What Social Work Educators and Practitioners Need to Know on Immigrants’ Health Care: a Systematic Review

Background: 47 million immigrants are living in the United States and they constitute 14.4 percent of the total population in the United States. As the immigrant population grows rapidly, their health care needs require ongoing and additional attention from social workers and health care practitioners. Methods: This study systematically reviewed content on immigrants and healthcare in social work literature and discussed implications for social services for immigrant populations. Systematic review and content analysis were employed. Research methods, topics, and samples of included studies were screened and coded. Results: 47 studies met eligibility for inclusion in this review. The majority of included studies were cross-sectional analysis (60%), focusing on mental health care issues (51%), health care utilization (51%) and adult immigrant samples (49%). Discussion: Encouraging diversity of social work research can directly promote social work services and health care practices for the underrepresented populations. Our findings suggest that more input from the social work profession on evidence-based practice for diverse immigrants are required. Social workers and health care practitioners must continually be reminded of the health care needs of immigrants.


Introduction
As the immigrant population grows rapidly, health care needs of immigrants require additional attention from social workers. 47 million immigrants are living in the U.S., 14.4 percent of the total population of the United States. The immigrant population has increased significantly in the past decade [1], and immigrants' countries of origin are more diverse than ever before [2]. While many immigrants arrive in the U.S. with good health, their health conditions deteriorate when they stay longer in the U.S. [3]. This might be due in part to the negative consequences of acculturation on health behaviors, such as unhealthy dietary habits [3].
Immigrants experienced inadequate health care due to a myriad of reasons [1,2,4]. Compared to U.S.-born individuals, immigrants were less likely to be insured [5,6]. The 1996 Personal Responsibility Work Opportunity Reconciliation Act (PRWORA) resulted in a significant decrease in public health coverage for immigrants; more recently, under the Patient Protection and Affordable Care Act, immigrants who have lived in the U.S. for less than five years are not eligible for Medicaid [6]. In addition to these structural barriers, cultural barriers exist; limited English proficiency and low levels of acculturation are common barriers for first-generation immigrants when seeking help for health care [7].
Social workers play a critical role in the provision of health care to immigrant populations by attending to social determinants of health (e.g., insurance gaps, social and family support, health literacy) and by addressing social and behavioral problems that affect health status and social functioning [8]. The National Association of Social Workers' (NASW) Code of Ethics [9] mandates that social workers in public health and primary care work to reduce race, ethnic, and gender-based health care disparities and ensure the health right for all. According to a national study conducted by the Center for Workforce, 52% of licensed social workers practice in health care settings, and approximately half of the social work jobs were in health care and social assistance settings [10]. To tackle health care disparities, it is necessary for social workers to address structural and cultural barriers through advocating for health care use, improving acculturation, and promoting social support among immigrant communities. Therefore, it is important for social work educators and practitioners to understand the health care needs of immigrant populations. The purpose of our study was to review the research studies conducted on immigrants and their health care, focusing on published scientific social work journals in the United States and discuss the implications to social work practice and research. We sought to answer this research question: What has been published in U.S.-based social work journals about immigrants' health care?

Methods
Adherence to the PRISMA guideline, we systematically reviewed social work literature, and an analytical approach to address our research question. Content analysis is a systematic approach used to identify and analyze content in the literature which relates to a specific topic. Summative content analysis (SCA) is an effective method that analyzes specific content in particular journals and attempts to explore the usage of certain content [11]. SCA starts with identifying and counting the frequency of specific content in text data with specific research purposes and then interprets the content [12].

Article Searching
We used the following key terms: "health care" OR "mental health" OR "physical health" OR "behavioral health" OR "health care utilization" AND "immigra*". Up to August 2019, the initial search yielded 10,048 articles from these 16 selected social work journals.

