Health Disparities and Children in Immigrant Families: a Research Agenda

SUPPLEMENT ARTICLE

Health Disparities and Children in Immigrant Families: A Research Agenda

AUTHOR: Fernando S. Mendoza, MD, MPH Division of General Pediatrics, Department of Pediatrics, School abstract of Medicine, Stanford University, Lucile Packard Children’s Children in immigrant families now comprise 1 in 5 children in the Hospital, Palo Alto, California United States. Eighty percent of them are US citizens, and 53% live in KEY WORDS immigrant children, immigrant families, health disparities, mixed-citizenship families. Their families are among the poorest, least acculturation, immigrant paradox, health policy educated, least insured, and least able to access health care. Nonethe- ABBREVIATION less, these children demonstrate better-than-expected health status, a SCHIP—State Children’s Health Insurance Program finding termed “the immigrant paradox” and one suggesting that cul- The views presented in this article are those of the authors, not tural health behaviors among immigrant families might be protective the organizations with which they are affiliated. in some areas of health. In this article the strength of the immigrant www.pediatrics.org/cgi/doi/10.1542/peds.2009-1100F paradox, the effect of acculturation on health, and the relationships of doi:10.1542/peds.2009-1100F acculturation, enculturation, language, and literacy skills to health dis- Accepted for publication Jul 20, 2009 parities are reviewed. The current public policy issues that affect the Address correspondence to Fernando S. Mendoza, MD, MPH, health disparities of children of immigrant families are presented, and Lucile Packard Children’s Hospital, Division of General a research agenda for improving our knowledge about children in Pediatrics, 770 Welch Rd, Suite 100, Palo Alto, CA 94304. E-mail: immigrant families to develop effective interventions and public poli- [email protected] cies that will reduce their health disparities is set forth. Pediatrics PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). 2009;124:S187–S195 Copyright © 2009 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The author has indicated that he has no financial relationships relevant to this article to disclose.

PEDIATRICS Volume 124, Supplement 3, November 2009 S187 Downloaded from www.aappublications.org/news by guest on October 2, 2021 In recent decades, the large growth in or second generation (US-born). The THE HEALTHY IMMIGRANT the number of children living in immi- current census data show that 80% of PHENOMENON grant families, whether born abroad children in immigrant families are US The “healthy immigrant phenomenon,” or in the United States, has produced citizens because they were born in the also known as the “immigrant para- problems with health care that are a United States, and 28% have at least 1 dox” or the epidemiologic paradox, is 3 concern. These children and their fam- US-born parent. The result is that that although Hispanic immigrants ilies can be characterized by their more than half of the children in immi- have higher poverty rates, lower edu- country of origin, culture, religious grant families (53%) live in a mixed- cation levels, and less access to health background, social class, reason for status family, with at least 1 citizen and care than US-born Hispanics and non- immigrating, health status before im- 1 noncitizen family member (parent or Hispanic whites, they have similar or migrating, access to resources, and sibling). better health outcomes for several receptiveness of the US sociopolitical Children in immigrant families have health parameters.5 Since the 1980s, environment. The common factors of different social and economic risk fac- the best substantiated findings sup- poverty and racial or ethnic biases can tors from native families. For example, porting the immigrant paradox are the affect health status and access to first- and second-generation children prevalence of low birth weight infants health care for these children. The are more likely than children from na- and infant mortality rates.6–8 In 1984, the characteristics of their immigrant tive families to live in a family headed prevalence of low birth weight infants family can also influence the health by a married couple (78.9%, 81%, and in first-generation Mexican American disparities they experience. Thus, it is 69.8%, respectively) and to live in a women (3.9%) was lower than that in US- imperative that the pediatric commu- multigenerational household (13.2%, born Mexican Americans (5.5%).9 Even nity understand the health disparities 12.9%, and 7.8%, respectively).4 First- after researchers controlled for the ef- among immigrant children and the im- and second-generation children are fects of smoking, drinking, marital sta- pact of current and future public poli- more likely to live in families that live tus, Medicaid coverage, access to care, cies on their health status. below the poverty line than children and levels of obesity, US-born Mexican In this article the demographic charac- from native families (28.3%, 19.4%, and American mothers were 1.73 times more teristics of children in immigrant fam- 16.7%, respectively). In addition, first- likely to have a low birth weight infant ilies, their health status and its rela- (55%) and second-generation (47.3%) than foreign-born Mexican American tionship to the “immigrant paradox,” children are more likely than native mothers.10 the roles of acculturation and encul- children (17%) to live in families in Several investigators have found that turation in their health outcomes, the which at least 1 parent has not gradu- the immigrant paradox’s effect varies legal issues that contribute to dispari- ated from high school and that have among immigrant groups but is most ties, and research priorities are pro- Ն1 parent who is not fluent in English consistent among Hispanic immi- filed. (76.4%, 55.2%, and 2.2%, respectively). grants.11–13 However, some of the larg- Although a significant proportion of est differences in low birth weight THE DEMOGRAPHIC SHIFT immigrant families own their home, (11.8% vs 8.0%) and infant mortality In 2030, non-Hispanic white children 60% of first-generation and 44% of rates (12.9 vs 10.5 per 1000) have oc- will constitute less than half of US chil- second-generation children live in curred between foreign- and US-born dren.1 Although higher birth rates crowded housing (Ͼ1 person per non-Hispanic blacks. The immigrant among minority groups will account room) versus 11% of children from na- paradox with respect to low birth for most of this demographic change, tive families. weight seems to be partially related to immigration will also contribute. Cur- Traditionally, the low economic and ed- drinking, smoking, and weight gain rently, 1 in 5 US children lives in an ucational achievement profile of immi- during pregnancy, although other fac- immigrant family, defined as a family grant families would indicate that tors might also be involved. The use of with at least 1 immigrant parent.2,3 The their children are at increased risk of prenatal care does not necessarily de- greatest proportions of immigrants health disparities. However, observa- crease the prevalence of low birth come from Latin America (57% in 2000) tions on their health status suggest weight among immigrant mothers, and Asia; among those from Latin Amer- that these relationships might be which seems to contradict our notion ica, ϳ75% are from Mexico.4 weaker than would be predicted from that prenatal care is essential for Children in an immigrant family can be models of health risk that focus solely healthy infants.13 The association of in- either first generation (foreign-born) on socioeconomic factors. fant mortality with the mother’s immi-

