Authors: Corelis Abreu, Rachel Aronov, Rhoda Ansong, Lara Castaneda, Amber Donald, Estephanie Garcia, Clarisse Iradukunda, Saba Iqbal, Shelly Jean-Louis, Cynthia Jiminez, Millennium  Manna, Nikky Mendoza, Madison Riojas, Chantelle Sanchez, Alina Shah, Merna Shohdy,  Marina Sitnikov & Rana Soliman 

Contributors: Mentoring in Medicine leadership team, Andrew Morrison 

Lab: Ethnic Medics 

Abstract: Due to the COVID-19 pandemic, U.S. immigrants have been disproportionately  impacted, which has further affected their access to healthcare. We hypothesize that as a result of  the COVID-19 pandemic, U.S. Immigrants will experience more limited access to reliable and  affordable healthcare than U.S. citizens due to socioeconomic status, immigration policies,  policy enforcement, and language barriers. Through a survey targeting U.S. immigrants and their  experience with healthcare during the COVID-19 pandemic, there has been a conclusion that the  hypothesis was shown to be correct. As a result of the survey, 44.1% of the 91 U.S. immigrants  said they had some difficulty with getting the routine medical care they needed. As for the  socioeconomic status recorded, the two highest percentages were high school degree holders  with 32.2% and Bachelor degree holders with 21.2%. At the same time, the two highest  percentages of income were 24.6% for those who earned $100,000 or more a year, and 22% who  earned $50,000 to $74,999 a year. The language barrier was also taken into account and was  surveyed that the top two percentages of issues with understanding their healthcare provider due  to language barrier was 63.5% of 122 responders, U.S. immigrants, and citizens, having no  problems, and 12.9% occasionally having issues. 

Keywords: immigrants, healthcare, socioeconomic status, immigration policies, COVID-19

INTRODUCTION 

The spread of COVID-19 in the United States has not only brought about a new amount of political and economic pressure but also revealed how the structure of our healthcare system  might be affecting who has access to reliable COVID-19 related resources and relief. Access to general and preventative healthcare has become even more scarce for minorities, specifically U.S. Immigrants, during the rise of this global pandemic. With U.S. Immigrants not being able to afford regular health check-ups, or simply not being comfortable to reach out to medical providers, the immigrant community has become more prone to pre-existing conditions that have  put them more at risk of being diagnosed with COVID-19. The lack of medical representation  and financial support given to U.S. immigrants has caused an overall distrust in health care  providers and an inability to refrain from working while experiencing symptoms, thus creating a  disproportionate amount of reported COVID-19 cases in the immigrant community. 

Immigrant COVID-19 patients were more susceptible to higher rates of exposure due to  the fact that they and their peers often refused or waited too long to contact health officials. Fear  of immigration-related consequences has deterred and delayed immigrant patients from visiting  hospitals and urgent care. The Department of Homeland Security implemented a law that revised  public charge rules, broadening the conditions in which the government can deny re-entry into  the country and visas based on an immigrant’s use of public benefits. This has decreased the  amount of government aid immigrants feel comfortable seeking, including health-related aid  such as Medicaid. As of 2016, Medicaid and Medicare have been used by an estimated 28 million immigrant families. Immigrants have depended on public healthcare for years, as it has  been their only option. However, within the past two years, immigrants have shown a decrease in  their use of government benefits, specifically those who resided as undocumented citizens (See figure 1.1). Studies have concluded that more immigrants  avoiding hospital visits out of fear, even when symptomatic, has led to a faster spread of COVID-19 within their community (Ross, 2020).  The minimal research on the impact of COVID-19 on the immigrant community has also heavily evaluated economic stress, specifically job conditions, on rising COVID-19 cases. Aside from working jobs with little to no benefits, many immigrants work under conditions that make them  more vulnerable to contracting the virus. One to two point seven million farmworkers are  immigrants, and in these positions, these workers work in close quarters for long hours  (Hlavinka, 2020). Lower-income immigrants are shown to be at an even higher risk as they tend  to live in more crowded and smaller dwellings with a larger number of people. Many of these immigrants cannot afford not to work during quarantine, and thus they are coming in and out of these homes on a daily basis (Hlavinka, 2020). Immigrants also make up a big portion of essential workers, such as working in grocery stores, auto repair, and delivery. For example, in  New York, which was once the epicenter of the virus, undocumented immigrants made up a significant portion of delivery workers during the pandemic (“Undocumented Immigrants and  the Covid-19 Crisis,” 2020). Essential workers are overall more exposed to the virus than non-essential workers which could also relate back to the disproportionate amount of cases within the immigrant community. Economic status plays a big role in how susceptible one is to the virus, and due to the fact that many immigrant communities consist of higher-risk environments, numbers have risen incredibly. A New York University study showed that neighborhoods with  the most confirmed COVID-19 cases in New York consisted of more Black, Hispanic, and immigrant residents of median income who resided in overcrowded homes (Muzafarr, 2020).  Many immigrants found themselves living in the epicenter of this virus.

