Migrant health

Migrant health, refugee health or immigrant health is the field of study on the health effects experienced by people who have moved to another area of the world, either by choice or as a result of unsafe circumstances such as war. The health of these displaced populations is mainly affected by infectious disease, mental health, and chronic diseases that are common in the country in which these displaced persons eventually settle. This is largely due to factors such as the migrant's geographic origin, conditions of refugee camps where the migrant lived, and personal, physical, and psychological conditions of the migrant, either pre-existing or acquired while traveling from their homeland to a camp or eventually to their new home.[1] It is common for people entering new countries for resettlement to undergo a comprehensive health assessment - In the United States, The Federal Refugee Act of 1980 recommends that all refugees are administered proper health screening. The Office of Refugee Resettlement (ORR) housed in the Department of Health and Human Services (DHHS) is charged with funding and oversight of this effort. Three medical interventions are either required or recommended in order to contain infectious disease and reduce the medical burdens that may be associated with refugee resettlement. First is a mandatory overseas screening for all refugees and immigrants, then a recommended domestic screening for refugees, and finally a required medical component to the Adjustment of Status (Green Card) process.

Overseas preventative action

The US Public Health Service requires a health screening for all immigrants and refugees prior to departure from their country of origin. Here, refugees undergo the most thorough screening. These medical exams are performed by approximately 400 physicians [called Panel Physicians] selected by the US Department of State (DOS) consular officials. The Centers for Disease Control and Prevention's (CDC) Division of Global Migration and Quarantine (DGMQ) provide the technical instructions and guidance to the physicians conducting the overseas exams. The screening is primarily aimed at detecting infectious diseases of public health concern. The overseas exam includes a medical history inquiry, physical exam, chest x-ray for persons older than 14 years of age (Southeast Asian refugees older than 2 years of age), and specific lab tests. Testing routinely includes screening for syphilis and HIV in people over 15 years of age.

Laws

The CDC's Division of Global Migration and Quarantine is responsible for providing the US Department of State and the United States Citizenship and Immigration Services (USCIS) with medical screening guidelines. The guidelines are developed in accordance with Section 212(a)(1)(A) of the Immigration and Nationality Act (INA), which outlines the reasons an alien is ineligible for a visa or admission to the United States, specifically based on health grounds. "The health-related grounds include those aliens who have a communicable disease of public health significance, who fail to present documentation of having received vaccination against vaccine-preventable diseases, who have or have had a physical or mental disorder with associated harmful behavior, and who are drug abusers or addicts."[2] Medical conditions recognized in refugees are categorized as Class A or Class B and are described below. If a refugee is found to have an inadmissible health-related condition, a waiver is required for the applicant to come to the US.

Class conditions

The health-related grounds for exclusion of refugees and immigrants set forth in the law are implemented by a regulation, "Medical Examination of Aliens" (42 CFR, Part 34). The regulation lists certain disorders that, if identified during the overseas medical examination, are grounds for exclusion (Class A condition) or represent such significant health problems (Class B condition) that they must be brought to the attention of consular authorities.

The purpose of the medical examination is to determine whether an alien has 1) a physical or mental disorder (including a communicable disease of public health significance or drug abuse/addiction) that renders him or her ineligible for admission or adjustment of status (Class A condition); or 2) a physical or mental disorder that, although not constituting a specific excludable condition, represents a departure from normal health or well-being that is significant enough to possibly interfere with the person's ability to care for himself or herself, or to attend school or work, or that may require extensive medical treatment or institutionalization in the future (Class B condition).