S188 MENDOZA Downloaded from www.aappublications.org/news by guest on October 2, 2021 SUPPLEMENT ARTICLE grant status is less well understood, Public Health Services (population) but as with low birth weight, multivar- iate analyses have indicated that immi- 13 grant status plays a significant role. Genetics Behavior Health After infancy, the immigrant paradox Outcome is less well documented, primarily because limited data are available on children beyond infancy in immigrant Medical Services families, and postinfancy samples usu- Socio-Physical (individual) Environment ally include children born outside the (Poverty) United States. Samples of immigrant groups other than Mexican Americans SES are usually small and frequently ag- FIGURE 1 gregated into general categories Traditional health model. SES indicates socioeconomic status. (Reproduced with permission from rather than country-specific groups Mendoza FS, Fuentes-Afflick E. West J Med. 1999;170(2):86.) (eg, Asian instead of Chinese, Vietnam- ese, Filipino, etc), thereby limiting A national study found that first- to immigrant mothers; the data for older analyses.14 Nonetheless, some insights generation adolescents were less likely children are less conclusive. Nonethe- can be drawn from the current litera- to report fair-to-poor health; missing less, taken as a whole, the current infor- ture. Depending on their country of or- school because of health or emotional mation suggests that when the immi- igin, children born outside the United problems; experiencing learning difficul- grant paradox occurs, it is associated States frequently experience several ties; having obesity or asthma; or engag- with positive health behaviors that, pre- health problems, including malnutri- ing in risky health behaviors involving sumably, the family and community envi- tion resulting in wasting and stunting, early sex, participating in violent acts, or ronment encourage and support. untreated infectious diseases, severe taking drugs.23 However, other studies Counter to the traditional health model dental problems, and serious mental have found that parents of first- in which the sociophysical environ- health problems that are a result of generation Mexican American children ment (primarily determined by socio- stress from the causes of migration and adolescents rated their children’s economic status) interacts with indi- (war and violence) or the migration health to be fair to poor more often than viduals’ genetics and behaviors (Fig 1), process itself.15–20 Yet, once in the native parents.2,20 a model proposed by Mendoza and United States, these immigrant children The strongest evidence for the immi- Fuentes-Afflick (Fig 2) includes the can improve if they receive the appropri- grant paradox comes from infants born health-promotion activities of the fam- ate services.15,21 Children in immigrant families can continue to be affected by Public Health Services (population) poverty, as exemplified by poor linear Mental growth, which results in greater risk of Health stunting and obesity.20,22 In other areas, Genetics Behavior Health Funconal they seem to be less affected. For exam- Outcomes Health ple, parents of children in immigrant families have reported that their chil- Medical Services Physical (individual) Health dren had asthma less often than native Socio-physical children (first generation: 4%; second environment generation: 10%; and native families: 15%).2 However, these children’s lack of Family Cultural SES Perceived access to health care could have led to Health Tradions Health undiagnosed disease. Socio-Cultural Children in immigrant families seem to Immigraon Community do somewhat better in the areas of FIGURE 2 mental health and risky health behav- The immigrant paradox: family-community health promotion model. (Reproduced with permission iors than do children of native families. from Mendoza FS, Fuentes-Afflick E. West J Med. 1999;170(2):88.)