Immigrants are more likely to test positive for COVID-19 and yet are less likely to receive treatment. This is an alarming conclusion made by multiple studies regarding healthcare, socioeconomics, and immigration status of U.S. immigrants. The purpose of this study is to  expand on these statistics by seeking out personal experiences. There is a lack of studies done regarding patient-doctor relationships, access to medical information, and living conditions of the many immigrants who are at a disproportionately high risk of being diagnosed with COVID 19. With our extensive survey, we are able to receive direct feedback from U.S. immigrants about what our healthcare system lacks and provide a raw and real example of how the structure of the American healthcare system treats marginalized groups. Based on previous research done, our group expects to receive results that reflect a lack of patient-doctor trust, minimal access to  COVID-19 resources, and economic disparity by the U.S. immigrants participating in this study.

Figure 1.1

The bar graph above depicts the percentages of immigrant families who have been denied  government aid between December of 2018 and December of 2019 due to fear of green card  renewal neglect. (“Immigrant Families Hit Hard by the Pandemic May Be Afraid to Receive the Help They Need,” 2020) 

MATERIALS AND METHODS

In order to be able to obtain reliable and relevant data, our lab administered an extensive survey to hear back from our targeted demographic on a personal level. Ethnic Medics recognizes the barriers that the pandemic has exacerbated for marginalized communities and set up a series of questions that range from basic background information to opinions and experiences with healthcare providers and the health care system in general during the pandemic. With our group of 18 individuals from various backgrounds, we aimed to select the  most representative and inclusive questions for our survey. After brainstorming a list of our own questions into subcategories of economic factors, social factors, and physical factors, we cross-referenced our questions to those found on PhenX to make final decisions. This process allowed  the voices of immigrants to be heard and our questions to be accessible and representative to our target populations. 

Various social media outlets were used to spread and advertise the survey. Outlets included Facebook and Instagram, social media applications that are relatively accessible to a majority of US citizens, making them efficient platforms for advertisement. An allotted budget was utilized to buy advertisements on Facebook. Furthermore, Ethnic Medics also targeted its audience by creating both an English and Spanish radio advertisement. 

RESULTS

English Speaking Survey Results:

After gathering all the data, these were the results: Given the US Immigration and Healthcare responses, we found that more than 65% of our sample population was in the 18-24 age range, and the rest of the majority were aged 25 and over. As for gender, 83.1% of the sample population surveyed expressed their gender identity as female, 16.1% were male, and about 0.8% identified as non-binary. Data concerning ethnicity showed that nearly 25.4% of the respondents reported that they were of Hispanic, Latino, or of Spanish origin, and approximately 73.7% of survey responses indicated otherwise. Language data showed that for at least 71.2% of respondents, English is their first language, and of those individuals, about 23.7% feel that they can speak and understand English well, but not perfectly. Our survey also found that more than 65.3% of survey respondents are essential workers, which include but are not limited to those working in public health/health care, law enforcement, first responders, and others.

When asked about insurance coverage, more than 88.1% of survey responses indicated that they were covered by health insurance or some other kind of health care plan, and the remaining either were not covered, unsure, or refused to answer. Concerning doctor visits, approximately 77.1% of individuals reported that it has been more than a year since they last saw a doctor or other health professional for a wellness visit, physical, or general-purpose check-up. When looking at costs, about 72.9% of total responses indicated that, during the past 3 months, there was a time when you needed medical care but did not get it because of the cost. Lastly, approximately 50% of the responses indicated that there has been a time when they felt that they would have gotten better medical care if they had belonged to a different race or ethnic group.