Class A conditions

Class A conditions are those that preclude a refugee from entering the US. They include communicable diseases of public health significance, mental illnesses associated with violent behavior, and drug addiction. Refugees must undergo treatment for these conditions if indicated. They could also request a waiver that would permit them to enter the US. Class A conditions include:

Class B conditions

Class B conditions are conditions that are identified as amounting to a substantial departure from normal well-being. A refugee identified as having a Class B condition will most likely receive treatment before departing for the United States and must seek follow-up soon after arrival in the US. Class B conditions include:

Domestic preventative actions

When refugees enter the United States, they must enter through one of five authorized ports of entry that have Quarantine Stations: John F. Kennedy International Airport in New York City, Newark Liberty International Airport, Miami International Airport, O'Hare International Airport in Chicago and Los Angeles International Airport. At these locations, US Public Health Service personnel review refugees' medical documents and perform limited inspections to look for obvious signs of illness. Through an electronic notification system maintained by the CDC, state health officials in the destination state are notified and sent copies of the overseas medical exam.

Upon arrival in the US, it is recommended that refugees complete a domestic health screening that seeks to reduce health-related barriers to successful resettlement and protect the health of the US population. Domestic health exams focus on infectious disease screening, but can also offer diagnosis and treatment for other health conditions identified. The parameters of the screening are based upon the 1995 Office of Refugee Resettlement Medical Screening Protocol, but new guidance is forthcoming.

Laws

The Refugee Act of 1980, which amended the Immigration and Nationality Act to establish a domestic refugee resettlement program, has outlined several public health activities with regards to refugee resettlement. First, all state or local health officials are to be notified of each refugee's arrival so that they can provide timely treatment for health conditions of public health significance identified overseas. The Director of ORR has the authority to make grants to state or local health agencies to help them meet the costs of providing medical screening and initial medical treatment to refugees. In this way, states can provide domestic health assessment services with federal refugee funding support. To qualify for this funding, the state health assessments need to be in accordance with ORR requirements and approved by the ORR director. It is recommended that a refugee receive a health screening within 90 days of entering the United States. The screening protocols are left to state health officials with the approval of ORR.

Domestic health assessment

A Medical Screening Protocol for Newly Arriving Refugees was developed by ORR in collaboration with CDC in 1995. Many states have added requirements in addition to the ORR protocol. DHHS is now drafting guidance for an expanded domestic protocol for screening refugees. The scope of the domestic health exam includes:

Special considerations

Cultural competence

When doctors or other health professionals work with refugee populations, it is necessary to strive for cultural competence. Refugees most often come from war-torn situations combined with prolonged time in refugee camps. Some of the educated among them may speak some English and may have knowledge of Western culture. However, some refugees from rural areas may speak only a local dialect and have very little if any knowledge of the Western world. Health care providers seeing refugees for their domestic screening are often the refugee's first experience with Western style medical care. Physicians, nurses and other health care providers would do well to learn about the cultural background of their refugee patients and ensure that a professional bi-lingual/bi-cultural medical interpreter is present for their encounters. Interpreters should not be a relative or friend of the refugee. A r2015 systematic review found that healthcare providers face challenges in taking care of immigrants health.[3] Often physicians face law restraints prohibiting them from providing proper healthcare for refugees, because they do not have legal right to have access to all healthcare resources.[3]

When seeing a patient, it is important to understand that it isn't just the patient's culture that is at play, but one's own culture, as well as the culture of medicine. All three of these cultures interact in ways we need to be sensitive to and aware of, as they influence the outcome of the encounter. To understand patients who are culturally different from ourselves, it is first necessary to recognize our own cultural beliefs, values, and behaviors as well as how our life experiences influence the way we think about health care, and how it shapes the way we make clinical decisions.[4]

In striving for cultural competence, a physician must be sure to consider all of the cultures at play: the refugee's culture, the physician's culture, and the inherent culture of medicine. As a minority, it is also important to remember that these refugee populations will be subject to various social determinants of health. These conditions coupled with their high incidence of infectious diseases, poor mental health, and susceptibility to chronic diseases result in poor health outcomes for many refugees. To avoid these poor outcomes, it is imperative for physicians treating refugee patients to establish a friendly, trusting physician-patient relationship which will allow them to provide adequate care.[5] Another important step in achieving cultural competence is understanding and respecting refugee's health beliefs. A person's beliefs in regard to their health and disease is largely shaped from the culture they come from. These beliefs also influence how people "perceive, experience, and express"[6] illness. If a physician is capable of administering care with sensitivity to these beliefs, she will find that the quality of care if greatly increased for the patient.[5]