PEDIATRICS Volume 124, Supplement 3, November 2009 S189 Downloaded from www.aappublications.org/news by guest on October 2, 2021 ily and the community.24 The model Latino health, however, Lara et al26 ated to US culture to a greater or suggests that support of positive cul- found that acculturation of children lesser degree depending on their age tural health behaviors by the family and adults leads to both negative and at migration, their length of contact and its community accounts for the positive health outcomes. In studies of with US culture, and the degree to protective effects of the immigrant children and adults, those who were which the family and community main- paradox. In the Mendoza–Fuentes- acculturated had poorer health behav- tain their culture of origin. As contact Afflick model, the support of culturally iors (such as increased rates of smok- with the US culture and the opportu- derived positive health behaviors by ing, drinking, and drug use) and nity for acculturation occur, children’s the family and its community buffers the poorer nutritional intake. However, ac- and adolescents’ values, attitudes, and detrimental effects of poverty. When pos- culturated individuals also reported behaviors may differ from those of itive cultural health behaviors are be- better access to health care and health their families. If these changes lead to lieved to produce good functional health screening, better satisfaction with dysfunctional mental health or an in- (eg, healthy infants or a sense of well- care, and less perceived poor health. crease in risky health behaviors, the being) and, consequently, good per- Other studies have demonstrated changes can result in poorer health ceived health, the family and community mixed results, which Lara et al be- outcomes. reinforce the behaviors through cultural lieved were a result of the inadequacy In contrast to acculturation, the encul- norms. In the model, the cultural milieu of the acculturation theoretical con- turation process of children and ado- is maintained by continued immigration struct and to problems with accultur- lescents results in the development of into the community, thereby creating a ation measures’ validity and reliability. an ethnic identity. In children, ethnic critical mass of people to support the Although an assessment of language identity is thought to be rudimentary cultural norms of the family and its usage is common to all acculturation and developed from the basic informa- community. measures and accounts for a signifi- tion received from parents about cul- Although the model’s components and cant portion of those measures’ vari- tural attitudes and behaviors.28 In con- their relationships need further explo- ance, language usage alone is not suf- trast, adolescents develop a true ration, this schematic nonetheless ficient to address the processes ethnic identity as they determine their points to the need to develop health involved in acculturation.27 Beyond lan- group’s identities and explore the models that are more sensitive to the guage usage, the cultural perceptions, meaning of that identity.29–31 A signifi- cultural milieu of family and commu- attitudes, and behaviors of non-English cant contributor to maintaining cul- nity. The immigrant paradox and the speakers differentiates them from tural identity for children and adoles- cultural nuances of health and well- English-speaking, acculturated immi- cents is proficiency in the ethnic being it emphasizes should open our grants. Furthermore, acculturation is language, which helps maintain the thinking about factors that can buffer not static but changes over time, and family’s cultural values, attitudes, and the effects of poverty and other tradi- immigrant family members usually behaviors.32 Phinney et al33 found 4 dis- tional risk factors to produce the unex- have different acculturation levels. As tinct profiles of adaptation to a new pected: good health. a result of these characteristics, accul- culture derived from the youths’ atti- turation’s impact on health is difficult tudes about becoming acculturated, HEALTH AND THE ACCULTURATION to assess.25,26 Not surprisingly, the ethnic and national identities, lan- RISK question of whether acculturation is a guage proficiency and usage, values Berry has defined acculturation as “a stressor or a facilitator of good health concerning family relationships, peer process of cultural and psychological remains unanswered but is important contacts, and perceived discrimina- change in cultural groups, families, for research to address. tion. These 4 profiles were integration and individuals following intercultural (equal participation in both cultures contact.”25 The Institute of Medicine re- CHILDREN IN IMMIGRANT [biculturalism]), ethnic (focus on eth- port on the health of children in immi- FAMILIES: PRODUCTS OF nic culture with limited participation in grant families indicated that as these ENCULTURATION AND receiving culture), national (assimila- children became acculturated to the ACCULTURATION tion [limited participation in own eth- American lifestyle, they developed All children of immigrant families be- nic culture]), and diffuse (confusion poorer outcomes for a number of come enculturated, or socialized to the and not identified with either culture). health-status measures.2 In a review of culture of their parents’ country of or- Berry25 developed a complementary the literature on acculturation and igin. Conversely, they become accultur- framework for understanding immi-

S190 MENDOZA Downloaded from www.aappublications.org/news by guest on October 2, 2021 SUPPLEMENT ARTICLE