Figure 1.2

The bar graph displayed above indicates the average percentage of survey responses received, highlighting the highest grade level of school completed or the highest degree received. At most, nearly 32.2% of individuals are a high school graduate, and at least, nearly 0.8% of individuals have received a doctoral degree.

Figure 1.3

The bar graph displayed above indicates the average percentage of survey responses signifying the combined gross family annual income, meaning the total pre-tax income from all sources earned in the past year. 

Figure 1.4

The pie chart above indicates the average percentage of survey responses displaying the country they were originally born in before immigrating to the US. A large percentage of individuals reported being born in Haiti, Dominican Republican, Ethiopia, Nigeria, Pakistan, and Vietnam. 

Figure 1.5

The graph displayed above shows the average responses for which health insurance plan these individuals were covered by, in which the majority was some sort of private healthcare. 

Figure 1.6

The pie chart above highlights the responses provided by Non-English speakers, addressing the times in which they often had a problem understanding what their healthcare provider is telling them, mainly due to the language barrier. 

Figure 1.7

The table above indicates recommended measures by the survey respondents that hospitals or health professionals can implement in efforts to improve the health of immigrants. 

Figure 1.8

The chart above showcases the overall responses to some of the survey questions in regards to COVID-19, testing, and impact of the pandemic on financial status. 

Forms response chart. Question title: How has COVID-19 affected your employment status? . Number of responses: .

Figure 1.9 

The bar graph above signifies how the US immigrant population’s employment status living amidst the COVID-19 pandemic was impacted before and currently. 

Spanish Speaking Survey Results:

Now let’s look at our US Immigration and Healthcare responses from Spanish speaking participants: Our data showed that 83% of our population sample was over the age of 35, and the rest fell between the age range of 25-34. Concerning gender, 66.7% of the population identified as female, and 33.3% identified as male. Data on ethnicity showed that 100% of the surveyed population (for this specific survey) stated they were of Hispanic or Latino origin. When asked about language, for the respondents that stated they primarily spoke a language other than English at home, 66.7% stated they felt they spoke English well or very well, and the remainder stated they did not feel they spoke English well at all. Our study also found that 16.7% of respondents stated that they were an essential worker, which includes but is not limited to those working in public health/health care, law enforcement, first responders, and others.

Moving on to insurance and healthcare treatment data, 100%  of respondents indicated they were covered by health insurance or some other kind of health care plan. 100% of respondents stated they had seen a doctor or other health professional for a wellness visit, physical, or general-purpose check-up sometime within the last year. When asked about costs, 33.3% of respondents stated that during the past 3 months, there was a time when they needed medical care but did not get it because of the cost. Lastly, 16.7% of respondents indicated that there has been a time when they felt that they would have gotten better medical care if they had belonged to a different race or ethnic group.

Figure 1.10

The bar graph here indicates the percentage of survey responses  received, highlighting the highest grade level of school completed or the highest  grade received. At most, about 50% of individuals who responded stated that they  had no high school degree, and at least 16.7% of respondents stated they had  some college education but did not receive a degree.

Figure 1.11

The bar graph displayed above indicates the average percentage of  survey responses signifying the combined gross family annual income, meaning  the total pre-tax income from all sources earned in the past year. 

Figure 1.12

The pie chart above indicates the average percentage of survey  responses displaying the country they were originally born in before immigrating to  the US. A large number of respondents stated they were from the Dominican  Republic or Mexico.

Figure 1.13 

The graph displayed above shows the average responses for which health  insurance plan these individuals were covered by, in which the majority was some sort of  private healthcare.

Figure 1.14 

The pie chart above illustrates the responses of Spanish speaking  respondents, addressing the times in which they often had a problem understanding  what their healthcare provider is telling them, mainly due to the language barrier.

Have you been tested for COVID-19? (Spanish speaking respondents)
Since becoming aware of the COVID-19 outbreak, how much difficulty have you had getting routine medical care that you need?  (Spanish speaking respondents)
Which of the following best describes the impact of the COVID-19 pandemic on your ability to meet financial needs such as rent, mortgage payments, utilities, and/or groceries? (Spanish speaking respondents)

Figure 1.15

The chart above shows the overall responses of some of the Spanish  survey questions in regards to COVID-19, testing, and impact of the pandemic on  financial status

Figure 1.16 

The table above indicates recommended measures by the Spanish  speaking survey respondents that hospitals or health professionals can implement,  in efforts to improve the health of immigrants.