Another important factor that health professionals must take in to consideration is the conceptualization of disease that refugee patients may have, and how these differ from our socially driven and accepted concepts. Although these concepts may differ greatly due to cultural differences, a physician will be better enabled to treat a refugee despite these differences if she has knowledge of the discrepancy prior to meeting the patient.[7]

Trauma

Prior to World War II, immigrants were often driven from their countries by forces such as unemployment, famine and poverty, often combined with various forms of prejudice and oppression. In other words, war and ethnopolitical conflict were not the primary causes for emigration. Beginning with World War II, however, civilians were increasingly targeted as a strategy of warfare. Since WWII, most newcomers (especially refugees) to the US have been victimized by war and/or political repression. Like previous immigrants, these recent arrivals have known social oppression, including inadequate education, lack of job opportunities, inability to practice their faith or marry whom they wished, and inability to live where they want. However, unlike most previous immigrants, many of them have also experienced or witnessed government-sponsored torture and/or terror. That said, refugees are survivors who possess amazing resiliency, strength and resourcefulness.[8] An assessment of mental health may be included in a refugee's domestic health screening.

Common health concerns

Refugees may be at a higher risk for contracting certain diseases or having other health problems due to factors such as poor nutrition, poor sanitation and lack of adequate medical care. The most common health concerns are listed below.

Immunizations

Refugees tend to arrive in the United States with a variety of immunization needs. They may have had vaccinations in their country of origin, but due to the often unplanned nature of their departure are unlikely to have vaccination documentation. Some may have received immunizations as part of their overseas exam, and some may have received no immunizations. Unlike persons with immigrant status, US-bound refugees are not required to have vaccinations in order to enter the US. However, it is mandated that at the time of applying for adjustment of status from legal temporary resident to legal permanent resident, a refugee must be fully vaccinated in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP). Recommendations by the World Health Organization's (WHO) Expanded Program on Immunizations (EPI) are generally followed by countries worldwide with minor variations in vaccine schedules, spacing of vaccine doses, and documentation. The majority of vaccines used worldwide are from reliable local or international manufacturers, and no potency problems have been detected, with the occasional exception of tetanus toxoid and the oral polio vaccine (OPV). A list of required vaccines in the US can be found on the vaccine schedule page.

Tuberculosis

"An estimated one third of the world's population is infected with Mycobacterium tuberculosis."[8] This high incidence necessitates that those conducting the overseas exam (Panel Physicians) screen all refugees for TB and further test anyone suspected of having active TB. Screening for tuberculosis generally involves a tuberculin skin test, followed by a chest X-ray when necessary, and laboratory testing depending on those results. Anyone between the ages of 2 and 14, living in a country with a tuberculosis incidence rate of 20 or more cases per 100,000 people (as identified by the WHO), is required to have a tuberculin skin test. Those aged 15 and older must have a chest x-ray. Those individuals identified as having active tuberculosis must complete treatment before being permitted to enter the US. Upon arriving in the US, the CDC recommends that all refugees be screened for tuberculosis using a tuberculin skin test. A follow-up chest x-ray is required if the tuberculin skin test is positive, or if the refugee was identified as having TB (either Class A or Class B) in their overseas exam, or if they are infected with HIV.

Sexually transmitted infections

All refugees aged 15 years and older are screened for syphilis and HIV during the overseas exam. STIs are a significant health risk and testing is often included in the domestic health screening based on need, as identified by the doctor conducting the screening. Refugees can be at a higher risk for contracting sexually transmitted infections because of a lack of access to protection and/or treatment, as well as the circumstances of war and flight, making them subject to higher incidences of rape and sexual abuse. Domestic screening often includes tests for syphilis, gonorrhea, chlamydia, and HIV infection as indicated by history and symptoms.

HIV

All refugees aged 15 years and older are screened for HIV as part of the overseas examination. It is not a routine part of the recommended domestic screening exam in the US unless deemed necessary by the provider conducting the exam based on risk factors or symptoms of the disease.