Maintenance of Heritage Culture and Identity on their arrival in the country. Non– English-speaking or limited–English- + - + - speaking parents frequently have + problems interacting with the health care system, thereby increasing their Relationship Multiculturalism Melting Pot children’s risk of poor health out- Sought Integration Assimilation 38 Among comes. Significant deficits in care and Separation Marginalization Groups Segregation Exclusion health outcomes result from imperfect or absent translational services.39 - Healthy People 2010 defines health lit- Strategies of Strategies of eracy as “the degree to which individ- Ethno-Cultural Larger Society uals have the capacity to obtain, pro- Group cess, and understand basic health FIGURE 3 information and services needed to Berry’s acculturation strategies framework. (Reproduced with permission from Berry JW. Accultur- ation strategies and adaptation. In: Lansford JE, Deater-Deckard K, Bornstein MH, eds. Immigrant make appropriate health decisions.”40 Families in Contemporary Society. New York, NY: Guilford Press; 1999:73.) Expanding on this construct, Duran41 has recommended viewing literacy in a broad context as “literate action”; in grant families’ acculturation process. Among all these options for accultura- other words, immigrants need to un- This framework is centered around 2 tion, Berry25 suggests that integration derstand the use of language and pivotal strategic decisions made by im- is the healthiest for immigrant fami- other forms of communication in their migrant families in their interactions lies because it lets them maintain their daily sociocultural context. This sug- with the outside society: (1) the fami- identity as an ethnic family while gests the need to extend literacy skills ly’s decision to maintain its cultural adapting to their new environment. So- for immigrant families beyond interac- heritage and identity and (2) its deci- ciety typically responds to the ethnic tions with the health care system and sion about how much contact it will group in 1 of 4 possible ways: the melt- to include the literacy skills needed to have with the larger society and other ing pot, multiculturalism, segregation, interact with other social systems ethnocultural groups. These 2 strate- and exclusion. Our country’s history in- (such as schools, social welfare, and gic preferences are in the context of cludes examples of all 4 scenarios. the legal system) that affect their chil- the larger society’s acceptance of dif- How does the interaction between en- dren’s well-being. This would be an im- ferent cultures and society’s willing- culturation and acculturation affect portant step in decreasing disparities ness to have all communities fully par- children’s health disparities? Children for their children. Literacy programs ticipate in its institutions. Figure 3 and adolescents with a strong ethnic for immigrant families need to take presents the relationship of the pivotal identity are more likely to have a sense strategies to each strategic decision into account racial, ethnic, religious, of self and good mental health.34,35 A and their consequence for the eth- and other cultural issues that can af- strong ethnic identity in immigrant ad- nocultural group and society. The im- fect the parents’ ability to become olescents has a positive correlation migrant family that wants a strong re- functionally literate in their environ- with self-esteem, coping, mastery, 42 lationship with the mainstream and mental context. school adjustment, and optimism and does not mind losing its cultural CHILDREN IN IMMIGRANT FAMILIES identity will choose to assimilate; a negative correlation with depression 36 those wanting to participate in the and loneliness. Therefore, immigrant AND MINORITY CHILDREN greater society but still keep their youth who select integrative accultur- Although children of immigrant fami- ethnocultural identity will integrate; ation are most likely to have the best lies and those in US minority families 37 those who feel disenfranchised and long-term well-being outcomes. commonly live in poverty, they display want to keep their cultural identity differences in health status. For exam- will become a separate ethnocul- IMPACT OF LANGUAGE AND ple, children of immigrant Mexican tural community; and those that have LITERACY American families (the largest immi- lost their identity and have limited Immigrant families’ need for access to grant group) are more likely to be im- participation in society are likely to services, particularly health care ser- poverished, have less educated par- be marginalized. vices, for their children usually starts ents, and be uninsured than third-