Figure 1.17

The bar graph above signifies how the employment status for the US  immigrant population living amidst the COVID-19 pandemic was impacted  before and currently, based on responses for Spanish speakers. 

DISCUSSION 

We researched how COVID-19 disproportionately impacts the U.S. immigrant  population and their access to healthcare. As a result of the COVID-19 pandemic, U.S.  Immigrants will experience more limited access to reliable and affordable healthcare than U.S.  citizens due to socioeconomic status, immigration policies/enforcement, and language barriers.  After a total of 122 responses, our hypothesis was shown to be true. According to the data  gathered, foreign-born citizens were more likely to experience unjust medical care. Regardless of the fact that 76.7% of the immigrants who filled out the survey feel that they can speak and  understand English very well, 59.5% feel that their ethnicity has impacted their general well being by limiting their ability to visit healthcare providers. 

According to our survey designated for English speakers, results revealed that a majority  of our U.S immigrant respondents are covered by health insurance or some other healthcare plan. We saw similar results with our Spanish speaking survey as well. However, approximately 77.1% of English speaking individuals reported that it has been more than a year since they last saw a doctor or other health professional for a wellness visit, physical, or a general-purpose  check-up. Compared with Spanish speaking respondents, where 100% stated that they had visited a doctor or health professional within the last year. Our data suggest that U.S. Immigrants continue to face difficulties in accessing proper healthcare during the ongoing COVID-19  pandemic. Over 72% of English speakers indicated that there was a time in the past three months where they needed medical care but didn’t receive medical attention due to the cost. If we compare this with Spanish-speaking individuals, we see that 33.3% stated that within the last 3 months they didn’t get medical care due to the cost. In addition, about half our English respondents indicated that they believe they would receive better quality care if they were of a  different race and/or ethnicity. As for Spanish speaking respondents, 16.7% stated that they felt they could’ve gotten better healthcare if they were of a different race or ethnicity. 

It came to our attention that the majority of those who took the survey were female. With only 21 males, the bulk of the survey data came from women. This occurrence could be a result of a multitude of factors. First and foremost, a possible cause for the gap in participation between the genders could be the chosen form of advertisement for the survey. Primarily, our online Google Forms Survey was promoted through social media platforms (Instagram and Facebook) that reported their users to consist of more women than men. As of July 2020, women make up 51% of Instagram users. Furthermore, as of 2019, women make up 54% of users (footnote). Due to the majority of women using social media apps that our survey was primarily advertised on, the advertisements most likely appeared more on women’s feeds rather than men’s therefore leading to the disparities in gender participation. Also, the Social Exchange Theory could be applied here. The Social Exchange Theory concludes that “males are more likely to possess or place a high value on separative characteristics than females, while females, on the other hand,  are more likely to possess or value characteristics more consistent with connective selves, such as empathy or emotional closeness”(Smith). If there is accuracy in this theory, then a possible reason for the increased likelihood of women participation in online surveys could come from differences in the characteristics that men and women possess that dictate their actions and decisions in an online setting (Smith). Therefore, we are exploring the idea of redoing the survey to achieve a more even ratio of men and women. There has been prior research on how gender has a distinctive impact on the quality of care given to patients, thus it may be reasonable to conclude that female immigrants may resonate more with the negative treatment explored in this study. Targeting the survey to reach this specific audience could lead to data that does not resemble what was gathered now. Another way to further develop research is by surveying men and women separately to see how the data looks once contrasted. 

Even though we accumulated a total of 122 responses, 31 responders reported being native-born. Based on their survey answers, it appears that they are likely to identify more with their country of ethnic origin rather than their birth country or even believe they relate closer to the immigrant experience than that of a native-born American. However, as we did not anticipate U.S. born citizens to take the survey, we could not inquire about their desire to take a survey targeted towards immigrants. Therefore, our belief is simply due to interpretation of the data rather than concluded from it. If the research study is further continued, asking US citizens whether they identify with their country of ethnic origin or their birth country should be prioritized. The survey remains open so that, over time, we can perform a time series analysis. Similar to how the world is changing over time, the results may start to lean in a different direction due to current events.

