Health Policy Research.  Access to Health Insurance and Health Care for Children in Immigrant Families.  Los Angeles, 1999.  www.healthpolicy.ucla.edu/publications/AccesstoHealthInsurance.pdf

     

    Brown ER, Wyn R, Ojeda V.  UCLA Center for Health Policy Research.  Noncitizen Children’s Rising Uninsured Rates Threaten Access to Health Care.  [Policy Brief]  Los Angeles, 1999.  www.healthpolicy.ucla.edu/publications/NoncitizenChildren’sPolicyBrief.pdf

     

    Capps, Randy.  The Urban Institute New Federalism National Survey of America’s Families.  Hardship Among the Children of Immigrants:  Findings from the 1999 National Survey of America’s Families.  Washington 2001Series B, No. B-29, February 2001.  http://newfederalism.urban.org/pdf/anf_b29.pdf

     

    Centers for Disease Control and Prevention. Recommendations for Prevention and Control of Tuberculosis Among Foreign-Born Persons: Report of the Working Group on Tuberculosis Among Foreign-Born Persons. MMWR  47;1998:1-31.

     

    Center for Disease Control.  Instructions to Panel Physicians for Completing New U.S. Department of State MEDICAL EXAMINATION FOR IMMIGRANT OR REFUGEE APPLICANT (DS-2035) and Associated WORKSHEETS (DS-3024, DS-3025, and DS-3026).  www.cdc.gov/ncidod/dq/technica.htm

     

    Center for Disease Control.  National Center for Infectious Diseases.  Division of Global Migration and Quarantine (formerly the Division of Quarantine).  Medical Examinations.  www.cdc.gov/ncidod/dq/health.htm

     

    Center for Disease Control.  National Center for Infectious Diseases.  Division of Global Migration and Quarantine (formerly the Division of Quarantine).  Technical Instructions and Updates.  www.cdc.gov/ncidod/dq/technica.htm

     

    Center for Disease Control.  National Center for Infectious Diseases.  Division of Global Migration and Quarantine (formerly the Division of Quarantine).  Related Diseases.  www.cdc.gov/ncidod/dq/diseases.htm

     

    Center for Disease Control.  National Center for Infectious Diseases.  Division of Global Migration and Quarantine (formerly the Division of Quarantine).  Health-Related Waivers.  www.cdc.gov/ncidod/dq/waiver.htm

     

    Cherlin A, Fomby P, Angel R, Henrici J.  Welfare, Children and Families, A Three City Study.  Public Assistance Receipt Among Native-Born Children of Immigrants.  [Policy Brief 01-3]  Baltimore, 2000.  www.jhu.edu/~welfare

     

    Cookson ST, Carballo M, Nolan C, Keystone JS, and EC Jong.  Migrating Populations—A Closer View of Who, Why, and So What.  [Conference Panel Summaries]  Emerging Infectious Diseases 2001;7(3S):551.

     

    Cookson S, Waldman R, Gushulak B, MacPherson D, Burkle F, Paquet C et al.  Immigrant and Refugee Health.  Emerging Infectious Diseases 1998;4(3):427-428.

     

    Department of Health and Human Services, Office of Minority Health.  National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care.  (65 Fed. Reg. 80865-79)  December 22, 2000.  www.omhrc.gov/CLAS

     

    Division of Tuberculosis Elimination, Centers for Disease Control.  Tuberculosis Morbidity Among U.S.-Born and Foreign-Born Populations-United States, 2000.  MMWR  51(05);2002:101-104.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5105a3.htm

     

    Ellwood M, Ku L.  Welfare and Immigration Reforms:  Unintended Side Effects for Medicaid.  Health Affairs.  17(3);1998:137-151.

     

    Fix M, Zimmerman W.  Urban Institute.  All Under One Roof:  Mixed-Status Families in an Era of Reform.  Washington, 1999.  www.urban.org/immig/all_under.html

     

    Geltman PL, Radin M, Zhang Z, Cochran J, and Meyers, AF.  Growth Status and Related Medical Conditions Among Refugee Children in Massachusetts, 1995-1998.  American Journal of Public Health  2001;91(11):1800-1805.

     

    Holahan J, Ku L. and Pohl M.  The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Is Immigration Responsible for the Growth in the Number of Uninsured?  Publication #2221.  February 2001.  www.kff.org

     

    Huff RM, and Kline MV, Editors.  Promoting Health in Multicultural Populations:  A Handbook for Practitioners.  Thousand Oaks:  Sage Publications, 1999.