PEDIATRICS Volume 124, Supplement 3, November 2009 S191 Downloaded from www.aappublications.org/news by guest on October 2, 2021 generation and later generations of TABLE 1 Restrictions on the Use of Federal Programs by Documented and Undocumented Mexican American children (US His- Immigrants panics) and black children.43 Program Documented Undocumented Child care and development fund subsidies Eligible Not eligible Although these characteristics sug- Federal earned income tax credit Eligible Not eligible gest that children of immigrant fami- Food stamps No restrictions for children; Not eligible lies have a greater risk or poor health adults barred for 5 y Housing assistance (public housing) Eligible Not eligible outcomes, the earlier discussion shows Public health insurance (Medicaid and SCHIP) Eligible Not eligible that children of immigrant families seem Supplemental Security Income Barred from benefit Not eligible to have better-than-expected outcomes Temporary Assistance for Needy Families Barred for 5 y Not eligible Unemployment insurance Eligible Not eligible in a number of health areas. What makes Special Supplemental Nutrition Program for Eligible Varies by state this happen? Perhaps having a greater Women, Infants, and Children likelihood of being part of an intact School lunch Eligible Eligible Emergency Medicaid Eligible Eligible 2-parent family, living with an extended Data source: Peninsula Family Advocacy Program, personal communication, 2009. family that provides social support, and being enculturated to an ethnic culture that helps define their self-identity buffer and what society can offer can make a health of documented immigrant chil- aspects of poverty in their environment significant difference. dren in the United States will improve. that seem to be detrimental to children’s Thus, as we study health disparities health. These characteristics of immi- LEGAL AND REGULATORY POLICIES among children in immigrant families, grant families are less common among Changes in immigration policy over the we need to examine disparities caused US minority groups living in poverty or past decades have influenced dispari- by public policy as well as those deter- low socioeconomic status conditions, ties for children in immigrant families mined by the environment and biology. particularly those who have had long- primarily by restricting access to Med- The Institute of Medicine report on the term family and community experiences icaid and the State Children’s Health health of children in immigrant fami- that have resulted in marginalization. Insurance Program (SCHIP). In 2000, lies described the impact of key public Berry’s acculturation models of families one third of all uninsured low-income policies since 1965.2 The policy on into the greater society can be applied to children were children of immigrant 25 “public charge” (the use of public all groups. Perhaps the differences oc- families, of which 33% were undocu- funds) has become critical for immi- cur because immigrant families came to mented children and 50% were citizen grant parents, who are concerned that this country seeking the opportunity to children of noncitizen parents.46 In con- integrate and have the perspective that trast, only 16% of citizen children with this could prevent them or their chil- this possibility exists, whereas US minor- naturalized immigrant parents were dren from becoming legal residents or ities have had experiences over genera- uninsured. citizens. The variability in and misun- derstanding of public-charge assess- tions that have erased that dream for The public policies that limit access to ment has led some immigrant families them and their communities. health and social service programs to avoid obtaining health services for Kao44 offered an example of this differ- have been major contributors to their children. Since 1996, the use of ence in a review of research on the health disparities among children of food stamps by mixed-citizenship fam- adaptation of immigrant youth to immigrant families. Table 1 lists the ilies has decreased by 20%, and the school. The review showed that al- current health and social services lim- proportion of children of immigrant though these youth endured greater itations for children in immigrant fam- parents without health insurance has rejection from native whites and their ilies, determined from the literature 47,48 own native ethnic group, they did bet- and personal communication with the increased to 28.4%. Many of these 49 ter in school than their native ethnic Peninsula Family Advocacy Program children are US citizens. group and showed strong resilience. (www.peninsulafap.org/index.php). As national public benefits policy for Moreover, their families promoted ed- Before the reauthorization of the SCHIP immigrants has changed, state and lo- ucational success, and immigrant par- this year, documented immigrant chil- cal governments have worked to im- ents were optimistic about their children were not able to access public prove health care access for children dren’s upward mobility in society.45 health insurance for the first 5 years of immigrant families. Communities in Ultimately, what parents transmit to after arrival. By changing this policy in California have taken the lead in devel- children about what their future holds the reauthorization of the CHIP, the oping health insurance programs for