Article Screening
One hundred and thirty articles were identified, and after duplicate articles were removed, 97 articles were left. These articles were further screened to meet the following criteria: (a) written in the English language; (b) sampled immigrant populations in the United States; and (c) focused on health care issues within the U.S. health care system. Two investigators independently reviewed abstracts of the 97 articles and, when needed, the full texts. Any disagreement on the inclusion decision of an article was resolved through discussion in consensus meetings, and a full consensus for the final list of articles was reached.

Content Coding
In this study, content referred to the text of selected studies, including results and discussion. Coding and themes were developed systematically. According to the research question, three categorical domains were developed: study samples, health issues, and research method. Initial codes were identified based on these three domains to categorize each article's immigrant populations, health issues, and methodology. Two investigators independently read and applied the coding structure to the identified articles. Any discrepancy between the investigators was discussed until consensus was reached. The initial rate of agreement between coders was 90%; after discussions, 100% agreement was reached.

Results
A final set of studies (n = 47) were analyzed to identify content related to immigrants' health care. An outline of the study selection process was provided in Figure 1. The 47 articles included in the final analysis were categorized by each article's study samples (Table 1), health issues (Table 2), and research methods ( Table 3). As for age sampling, about half (n = 23, 49%) of the 47 studies sampled immigrant adults (aged 18 to 54), while the rest of studies sampled immigrants aged 55 or older (n = 13, 28%) and children and youth (n = 12, 26%) immigrants. By race and ethnicity, the majority of the articles focused on Latin American immigrants (n = 21, 45%) or Asian (n = 19, 40%), while 3 studies focused on African immigrants and 1 focused on Middle Eastern immigrants. Among these studies, the study conducted by [15] focused on both Latin American and Asian immigrants.  Note: Some studies cover more than one health topics. By health issues, half (n = 24, 51%) of the articles presented results on mental health issues. 24 (51%) articles addressed health care utilization by immigrants, followed by 8 articles on the topic of physical health care. Also, among these studies, some studies cover more than one topic. For example, studies conducted by [7,8] paid attention to all three health topics. Besides, studies conducted by [16,17] focused on physical health care and mental health issues. In addition, studies conducted by [18][19][20] focused on mental health issues and health care utilization. A variety of research methodological approaches were employed. The majority (n = 28, 60%) were crosssectional analyses, followed by 9 qualitative studies, 3 literature reviews, 2 cohort studies, 2 conceptual studies, 2 mixed-method study and 1 non-randomized controlled trial (RCT).

Discussion
The present study reviewed previous studies on immigrants' health care published in social work journals in the United States and comprehensively answered the research question about immigrants/ their health care needs. Findings of the review provided important insights for social work profession on the immigrant and their health care. Research methods, health topics, and target populations of the reviewed studies, as well as implications of social work practice and research were discussed in the following.

Research Methods of Reviewed Studies
More than half of the social work articles on immigrants' health care used quantitative methods and relied heavily on cross-sectional analyses. 28 studies used cross-sectional, secondary data analysis to examine the correlation between demographic factors, such as level of acculturation, socioeconomic status, education, and healthcare outcomes. The cross-sectional analysis used in the observational study primarily described odds ratios [21]. In health research, crosssectional analysis was a useful tool to assess health care utilization, health behavior, and health conditions in the populations of interest. However, the cross-sectional study design was less sensitive to the systematic bias than RCT design, which was currently considered the best method to avoid such bias by selecting and allocating samples randomly to control vs. comparative groups [22]. Only one study used a non-RCT design to test the effect of cognitive-behavioral group therapy intervention on reducing depression among Latino immigrants [23]. Although RCT designs were underutilized in the social work articles methodologically, when inferring causality, RCT designs were not preferred over non-RCT designs.
Of the included studies, 19% (n = 9) were included in this review used qualitative methods. These nine qualitative studies [17,18,[24][25][26][27][28][29][30] used individual interviews or focus groups as the primary data collection methods to explore immigrants' experiences with health care. Qualitative methods are more appropriate in understanding subjective meanings of a phenomenon, providing in depth information that quantitative methods often fail to capture. Qualitative studies can be very useful to social work health research as they are centered on an individual's experience and respect diverse backgrounds, which is consistent with a core social work value, respect for "dignity and worth of the person" [31].