     

    Joyce T, Bauer T, Minkoff H, Kaestner R.  Welfare Reform and the Perinatal Health and Health Care Use of Latino Women in California, New York City, and Texas.  American Journal of Public Health  2001;91:1857-1864.

     

    The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access, Report #2203.  August, 2000.  www.kff.org

     

    The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Key Facts:  Immigrants’ Health Care Coverage and Access.  August, 2000.  www.kff.org

     

    The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Medicaid Eligibility and Citizenship Status:  Policy Implications for Immigrant Populations, Publication #2201.  [Policy Brief]  August, 2000.  www.kff.org

     

    Kramer EJ, Ivey SL, Ying YW, Editors.  Immigrant Women’s Health:  Problems and Solutions.  San Francisco:  Jossey-Bass Publishers, 1999.

     

    Ku L, and Freilich A.  The Urban Institute and The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Caring for Immigrants:  Health Care Safety Nets in Los Angeles, New York, Miami and Houston.  Publication #2227.  February, 2001.  www.kff.org

     

    Ku L, Blaney S.  Center on Budget and Policy Priorities.  Health Coverage for Legal Immigrant Children:  New Census Data Highlight Importance of Restoring Medicaid and SCHIP Coverage.  Washington, 2000.  http://www.cbpp.org/10-4-00health.pdf

     

    Loue S.  25 Frequently Asked Questions about Immigration and Health.  Journal of Immigrant Health  2000;2(2):59-66.

     

    Loue S, Editor.  Handbook of Immigrant Health.  New York:  Plenum Press; 1998.

     

    Loue S.  Editorial.  Journal of Immigrant Health  2001;3(3):113-114.

     

    Loue S, Bunce A.  The Assessment of Immigration Status in Health Research.  Vital and Health Statistics—Series 2:  Data Evaluation and Methods Research.  127;1999:1-115.

     

    Maloy K, Darnell J, Nolan L, Kenney K, Cyprien S.  Center for Health Services Research and Policy, School of Public Health and Health Services, The George Washington University Medical Center.  Effect of the 1996 Welfare and Immigration Reform Laws on Immigrants’ Ability and Willingness to Access Medicaid and Health Care Services.  Washington, 2000.  www.gwu.edu/~chsrp/pdf/synth.pdf

     

    Mautino KS.  Health Issues Among Immigrant Children [Law Watch].  Journal of Immigrant Health  2001;3(4):169-171.

     

    Mautino K.  Welfare Reform:  An Update.  [Law Watch]    Journal of Immigrant Health  2000;2(1):1-3.

     

    Mautino KS.  Women, Health, and United States Immigration Law.  Journal of Immigrant Health  2001;3(1):1-3.

     

    Meadows LM, Thurston WE, and Melton C.  Immigrant Women’s Health.  Social Science and Medicine  2001;52:1451-1458.

     

    National Conference of State Legislatures.  SCHIP and Access for Children in Immigrant Families.  Washington, 2000.  27 pp.

     

    National Health Law Program.  Health Related Provisions in the Illegal Immigration Reform and Immigrant Responsibility Act of 1996.  October 8, 1996.  www.healthlaw.org/pubs/19961008immigrant.html

     

    National Immigration Law Center.  Background on Immigrant Children’s Health Improvement Act of 2000, H.R. 4707 (Diaz-Balart) – S.1227 (Chafee).  Washington, 2000.  www.nilc.org/immspbs/health/health009.htm

     

    Nickel, James.  Should Undocumented Aliens be Entitled to Health Care?  Hastings Center Report.  December, 1986:19-23.

     

    Perry MJ, Sytark E, Burciaga VR for Kaiser Family Foundation.  Barriers to Medi-Cal Enrollment and Ideas for Improving Enrollment:  Findings from Eight Focus Groups in California with Parents of Potentially Eligible Children. October, 1998.   www.kff.org

     

    Quill BE.  Book Review:  SCHIP and Access for Children in Immigrant Families.  Journal of Immigrant Health  2001;3(2):111-112.

     

    Schlosberg C, National Health Law Program.  Immigrant Access to Health Benefits:  A Resource Manual.  Prepared for the Access Project.  Washington, 2001.  189 pp.

     

    Schlosberg, Claudia.  Not-qualified Immigrants’ Access to Public Health and Emergency Services After the Welfare Law.  January 12, 1998.  www.healthlaw.org/pubs/19980112immigrant.html

     

    Schlosberg, Claudia and Dinah Wiley.  National Health Law Program and National Immigration Law Center.  The Impact of INS Public Charge Determinations on Immigrant Access to Health Care.  May 22, 1998.  www.healthlaw.org/pubs/19980522publiccharge.html

     

    Scott, Janny.  Foreign Born in U.S. at Record High.  New York Times.  2/7/02.