S192 MENDOZA Downloaded from www.aappublications.org/news by guest on October 2, 2021 SUPPLEMENT ARTICLE undocumented children, such as the Currently, research on how to improve fore, as we retool our health care sys- “Healthy Kids” program supported by a access to health care for children in tem to provide patient-centered and mix of public and private funds.50 They immigrant families is critical. Re- transparent care, we need to consider have also attempted to increase ac- search to understand the barriers and how to train our health care providers cess to Medicaid and the SCHIP for cit- develop interventions could have the and teach our future providers to pro- izens and legal immigrant children in greatest immediate impact on these vide culturally competent care, and immigrant families through informa- children and would have a timely im- how we insure that access to care is tional campaigns. These efforts have pact on policy makers, particularly in also appraised by the quality of the reduced the number of uninsured chil- states with large immigrant popula- care received by these children. Al- dren, but the battle to provide consis- tions. The present crisis in the cost of though some health care systems tent and sustainable health insurance health care along with the economic have started to address these issues, for all children, particularly in border downturn will clearly increase the risk the economic drive to provide cost- states, is a significant problem for that a greater proportion of these chil- efficient care (getting it right the first health and public policy makers.49 dren will become uninsured. There- time) will increase incentives to move State policies concerning coverage of fore, research on access to health care in this direction as the populations of legal immigrants vary according to for these children needs to explore children become more diverse. Re- state.51 Fortunately, the reauthoriza- venues for providing care that are dif- search in this area will not only im- tion of the SCHIP will help improve this ferent from traditional systems. Com- prove care for children of immigrant situation. A humane national policy for munity health workers, group care, families but for all families by empha- children in immigrant families is and binational health care systems sizing the family’s individual needs. clearly needed, and Congress has might provide the economic models Finally, the immigrant paradox can ex- taken the first step in that direction. needed to expand access more cost- pand the discussion of health risks efficiently. and disparities to involve the possible RESEARCH PRIORITIES Research on the quality of care given benefits of culture in maintaining good From the discussion above, the priori- to children in immigrant families is the health. The implications of this are ac- ties for research on children in immi- other half of the critical agenda for ademically interesting and economi- grant families can be divided into 3 ar- children in immigrant families. Even cally intriguing. For example, in perina- eas: (1) improving their access to when children in immigrant families tal care, which involves significant health care; (2) improving the quality have access to health care, the quality morbidity and health care costs, main- of their health care; and (3) elucidating of that care might be reduced because taining the low prevalence of low birth the cultural factors that support posi- providers or the health care system do weight infants among immigrant tive health and developmental out- not provide culturally competent care. women and translating the contribut- comes. To achieve these goals, investi- The use of medical interpreters, al- ing factors to other groups of women gators will need data on these children though important, is not sufficient to is a high priority for research. Re- that allow identification of the chil- ensure high-quality care for immi- search also needs to explore and mod- dren’s country of origin and their par- grant families and their children be- ify cultural factors that contribute to ents’ residential status. Researchers cause they also usually have a differ- poor health, such as attitudes about will also need to acquire research in- ent culture, religion, or social class obesity. Effective research in this area struments that provide culturally valid that affects their interactions with the will require a multidisciplinary ap- information on these diverse popula- provider and the health care system. proach with researchers from outside tions. One survey that has addressed Furthermore, disparity in quality of the fields of health and public health. the challenges in assessing immigrant care can arise because access to Understanding the triad of biology, en- communities is the California Health health care for these children fre- vironment, and culture will provide the Interview Survey.52 This unique survey quently occurs at high-volume facili- basis for improved health for children has become an important data source ties that commonly have limited re- in immigrant families and will be a for researchers and policy makers in sources and may have less access to step forward in reducing children’s California. regionalized pediatric services. There- health disparities in the United States.

PEDIATRICS Volume 124, Supplement 3, November 2009 S193 Downloaded from www.aappublications.org/news by guest on October 2, 2021 REFERENCES