Hepatitis B

Hepatitis B infection is endemic in Africa, Southeast Asia, East Asia, Northern Asia, and most of the Pacific Islands. According to the CDC, the rate of chronic infection among persons emigrating to the US from these areas is between 5% and 15%. Many states require or recommend that all refugees be screened for hepatitis B, and proceed with immunizations for all who are susceptible to this infection.

Lead poisoning

Lead poisoning is an important health issue for children all around the world. The prevalence of elevated blood lead levels (i.e., BLLs ≥ 10 µg/dL) among newly resettled refugee children is substantially higher than the 2.2% prevalence for US children. A 2001 Massachusetts study found as many as 27% of newly arrived refugee children with elevated BLLs, making refugees one of the highest risk groups.[9] Refugees may be exposed to lead from a number of sources which can include: leaded gasoline, herbal remedies, cosmetics, spices that contain lead, cottage industries that use lead in an unsafe manner, and limited regulation of emissions from larger industries.[10] The detrimental effects of lead on children may occur with no overt symptoms and blood lead testing is the only way to determine exposure or poisoning. The CDC recommends lead testing for newly arrived refugee children younger than 16 years of age. Guidelines for testing vary among states, ranging from testing children younger than six years of age to the CDC age limits of testing those younger than 16 years of age.

Parasitic infections

Intestinal parasites are a major health problem for many groups, including refugees, and the presence of pathogenic parasites requires medical attention. "Over one billion persons worldwide are estimated to be carriers of Ascaris. Approximately 480 million people are infected with Entamoeba histolytica. At least 500 million carry Trichuris. At present, 200 to 300 million people are infected with one or more of the Schistosoma species and it is estimated that more than 20 million persons throughout the world are infected with Hymenolepsis nana".[8] Consequences of parasitic infection can include anemia due to blood loss and iron deficiency, malnutrition, growth retardation, invasive disease, and death. Refugees are particularly at risk given the likelihood of poor or contaminated water and poor hygienic conditions in camps. Since 1999, the CDC has recommended that US-bound refugee populations from Africa and Southeast Asia undergo presumptive treatment for parasitic infections prior to departure. The US Protocol includes a single dose of albendazole.[11] In many states, the domestic health screening exam recommends that all refugees be screened for parasitic infections whether or not they appear symptomatic. Screening often includes two stool specimens obtained more than 24 hours apart and/or a CBC with differential for evaluation of eosinophilia.

Malaria

Malaria is considered endemic in the Americas from as far north as Mexico to as far south as Argentina, in Africa from Egypt to South Africa, in Asia from Turkey to Indonesia, and in the islands of Oceania. It is estimated that 300 to 500 million people are infected each year with malaria, and over one million people die every year from the disease, predominantly in sub-Saharan Africa. Based on the high prevalence of asymptomatic malaria in sub-Saharan Africa, the CDC recommends that US-bound refugee populations from this region undergo presumptive treatment prior to departure to the US. For those refugee arrivals from sub-Saharan Africa with no pre-departure treatment documentation, the CDC recommends either they receive presumptive treatment on arrival (preferred) or have laboratory screening to detect Plasmodium infection. For refugees from other areas of the world where asymptomatic malaria is not prevalent, the CDC recommends that any refugee with signs or symptoms of malaria should receive diagnostic testing for Plasmodium, and subsequent treatment for confirmed infections, but not presumptive treatment.

Anemia

Anemia is a common blood disorder worldwide. The WHO estimates the number of people affected at close to 2 billion. Acquired causes of anemia in refugees and other immigrants include iron deficiency, malaria, parasitic infection, tuberculosis, HIV, and anemia of chronic diseases. There are also several genetically based red blood cell disorders related to geographic distribution that should be considered when assessing an anemic condition, including α and β-thalassemia, hemoglobin E, sickle cell disease, hemoglobin C, G6PD deficiency and red blood cell membrane defects.[12]

Mental health

Refugee mental health and integration into a new society are exquisitely interwoven. Traumatic experiences that occurred in the home country or during the resulting flight from that country are common. These experiences, in addition to the stresses of resettling in the host country, increase the chances of a less successful adjustment to the society of the host country. The influence of these traumatic and stressful events may be temporary and manageable with straightforward solutions or may be disabling and enduring.