     

    Spetz J, Baker L, Phibbs C, Pederson R, and S Tafoya.  The Effect of Passing an “Anti-immigrant” Ballot Proposition on the Use of Prenatal Care by Foreign-Born Mothers in California.  Journal of Immigrant Health  2000;2(4)203-212.

     

    Stephen EH, Foote K, Hendershot GE, Schoenborn CA.  Health of the Foreign-Born Population:  United States, 1989-1990.  Advance Data From Vital Health and Statistics.  241;1994.  www.cdc.gov/nchs/data/ad/ad241.pdf

     

    U.S. Census Bureau.  Census Brief:  Coming to America:  A Profile of the Nation’s Foreign Born.  August 2000.  www.census.gov/prod/2000pubs/cenbr002.pdf

     

    US Census Bureau. The foreign-born population in the United States, March 2000 (US Census Bureau Current Population Reports, P20-534).  http://www.census.gov/population/www/socdemo/foreign/cps2000.html

     

    U.S. Department of Justice, Immigration and Naturalization Service.  INS Implements New Guidance to Improve the Review of Naturalization Cases of Applicants with Disabilities.  News Release April 14, 1999.  www.ins.usdoj.gov/graphics/publicaffairs/newsrels/natz-dis.htm

     

    U.S. Department of Justice, Immigration and Naturalization Service.  Summary:  A Quick Guide to ‘Public Charge’ and Receipt of Public Benefits.  October 18, 1999.  www.ins.usdoj.gov/graphics/publicaffairs/summaries/public.htm

     

    The Urban Institute.  Check Points:  Data Releases on Economic and Social Issues.  Washington, 2000.  www.urban.org/news/press/cp_000911.html

     

    Walker PF, Jaranson J.  Refugee and Immigrant Health Care.  Medical Clinics of North America  1999;83(4):1103-1120.

     

    Watters, C.  Emerging Patterns in the Mental Health Care of Refugees.  Social Science and Medicine.  52;2001:1709-1718.

     

    Zimmerman W, and Tumlin KC, The Urban Institute.  Patchwork Policies:  State Assistance for Immigrants Under Welfare Reform, Occasional Paper Number 24.  Washington, 1999:112 pp.

     

    Ziv TA, Lo B.  Denial of Care to Illegal Immigrants:  Proposition 187 in California.  New England Journal of Medicine  1995;332:1095-1098.

     

    Recommended Websites:

    Access to Resources for Community Health:  an electronic health information and resource center.  www.mgh.harvard.edu/library/arch/immigrant.asp

     

    The American International Health Alliance (AIHA) searchable Directory of Translated Materials-health and medical documents--a directory of over 400 health related materials translated into languages of the former Soviet Union and Central and Eastern Europe.

    http://www.aiha.com/

     

    Asian and Pacific Islander American Health Forum.  www.apiahf.org/

     

    Associations of Asian Pacific Community Health Organizations.  http://ahschc.org/defaultothers.htm

     

    The Center for Cross Cultural Health.  www.crosshealth.com/

     

    CDC—The Office of Global Health.  www.cdc.gov/ogh/issues/refugee.htm

     

    The Cross Cultural Health Care Program.  www.hcfa.org/Immigrant.html

     

    CulturedMed  The SUNY Institute of Technology Library Resource Center.  www.sunyit.edu/library/html/culturedmed/

     

    Church World Service.  http://ncccusa.org/cws/errss.html

     

    Department of Health and Human Services, Office of Refugee Resettlement, Administration for Children and Families.  http://www.acf.dhhs.gov/programs/opa/facts/orr.html

     

    DiversityRX.  www.diversityrx.org/

     

    EthnoMed:  Ethnic Medicine Information from Harborview Medical Center.  Includes link to immigration issues.  http://ethnomed.org

     

    Immigration and Refugee Services of America (IRSA).  http://www.irsa-uscr.org

     

    InterAction—the nation’s largest coalition of relief, development, and refugee agencies.  http://www.interaction.org/contents.html

     

    Massachusetts Office of Refugee and Immigrant Health.  www.state.ma.us/dph/orih/orih.htm

     

    Migrant Clinicians Network.  www.migrantclinician.org/

     

    National Asian Women’s Health Organization (NAWHO).  www.nawho.org/home.htm

     

    National Coalition of Hispanic Health and Human Services Organizations.  www.cossmho.org/

     

    National Health Law Program (NheLP):  Immigrant Health. www.healthlaw.org/immigrant.shtml

     

    National Immigration Law Center.  www.nilc.org/

     

    NYU School of Medicine:  Center for Immigrant Health.  (Formerly the New York Task Force on Immigrant Health)  www.med.nyu.edu/cih

     

    Office of Minority Health.  www.omhrc.gov/

     

    United Nations High Commissioner for Refugees.  http://www.unhcr.ch

     

    US Immigration and Naturalization Service.  http://www.ins.usdoj.gov

     

    The Urban Institute.  http://www.urban.org

     

    The Welfare Information Network.  http://www.welfareinfo.org/immighealth.htm

     

     


     

    [1]The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Key Facts:  Immigrants’ Health Care Coverage and Access.  August, 2000.