1. Hernandez D, Denton N, Macartney S. Chil- 13. Landale NS, Oropesa RS, Gorman BK. Immi- aptation. In: Lansford JE, Deater-Deckard K, dren in America’s Newcomer Families [Re- gration and infant health: birth outcomes of Bornstein MH, eds. Immigrant Families in search Brief Series]. Albany, NY: Child immigrant and native-born women. In: Her- Contemporary Society. New York, NY: Guil- Trends & the Center for Social and Demo- mandez DJ, ed. Children of Immigrants: ford Press; 1999:69–82 graphic Analysis, State University of New Health, Adjustment, and Public Assistance. 26. Lara M, Gamboa C, Kahramanian M, Mo- York at Albany; 2007 Washington, DC: National Academies Press; rales L, Hayes Bautista D. Acculturation and 2. Hernandez DJ, Charney E. From Generation 1999:244–285 Latino health in the United States: a review to Generation: The Health and Well-being of 14. Mendoza FS, Javier JR, Burgos AE. Health of of the literature and its sociopolitical con- Children in Immigrant Families. Washing- children in immigrant families. In: Lansford text. Annu Rev Public Health. 2005;26: ton, DC: National Academies Press; 1998 JE, Deater-Deckard K, Bornstein MH, eds. Im- 367–397 3. Hernandez DJ, Denton NA, Macartney SE. migrant Families in Contemporary Society. 27. Marin G. Issues in the measurement of ac- Family circumstances of children in immi- New York, NY: Guilford Press; 2007:30–50 culturation among Hispanics. In: Geisinger grant families. In: Landford JE, Deater- 15. Schumacher LB, Pawson IG, Kretchmer N. KF, ed. Psychological Testing in Hispanics. Deckard K, Bornstein MH, eds. Immigrant Growth of immigrant children in the new- Washington, DC: American Psychological Families in Contemporary Society. New comer schools of San Francisco. Pediatrics. Association; 1992:23–51 York, NY: Guilford Press; 2007:9–29 1987;80(6):861–868 28. Bernal ME, Knight GP, Garza CA, Ocampo KA, 4. US Census Bureau. Selected Characteris- 16. Nelson LJ, Schneider E, Wells CD, Moore M. Cota MK. Development of Mexican American tics of the Foreign-Born Population by Pe- Epidemiology of tuberculosis in the United identity. In: Bernal M, Knight G, eds. Ethnic riod of Entry Into the United States: Ameri- State, 1993–2001: the need for continued Identity: Formation and Transmission can Community Survey. Washington, DC: US vigilance. Pediatrics. 2004;114(2):333–341 Among Hispanics and Other Minorities. Al- Census Bureau; 2006 17. Armstrong GL, Mast EE, Wojczynski M, Mar- bany, NY: State University of New York 5. Markides KS, Coreil J. The health of Hispan- golis HS. Childhood hepatitis B virus infec- Press; 1993:31–46 ics in the southwestern United States: an tions in the United States before hepatitis B 29. Phinney JS, Ong AD. Ethnic identity develop- epidemiologic paradox. Public Health Rep. immunization. Pediatrics. 2001;108(5): ment in immigrant families. In: Lansford JE, 1986;101(3):253–265 1123–1128 Deater-Deckard K, Bornstein MH, eds. Immi- 6. Ventura SJ, Taffel SM. Childbearing charac- 18. Weine SM, Kuauzovic Y, Besic S, et al. Family grant Families in Contemporary Society. teristics of U.S.- and foreign-born Hispanic consequences of refugee trauma. Fam Pro- New York, NY: Guildford Press; 2007:51–68 mothers. Public Health Rep. 1985;100(6): cess. 2004;43(2):147–160 30. Knight GP, Bernal ME, Garza CA, Cota MK, 647–652 19. American Psychological Association. The Ocampo K. Family socialization and the ethnic 7. Williams RL, Binkin NJ, Clingman EJ. Preg- mental health needs of immigrants. Avail- identity of Mexican-American children. nancy outcomes among Spanish-surname able at: www.apa.org/ppo/ethnic/immigrant J Cross-Cultural Psych. 1993;24(1):99–114 women in California. Am J Public Health. 1986; health.html. Accessed February 2, 2009 31. Phinney JS. A three-stage model of ethnic 76(4):387–391 20. Mendoza FS, Dixon LB. The health and nutri- identity development in adolescence. In: 8. Mendoza FS, Ventura SJ, Valdez RB, et al. tional status of immigrant Hispanic chil- Knight GP, Bernal ME, eds. Ethnic Identity: Selected measures of health status for dren. In: Hernandez DJ, ed. Children of Im- Formation and Transmission Among His- Mexican-American, mainland Puerto Rican, migrants: Health Adjustment and Public panic and Other Minorities. Albany, NY: and Cuban-American children. JAMA. 1991; Assistance. Washington, DC: National Acad- State University of New York Press; 1993: 265(2):227–232 emies Press; 1999:187–243 61–79 9. Scribner R, Dwyer J. Acculturation and low 21. Daley TC. Beliefs about treatment of mental 32. Phinney JS, Romero I, Nava M, Huang D. The birthweight among Latinos in the Hispanic health problems among Cambodian Ameri- role of language, parents, and peers in eth- HANES. Am J Public Health. 1989;79(9): can children and parents. Soc Sci Med. 2005; nic identity among adolescents in immi- 1263–1267 61(11):2384–2395 grant families. J Youth Adolesc. 2001;30(2): 10. Guendelman S, Gould J, Hudes M, Eskenazi 22. Martorell R, Malina RM, Castillo RO, Men- 135–153 B. Generational differences in perinatal doza FS, Pawson IG. Body proportions in 33. Phinney JS, Berry JW, Vedder Pl, Liebkind K. health among the Mexican American pop- three ethnic groups: children and youths The acculturation experience: attitudes, ulation: findings from the HHANES 1982– 2–17 years in NHANES II and HHANES. Hum identities, and behaviors of immigrant 1984. Am J Public Health. 1990;80(suppl): Biol. 1988;60(2):205–222 youth. In: Berry JW, Phinney JS, Sam DL, 61–65 23. Harris KM. The health status and risk behav- Veder P, eds. Immigrant Youth in Cultural 11. Fuentes-Afflick E, Hessol NA, Pe´rez-Stable EJ. iors of adolescents in immigrant families. Transition: Acculturation, Identity, and Ad- Maternal birthplace, ethnicity, and low In: Hernandez DJ, ed. Children of Immigrants: aptation Across National Contexts. Mah- birth weight in California. Arch Pediatr Ado- Health, Adjustment, and Public Assistance. wah, NJ: Erlbaum; 2006:71–116 lesc Med. 1998;152(11):1105–1112 Washington, DC: National Academies Press; 34. Phinney JS, Kohatsu EL. Ethnic and racial 12. Gould JB, Madan A, Oin C, Chavez G. Perina- 1999:286–347 identity development and mental health. In: tal outcomes in two dissimilar immigrant 24. Mendoza FS, Fuentes-Afflick E. Latino chil- Maggs JL, Schulenberg J, eds. Health Risks populations in the United States: a dual ep- dren’s health and the family-community and Developmental Transitions During Ado- idemiologic paradox. Pediatrics. 2003;111(6 health promotion model. West J Med. 1999; lescence. New York, NY: Cambridge Univer- pt 1). Available at: www.pediatrics.org/cgi/ 170(2):85–92 sity Press; 1997:420–443 content/full/111/6/e676 25. Berry JW. Acculturation strategies and ad- 35. Nesdale D, Rooney R, Smith L. Migrant ethnic