High rates of mental health concerns have been documented in various refugee populations. Most studies reveal high rates of post-traumatic stress disorder (PTSD), anxiety, depression, and somatization among newly arrived refugees. Variations reported in the prevalence of PTSD and depression may be ascribed to a number of factors, including prior life in their homeland, the experience of flight from that homeland, life in refugee camps, and stressors during and after resettlement in a third country.[13] More specifically, socioeconomic status, educational background, and gender all affect levels of mental illness.[14]

It is critical that mental health issues be addressed in the screening process. Leaving behind all that is familiar and starting a new life in a new country with a different language and culture in addition to previous trauma and dislocation produces an immediate challenge that can have long-term effects. This is true whether an individual is coming from Europe, sub-Saharan Africa, Central America, or elsewhere in the world. Many refugees will not share a Western perspective or vocabulary, so questions will need to be explained through specific examples or re-framed in culturally congruent terms with the assistance of an interpreter or bicultural worker.[8] One option is to administer an efficient and valid screener for emotional distress, such as the Refugee Health Screener - 15, in the context of the overall health screening.[15]

Methods of treatment for refugees with mental health issues must also be culturally congruent. Western psychiatric methods may not applicable to individuals who do not conceive of the body and mind in the same way as people in the United States.[16] For example, studies of Tibetan refugees have shown how important the Tibetan religion of Buddhism is in helping the refugees cope with their situation. The religion provides them with an explanation for their situation and hope for a better future.[17] In some cases, indigenous methods of coping and psychological therapy can be integrated with Western methods of therapy to provide a wide spectrum of mental help to refugees.[18]

Occupational health

Demand for labor is an important reason for migration. Despite the difficulty in researching immigrant populations, there is evidence that occupational health is an area in which immigrants face disparities. Many migrant or foreign-born workers fill low-wage, temporary or seasonal work in industries and jobs that may pose greater risks for worker health and safety such as agriculture, construction and services.[19] In the United States, agriculture sector occupational risks such as asthma are more likely to affect immigrant workers.[20] Overall, immigrants have higher rates of occupational morbidity and mortality than those who are native born, including higher rates of fatal and non-fatal injury.[21][22] Evidence from Southern Europe points to higher rates of occupational risks such as working many hours per day and extreme temperatures[23] and greater exposure to poor employment conditions and job precariousness.[24] Health prevention and training programs related to occupational safety and health may not reach immigrants due to language, cultural and/or economic barriers.[25] An emerging occupational health issue for immigrants relates to the health risks faced by people who are trafficked into situations of forced labor and debt bondage.

Social support

Social support can also be very helpful in preventing mental health issues and coping with living in a new land,[17] so refugees from the same areas should be able to live close to each other. However, even in this case, it may be necessary for social support to be offered by statutory or voluntary agencies from outside the refugee and asylum-seeking community in line with local informal and formal structures and networks.

One model for such support was proposed by British authors in 2014, the WAMBA process, in which five essential components of refugee and asylum seeker support are identified:

Welcome: a person-centred and benign enquiry as to the asylum seeker's history in a friendly setting and with the use of interpreters if necessary.

Accompaniment: the availability of social support in an asylum-seeking client’s life (amongst other presences such as an exilic community and intimate attachments) may foster assurance that moments of crisis can be negotiated by asylum seeker and support worker together.

Mediation: offering a type of humanitarian solidarity and care which will offset some of the negative consequences of the asylum-seeking process and the hegemonic order which it represents and mediating between the individual asylum seeker and the systemic constraints of the asylum process.