    [2] Aleinikoff, TA, Century Foundation.  Immigration Reform, The Basics:  A Century Foundation Guide to the Issues.  New York City:  Century Foundation Press, 2000.

    [3]Waddell B.  United States Immigration:  A Historical Perspective.  In Loue S, Editor.  Handbook of Immigrant Health.  New York:  Plenum Press; 1998, p.4.

    [4] Waddell B, p. 4, 13-14.

    [5] Waddell B, p. 4-5.

    [6] Waddell B, p. 7-8.

    [7] Waddell B, p. 9.

    [8] Waddell B, p. 12-13 and Henry J. Kaiser Family Foundation.  Key Facts:  Immigrants’ Health Care Coverage and Access.

    [9] US Census Bureau. The foreign-born population in the United States, March 2000 (US Census Bureau Current Population Reports, P20-534).

    [10] Scott, Janny.  Foreign Born in U.S. at Record High.  New York Times.  2/7/02.

    [11] The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access, Report #2203.  August, 2000.

    [12] Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access.

    [13] U.S. Census Bureau.  Census Brief:  Coming to America:  A Profile of the Nation’s Foreign Born.  August 2000.

    [14] Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access.

    [15] Riedel RL.  Access to Health Care.  In Loue S, Editor.  Handbook of Immigrant Health.  New York:  Plenum Press; 1998, p. 109.  This citation also encompasses the following 6 definitions. 

    [16] Schlosberg C, National Health Law Program.  Immigrant Access to Health Benefits:  A Resource Manual.  Prepared for the Access Project.  Washington, 2001.

    [17] Loue S.  Defining the Immigrant.  In Loue S, Editor.  Handbook of Immigrant Health.  New York:  Plenum Press; 1998.  and  Loue S, Bunce A.  The Assessment of Immigration Status in Health Research.  Vital and Health Statistics—Series 2:  Data Evaluation and Methods Research.  127;1999:1-115.

    [18] Holahan J, Ku L. and Pohl M.  The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Is Immigration Responsible for the Growth in the Number of Uninsured?  Publication #2221.  February 2001.

    [19]Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access.

    [20] Mizoguchi N.  Propostition 187:  California’s Anti-Immigrant Statute.  In Kramer EJ, Ivey SL, Ying YW, Editors.  Immigrant Women’s Health:  Problems and Solutions.  San Francisco:  Jossey-Bass Publishers, 1999.

    [21] Spetz J, Baker L, Phibbs C, Pederson R, and S Tafoya.  The Effect of Passing an “Anti-immigrant” Ballot Proposition on the Use of Prenatal Care by Foreign-Born Mothers in California.  Journal of Immigrant Health  2000;2(4)203-212.

    [22] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 10-11.  Encompasses 9 listed categories.

    [23] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 12.

    [24] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 12-13.

    [25] Fix M, Zimmerman W.  Urban Institute.  All Under One Roof:  Mixed-Status Families in an Era of Reform.  Washington, 1999. 

    [26] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 11.

    [27]Fix M, Zimmerman W.  Urban Institute.  All Under One Roof:  Mixed-Status Families in an Era of Reform.  Washington, 1999.  

    [28] Schlosberg, Claudia and Dinah Wiley.  National Health Law Program and National Immigration Law Center.  The Impact of INS Public Charge Determinations on Immigrant Access to Health Care.  May 22, 1998. 

    [29]U.S. Department of Justice, Immigration and Naturalization Service.  Summary:  A Quick Guide to ‘Public Charge’ and Receipt of Public Benefits.  October 18, 1999.  

    [30] Ku L, Blaney S.  Center on Budget and Policy Priorities.  Health Coverage for Legal Immigrant Children:  New Census Data Highlight Importance of Restoring Medicaid and SCHIP Coverage.  Washington, 2000. 

    [31]Capps, Randy.  The Urban Institute New Federalism National Survey of America’s Families.  Hardship Among the Children of Immigrants:  Findings from the 1999 National Survey of America’s Families.  Washington 2001Series B, No. B-29, February 2001.