CONCLUSION

Through this thorough analysis on the impact of COVID-19 on US immigrants we can conclude an overall lack of attention and access to both financial and health related resources distributed throughout the pandemic. Based on previous research stated earlier, if we compare these results to those of similar studies conducted on white native born Americans, we can see how race and immigration status can affect patient-doctor relationship and overall how much trust individuals put into our healthcare system and how much COVID-19 has affected that. Arguably the most important section of our survey was where our participants were able to speak on what they would like to see change in how our healthcare system functions. With a resounding number of participants saying they would like more access to translators and more healthcare professionals to actively explain to immigrants how to use the healthcare system and take advantage of its resources, it opens up the discussion on how important proper representation is in this field. With healthcare access becoming more and more political, immigrants struggle with feeling safe and secure in the hands of healthcare providers. Vulnerable demographics have not had the liberty of following COVID-19 protocols while also maintaining liveable households, putting them more at risk which is reflected in the disproportionate amount of COVID-19 cases in these communities. It is very important that marginalized communities are given opportunities to voice their concerns especially about an institution that could very much have their life in their hands.  Being that US immigrants make up a large number of the lower and working class, it makes sense that so many of our participants reported an increase in difficulty in ability to access routine healthcare as well as reporting back that the majority of them have observed a major impact on their ability to meet financial obligations. Our results support the claim that pandemic related resources and relief were extended and promoted towards only certain demographics, while leaving lower served communities without the proper support to adapt to the crippling effects COVID-19 has had on the country. Moving forward there are many more sides to this issue that are important to explore when it comes to transitioning into some type of healthcare reform. It is necessary to continue to conduct these studies in which scientists and professionals can access a more personal and direct view on communities that are often omitted  from these conversations. We feel that the next step would be testing out new ways to include more ethnic friendly resources in hospitals and clinics, and implement security for all Americans regardless of immigration status during a crisis. 

Acknowledgments 

We thank Mentoring in Medicine Inc. for providing the resources and leadership necessary to collect sufficient data for analysis and to synthesize this data into a coherent paper. We also thank Mr. Andrew Morrison and the MIM Leadership Team for coordinating the internship under which the paper was written and providing a timeline for its publication.

References

  1. Clement, J. (2020, October 29). Global Instagram user distribution by gender 2020. Retrieved    November 01, 2020, from https://www.statista.com/statistics/802776/distribution-of-users-on-instagram-worldwide-gender/ 
  2. Facebook by the Numbers: Stats, Demographics & Fun Facts. (2020, October 28). Retrieved October 31, 2020, from https://www.omnicoreagency.com/facebook-statistics/#:~:text=Facebook%20users%20are%2054%25%20female,75%25%20of%20Men%20use%20Facebook
  3. Smith, W. G. (2008, June). Does Gender Influence Online Survey Participation?: A Record-linkage Analysis of University Faculty Online Survey Response Behavior. Retrieved November 01, 2020, from https://files.eric.ed.gov/fulltext/ED501717.pdf 
  4. Hlavinka, E. (2020, April 23). Public Charge & COVID-19: ‘Perfect Storm’ for the  Undocumented. Retrieved November 01, 2020, from https://www.medpagetoday.com/infectiousdisease/covid19/86123
  5. Immigrant Families Hit Hard by the Pandemic May Be Afraid to Receive the Help They Need. (2020, June 05). Retrieved November 01, 2020, from https://www.gcir.org/news/immigrant-families-hit-hard-pandemic-may-be-afraid-receive-help-they-need
  6. Muzaffar Chishti, J. (2020, July 01). Vulnerable to COVID-19 and in Frontline Jobs, Immigrants Are Mostly Shut Out of U.S. Relief. Retrieved November 01, 2020, from https://www.migrationpolicy.org/article/covid19-immigrants-shut-out-federal-relief
  7. Ross, M. (2020, August 01). The Disproportionate Burden of COVID-19 for Immigrants in the Bronx, New York. Retrieved November 01, 2020, from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2765826?resultClick=1
  8. Undocumented Immigrants and the Covid-19 Crisis. (2020, April 4). Retrieved November 01, 2020, from https://research.newamericaneconomy.org/report/undocumented-immigrants-covid-19-crisis/