Target Populations of Reviewed Studies
Children in immigrant families were underrepresented in social work research. Of all children in the U.S., 25.8 percent were children who have at least one immigrant parent (22.5%) or were immigrants themselves (3.3%) (U.S. Department of Health and Human Services, 2015). In this review, the majority of studies (n = 36; 77%) focused on adults and older immigrant, while only 26% of studies (n = 12) were about children in immigrant families. Among these studies, 5 studies [17,18,27,32,33] focused on the children immigrants themselves, and the rest (n = 7) focused on children in immigrant families. A growing concern considering that the number of children in immigrant families grew quickly, and they became more ethnically diverse [34].
Also, children in immigrant families were at a disadvantage in many aspects of health care [35]. For example, immigrant children were more likely than those from U.S. citizen families to lack health insurance coverage [36], and to significantly underutilize health care services [37,38]. Prior studies also showed that children from immigrant families were at a greater risk for developing psychosocial problems (e.g., substance abuse, depression, low self-efficacy, and violent behaviors) [39,40] due to the gaps between their immigrant parents' level of acculturation [41] and their parents' limited knowledge of health care resources [42,43]

Health Topics of Reviewed Studies
According to the findings of the present study, mental health, health care utilization, and physical health were the most prominent findings on immigrants and their health care. These three health care topics attracted academic attention and plural of studies have been done in immigrants and their health care. In this review, care issues related to mental health (n = 24; 51%) and health care utilization (n = 24; 51%) were the most popular topic among reviewed studies, followed by and physical health care (n = 8; 17%). The results of this current review suggested that helpful information exists to inform social workers about immigrants' health care. However, some health issues were understudied in social work professions, such as selfmanagement of chronic illnesses, well-known disease epidemics, sexual and reproductive health including teen pregnancy, cancers with high incidence rates, and mental health care of LGBTQ among immigrant populations [21,[44][45][46].
In addition, since many immigrants experience barriers in accessing health care, such as low acculturation, lack of knowledge, and lack of resources and information, a gradual approach to improving their access should include educational programs [47] and outreach efforts [48]. Such efforts can include partnerships between social work professionals and immigrant communities, involving service providers, faith organizations, and community leaders [49,50].

Implications for Practice
The importance of providing health care services to immigrants in a culturally appropriate manner has repeatedly been emphasized in prior research [10,16,24,28,47,51]. Practitioners should be keenly aware of the cultural differences in conceptualization and the expression of health problems to provide culturally sensitive service [24,[51][52][53]. Some immigrants might prefer alternative treatments (e.g., folk healers, herbal medicine, and acupuncture) or prefer to seek help from providers from their native countries who are more in line with their cultural beliefs [8]. Understanding patients' cultural backgrounds could facilitate better communications and interactions between health care practitioners and immigrant patients, potentially improving immigrants' health care satisfaction in the U.S. [10,54].
Health care practitioners also play a critical role as cultural brokers. One useful tip for practitioners is to allow enough time for immigrants to describe their symptoms and to build a trusted relationship [28]. Furthermore, a huge need exists for bilingual healthcare workers or translation services since many immigrants have limited English proficiency [20,32,33,51,53]. It would be helpful if health care practitioners could be trained with bilingual capability [50]. Supportive relationships have been identified as a source of resilience for individuals' health conditions [55]. Prior research suggests that social work professionals work to strengthen immigrants' social support systems [10,16,49,[55][56][57][58][59], especially for single female immigrants [20,23] and older Asian immigrants [16,59,60]. Since many immigrants have a strong family-centered culture of care [61,62], it is recommended that health care practitioners work both with immigrant patients and their family members [52].
In addition to families, the community is another major source of social support for immigrants. Therefore, social work professionals should attend to those experiencing weak ties to their communities [20,58]. The recent health care bill dispute put immigrant populations in a more vulnerable position, especially for undocumented immigrants [44]. Undocumented immigrants are historically excluded from almost all governmental social services and many public services. Therefore, health care practitioners face significant difficulties in advocating for health care services for undocumented immigrants or low income documented immigrants who are not yet eligible for governmental social services (e.g., immigrants who stay in the U.S. less than five years) [63,64].
To bridge this critical gap of immigrants' health care services, many non-profit organizations and programs might provide health care services for immigrants across the nation, but only a specific fraction of needs for immigrants who are excluded from governmental social services [63,65]. Therefore, it is the critical time for health care practitioners to take all possible actions for policy advocacy, which should include strongly urging all stakeholders to revisit and repeal the bans on public health care programs for undocumented immigrants and certain legal immigrants and their families [48].