    [32]Brown ER, Wyn R, Ojeda V.  UCLA Center for Health Policy Research.  Access to Health Insurance and Health Care for Children in Immigrant Families.  Los Angeles, 1999.  

    [33]Brown ER, Wyn R, Ojeda V.  UCLA Center for Health Policy Research.  Noncitizen Children’s Rising Uninsured Rates Threaten Access to Health Care.  [Policy Brief]  Los Angeles, 1999.  

    [34] Cherlin A, Fomby P, Angel R, Henrici J.  Welfare, Children and Families, A Three City Study.  Public Assistance Receipt Among Native-Born Children of Immigrants.  [Policy Brief 01-3]  Baltimore, 2000. 

    [35] National Immigration Law Center.  Background on Immigrant Children’s Health Improvement Act of 2000, H.R. 4707 (Diaz-Balart) – S.1227 (Chafee).  Washington, 2000. 

    [36] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 17-26.

    [37]Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 17-26.

    [38] Zimmerman W, and Tumlin KC, The Urban Institute.  Patchwork Policies:  State Assistance for Immigrants Under Welfare Reform, Occasional Paper Number 24.  Washington, 1999:112 pp.

    [39] Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access.

    [40] Perry MJ, Sytark E, Burciaga VR for Kaiser Family Foundation.  Barriers to Medi-Cal Enrollment and Ideas for Improving Enrollment:  Findings from Eight Focus Groups in California with Parents of Potentially Eligible Children.   

    [41] Spetz et. al.

    [42] Berk M and Shur C.  The Effect of Fear on Access to Care Among Undocumented Latino Immigrants.  Journal of Immigrant Health  2001;3(3):151-156.

    [43] Joyce T, Bauer T, Minkoff H, Kaestner R.  Welfare Reform and the Perinatal Health and Health Care Use of Latino Women in California, New York City, and Texas.  American Journal of Public Health  2001;91:1857-1864.

    [44] Kramer EJ, Ivey SL, Ying YW, Editors.  Demographics, Definitions, and Data Limitations.  Immigrant Women’s Health:  Problems and Solutions.  San Francisco:  Jossey-Bass Publishers, 1999.  Page 11.

    [45] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 55-56.

    [46] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 57.

    [47] Department of Health and Human Services, Office of Minority Health.  National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care.  (65 Fed. Reg. 80865-79)  December 22, 2000.

    [48] Castro, Felipe, Cota, Marya and Santos Vega.  Health Promotion in Latino Populations:  A Sociocultural Model for Program Planning, Development, and Evaluation.  In,  Promoting Health in Multicultural Populations:  A Handbook for Practitioners.  1999, Thousand Oaks:  Sage Publications, p. 142-143.

    [49] Castro et. al., p. 138.

    [50]Huff RM, Kline MV.  The Cultural Assessment Framework.  In,  Promoting Health in Multicultural Populations:  A Handbook for Practitioners.  1999, Thousand Oaks:  Sage Publications, p. 481.

    [51] Huff and Kline, p. 481.

    [52] Division of Tuberculosis Elimination, Centers for Disease Control.  Tuberculosis Morbidity Among U.S.-Born and Foreign-Born Populations-United States, 2000.  MMWR  51(05);2002:101-104. 

    [53] Centers for Disease Control and Prevention. Recommendations for Prevention and Control of Tuberculosis Among Foreign-Born Persons: Report of the Working Group on Tuberculosis Among Foreign-Born Persons. MMWR  47;1998:1-31.

    [54] Edman J, Moss M, Younge M.  Predictors of Adherence to INH Prophylaxis.  American Journal of Respiratory and Critical Care Medicine, Mar 2000;161(3):A.  Presented at ALA-ATS International Conference, Toronto Canada, May 2000.  Manuscript in process of submission.  Contact author for figures and calculations.

    [55] Walker PF, Jaranson J.  Refugee and Immigrant Health Care.  Medical Clinics of North America  1999;83(4):1103-1120.

    [56]Center for Disease Control.  Instructions to Panel Physicians for Completing New U.S. Department of State MEDICAL EXAMINATION FOR IMMIGRANT OR REFUGEE APPLICANT (DS-2035) and Associated WORKSHEETS (DS-3024, DS-3025, and DS-3026).  

    [57] Centers for Disease Control and Prevention. Recommendations for Prevention and Control of Tuberculosis Among Foreign-Born Persons: Report of the Working Group on Tuberculosis Among Foreign-Born Persons. MMWR  47;1998:1-31.