Befriending: Befriending is another side to the relationship of accompaniment and which seeks to mitigate the political reality within which asylum seekers find themselves and which is distinctly unfriendly: tightly controlled, suspicious, rebarbative and highly hostile.

Advocacy: The professional helping relationship between worker and client can potentially diminish the isolation brought about by the circumstances within which some asylum seekers may live by giving time to hear the voice of the individual and providing support that attends to the individual’s needs.[26]

Adjustment of status exam

Refugees are eligible to apply for adjustment of status after one year in the US. While most immigrants are required to have a full medical exam at the time of applying for adjustment of status, refugees are an exception. Refugees who arrived without a Class A condition (see Section 2.2.1) only require vaccinations with their adjustment of status; the full medical examination is not required. A full medical exam is only required for refugees if a Class A condition existed prior to arrival in the US. This full medical exam is performed by a Civil Surgeon. Civil Surgeons are designated by the District Director of the US Citizenship and Immigration Services (USCIS). Immigration regulations state that each civil surgeon selected shall be a licensed physician with no less than 4 years of professional experience. If only the vaccination assessment is necessary for refugees, this may be performed by either a Civil Surgeon or local public health.[27]

Sample US programs

Because each state is responsible for coordinating refugee health screenings, protocols vary by state. A sampling of information about various state Refugee Health Programs are listed below:

References

  1. ↑ Palinkas, Lawrence A.; Pickwell, Sheila M.; Brandstein, Kendra; Clark, Terry J.; Hill, Linda L.; Moser, Robert J.; Osman, Abdikadir. "The Journey to Wellness: Stages of Refugee Health Promotion and Disease Prevention". Journal of Immigrant Health. 5 (1): 19–28. doi:10.1023/A:1021048112073. ISSN 1096-4045.
  2. ↑ Section 212(a)(1)(A) of the Immigration and Nationality Act
  3. 1 2 Suphanchaimat, Rapeepong; Kantamaturapoj, Kanang; Putthasri, Weerasak; Prakongsai, Phusit (2015-01-01). "Challenges in the provision of healthcare services for migrants: a systematic review through providers' lens". BMC health services research. 15 (1): 390. doi:10.1186/s12913-015-1065-z. ISSN 1472-6963. PMC 4574510Freely accessible. PMID 26380969.
  4. ↑ Immigrant Medicine, Chapter 8: Cultural Competence p. 85.
  5. 1 2 Betancourt, Joseph R.; Green, Alexander R.; Carrillo, J. Emilio; Ananeh-Firempong, Owusu (2016-08-01). "Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care". Public Health Reports (Washington, D.C.: 1974). 118 (4): 293–302. ISSN 0033-3549. PMC 1497553Freely accessible. PMID 12815076.
  6. ↑ Bhui, Kamaldeep; Dinos, Sokratis (2012-10-11). "Health Beliefs and Culture". Disease Management & Health Outcomes. 16 (6): 411–419. doi:10.2165/0115677-200816060-00006. ISSN 1173-8790.
  7. ↑ Jr, Horacio Fabrega (2015-01-07). "Concepts of Disease: Logical Features and Social Implications". Perspectives in Biology and Medicine. 15 (4): 583–616. doi:10.1353/pbm.1972.0006. ISSN 1529-8795.
  8. 1 2 3 4 Minnesota Refugee Health Provider Guide (www.health.state.mn.us/refugee)
  9. ↑ Geltman PL, Brown MJ, Cochran J. Lead poisoning among refugee children resettled in Massachusetts, 1995-1999" Pediatrics 2001; 108:158-162
  10. ↑ Zabel, E., Smith, M.E., O’Fallon, A. Implementation of CDC Refugee Blood Lead Testing Guidelines in Minnesota. Public Health Rep. 2008 Mar-Apr;123(2):111-6.
  11. ↑ Swanson, S., Lee, B., Mamo, B., Smith, K., Stauffer, W. Changing prevalence of intestinal parasites among newly arrived Southeast Asian and African refugees after empiric predeparture albendazole treatment, Minnesota, 1993-2005. Poster presentation, ASTMH 54th annual meeting, December 2005.
  12. ↑ Immigrant Medicine, Chapter 46: Anemia and Red Blood Cell Disorders p. 611.
  13. ↑ Immigrant Medicine, Chapter 47: Mental Health and Illness in Immigrants: Epidemiology and Risk Factors, pp. 627-628.
  14. ↑ Predisplacement and Postdisplacement Factors Associated With Mental Health of Refugees and Internally Displaced Persons http://jama.ama-assn.org/cgi/content/full/294/5/602
  15. ↑ Gen Hosp Psychiatry. 2013 Mar-Apr;35(2):202-9
  16. ↑ Mercer et al Psychosocial distress of Tibetans in exile: integrating western interventions with traditional beliefs and practice
  17. 1 2 Sachs et al. Entering exile: Trauma, Mental Health and Coping among Tibetan Refugees Arriving in Dharamsala, India http://www.survivorsoftorture.org/old/pix/Sachs%20et%20al%202008%20Dsala%20JOTS.pdf
  18. ↑ Mercer et al. Psychosocial distress of Tibetans in exile: integrating western interventions with traditional beliefs and practice
  19. ↑ Schenker, Marc B. (2010-04-01). "A global perspective of migration and occupational health". American Journal of Industrial Medicine. 53 (4): 329–337. doi:10.1002/ajim.20834. ISSN 1097-0274.
  20. ↑ Stoecklin-Marois, Maria T.; Bigham, Corina W.; Bennett, Deborah; Tancredi, Daniel J.; Schenker, Marc B. "Occupational Exposures and Migration Factors Associated With Respiratory Health in California Latino Farm Workers". Journal of Occupational and Environmental Medicine. 57 (2): 152–158. doi:10.1097/jom.0000000000000325.
  21. ↑ Salvatore, Michele Antonio; Baglio, Giovanni; Cacciani, Laura; Spagnolo, Amedeo; Rosano, Aldo (2012-07-03). "Work-Related Injuries Among Immigrant Workers in Italy". Journal of Immigrant and Minority Health. 15 (1): 182–187. doi:10.1007/s10903-012-9673-8. ISSN 1557-1912.
  22. ↑ Schenker, Marc (2008-11-01). "Work-related injuries among immigrants: a growing global health disparity". Occupational and Environmental Medicine. 65 (11): 717–718. doi:10.1136/oem.2008.040907. ISSN 1470-7926. PMID 18940954.
  23. ↑ Ronda, Elena; Agudelo-Suárez, Andrés A.; García, Ana M.; López-Jacob, Maria José; Ruiz-Frutos, Carlos; Benavides, Fernando G. (2012-06-28). "Differences in Exposure to Occupational Health Risks in Spanish and Foreign-Born Workers in Spain (Itsal Project)". Journal of Immigrant and Minority Health. 15 (1): 164–171. doi:10.1007/s10903-012-9664-9. ISSN 1557-1912.
  24. ↑ Ronda-Pérez, Elena; Agudelo-Suárez, Andrés A.; López-Jacob, María José; García, Ana M.; Benavides, Fernando G. "Scoping review about working conditions and health of immigrant workers in Spain". Revista Española de Salud Pública. 88 (6): 703–714. doi:10.4321/S1135-57272014000600004. ISSN 1135-5727.
  25. ↑ "CDC - NIOSH Science Blog – Immigrant Worker Safety and Health". blogs.cdc.gov. Retrieved 2016-05-10.
  26. ↑ Fell, B.; Fell, P. (29 January 2013). "Welfare Across Borders: A Social Work Process with Adult Asylum Seekers". British Journal of Social Work. 44 (5): 1322–1339. doi:10.1093/bjsw/bct003.
  27. ↑ Centers for Disease Control and Prevention Division of Global Migration and Quarantine (DGMQ), www.cdc.gov/ncidod/dq/civil.htm

Further reading

Federal Policy

Centers for Disease Control and Prevention

Refugee Health Provider Guide

Refugee Mental Health

Cultural Competence

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