S194 MENDOZA Downloaded from www.aappublications.org/news by guest on October 2, 2021 SUPPLEMENT ARTICLE

identity and psychological distress. J Cross 42. Gadsden VL. Designing and conducting fam- 47. Dinan KA. Federal policies restrict immi- Cult Psychol. 1997;28(5):569–588 ily literacy programs that account for ra- grant children’s access to key public bene- 36. Roberts RE, Phinney JS, Masse LC, Chen Y, cial, ethnic, religious, and other cultural dif- ﬁts. In: Children in Low-Income Immigrant Roberts CR, Romero A. The structure of eth- ferences. In: Benjamin L, Lord J, eds. Family Families: Policy Brief. New York, NY: Mail- nic identity of young adolescents from di- Literacy: Directions in Research and Impli- man School of Public Health, Columbia verse ethnocultural groups. J Early Adolesc. cations for Practice: Summary and Papers University; 2005:1–11 1999;19(3):301–322 of a National Symposium. Washington, DC: 48. Kaushal N, Kaestner R. Welfare reform and Department of Education; 1996:31–38 37. Berry JW. Immigration, acculturation, and health of immigrant women and their chil- adaptation. Appl Psychol. 1997;46(1):5–68 43. Burgos A, Schetzina K, Dixon B, Mendoza F. dren. J Immigr Minor Health. 2007;9(2):61–74 Importance of generational status in ex- 49. Lavarreda SA, Brown ER, Yoon J, Glenn S. 38. Berkman ND, DeWalt DA, Pignone MP, et al. amining access to and utilization of More than half of California’s uninsured Literacy and health outcomes. Evid Rep health care services by Mexican Ameri- children eligible for public programs but Technol Assess (Summ). 2004;(87):1–8 can children. Pediatrics. 2005;115(3). not enrolled. In: Brown ER, ed. Health Policy 39. Flores G. The impact of medical interpreter Available at: www.pediatrics.org/cgi/ services on the quality of health care: a sys- content/full/115/3/e322 Fact Sheet. Los Angeles: University of Cali- fornia at Los Angeles; 2006:1–2 tematic review. Med Care Res Rev. 2005;62(3): 44. Kao G. Psychological well-being and educa- 255–299 tional achievement among immigrant 50. Stevens GD, Rice K, Cousineau MR. Chil- 40. US Department of Health and Human Ser- youth. In: Hernandez DJ, ed. Children of dren’s health initiatives in California: the vices. Healthy People 2010. Washington, DC: Immigrants: Health, Adjustment, and Public experiences of local coalitions pursing uni- US Government Printing Ofﬁce; 2000 Assistance. Washington, DC: National Acad- versal coverage for children. Am J Public Health. 2007;97(4):738–743 41. Duran R. English immigrant language emies Press; 1999:410–477 learners: cultural accommodation and fam- 45. Kao G, Tienda M. Optimism and achieve- 51. Ku L. Reducing Disparities in Health Cover- ily literacy. In: Benjamin L, Lord J, eds. Fam- ment: the educational performance of im- age for Legal Immigrant Children and Preg- ily Literacy: Directions in Research and Im- migrant youth. Soc Sci Med. 1995;76(1): nant Women. Washington, DC: Center on plications for Practice: Summary and 1–19 Budget and Policy Priorities; 2007 Papers of a National Symposium. Washing- 46. Lessard G, Ku L. Gaps in coverage for chil- 52. California Health Interview Survey. Making ton, DC: Department of Education; 1996: dren in immigrant families. Future Child. an impact. Available at: www.chis.ucla.edu/ 25–30 2003;13(1):101–115 about.html. Accessed September 3, 2009

PEDIATRICS Volume 124, Supplement 3, November 2009 S195 Downloaded from www.aappublications.org/news by guest on October 2, 2021 Health Disparities and Children in Immigrant Families: A Research Agenda Fernando S. Mendoza Pediatrics 2009;124;S187 DOI: 10.1542/peds.2009-1100F

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/124/Supplement_3/S187 References This article cites 24 articles, 3 of which you can access for free at: http://pediatrics.aappublications.org/content/124/Supplement_3/S187 #BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Community Pediatrics http://www.aappublications.org/cgi/collection/community_pediatrics _sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on October 2, 2021 Health Disparities and Children in Immigrant Families: A Research Agenda Fernando S. Mendoza Pediatrics 2009;124;S187 DOI: 10.1542/peds.2009-1100F

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/124/Supplement_3/S187

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2009 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on October 2, 2021