Implication to Social Work Research
According to the results of the content analysis, we proposed four suggestions for social work research development. First, social work research should apply more randomized controlled study design to generate new findings and infer causality, which can be useful for best evidence healthcare practice. Also, social work journals should provide more opportunities for qualitative researchers to publish studies on immigrants' health care to inform culture-competent health care services. Third, studies on sub-groups of vulnerable populations and their health are needed to promote evidence-based practice and education in the field of social work. Since the social work discipline pays close attention to marginalized, vulnerable groups regardless of their population size, concerning that little information exists in the most-often cited journals of the social work profession on those other than Asian and Latin American immigrants. Finally, encouraging academic diversity can be one way to increase the capacity for social work research, practice, and education on health care issues of diverse immigrant groups.

Limitation
The present study systematically reviewed research articles published in the most-often cited U.S.-based social work journals focusing on immigrants' health care. Selecting social work journals by impact factors from journal citation reports might have caused the omission of other journals with articles on the immigrants' health care. However, our review does not aim to explain the reasons for the current lack of such content in social work journals. More research efforts and dissemination of research findings by our profession through social work journals can help relatively remedy the lack of studies on immigrants' health care needs.
It was beyond the scope of our review to include non-U.S. based social work journals; thus, results must be interpreted with caution, especially when the findings are generalized to immigrants' health care in other countries. In addition, the search terms used for this study are limited. Some specific terms of health issues were not applied, such as reproductive health, which may have excluded some potential studies on immigrants' health care. Further studies could consider focusing on reviewing specific health issues, such as teen pregnancy and sexual health among LGBTQ populations among immigrants.

Conclusion
The present study reviewed prior studies on immigrants' health care which were published in the peer-reviewed journals in the United States. In light of research findings suggested that further social work studies make more efforts to investigate marginalized immigrant populations' health care and some understudied health issues, particularly social work researchers may consider to conducting more randomized controlled studies on immigrant populations' health care. For instance, social work researchers might pay closer attention to the health of children in immigrant families and immigrant teens' reproductive health.
The current social work literature provided some promising implications of practice in our review. Social workers may promote social justice by advocating policy changes to provide a supportive, culturally and linguistically appropriate health care environment for immigrants [66]. Health care advocacy should aim to eliminate Social workers should be further encouraged to condemn discriminatory practices against immigrant populations and continue to advocate for their rights in physical and mental well-being. In addition, further efforts should be made to promote social justice in health care, which include but are not limited to providing affordable health care to low-income immigrants, improving health insurance coverage rate among immigrants, and expanding the proportion of receiving health care services and developing tailored services in child welfare systems for children in immigrant families [8,24,52,66].
Findings provide future direction in the development of social work education, research and professional practice regarding immigrants' health care. Social workers must continually be reminded of the health care needs of immigrants. An ongoing focus on this topic in the primary journals of social work can help keep practitioners and educators updated in their efforts to promote immigrants' health care.