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ANNUAL
REVIEWS
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Immigration as a Social
Determinant of Health
Heide Castañeda,1,∗ Seth M. Holmes,2,3,∗
Daniel S. Madrigal,2 Maria-Elena DeTrinidad Young,4
Naomi Beyeler,5 and James Quesada6
1
Department of Anthropology, University of South Florida, Tampa, Florida 33620;
email: hcastaneda@usf.edu
2
School of Public Health and 3 Graduate Program in Medical Anthropology, University of
California, Berkeley, California 94720; email: sethmholmes@berkeley.edu,
dsmadrigal@gmail.com
4
Fielding School of Public Health, University of California, Los Angeles, California 90024;
email: mariaelenayoung@yahoo.com
5
Global Health Sciences, University of California, San Francisco, California 94105;
email: nbeyeler@gmail.com
6
Department of Anthropology and Cesar Chavez Institute, San Francisco State University,
San Francisco, California 94132; email: jquesada@sfsu.edu
Annu. Rev. Public Health 2015. 36:375–92
Keywords
First published online as a Review in Advance on
December 10, 2014
immigration, immigrant health, migrant health, social determinants of
health
The Annual Review of Public Health is online at
publhealth.annualreviews.org
This article’s doi:
10.1146/annurev-publhealth-032013-182419
c 2015 by Annual Reviews.
Copyright
All rights reserved

These authors contributed equally to this work.
Abstract
Although immigration and immigrant populations have become increasingly
important foci in public health research and practice, a social determinants
of health approach has seldom been applied in this area. Global patterns of
morbidity and mortality follow inequities rooted in societal, political, and
economic conditions produced and reproduced by social structures, policies,
and institutions. The lack of dialogue between these two profoundly related
phenomena—social determinants of health and immigration—has resulted
in missed opportunities for public health research, practice, and policy work.
In this article, we discuss primary frameworks used in recent public health
literature on the health of immigrant populations, note gaps in this literature, and argue for a broader examination of immigration as both socially
determined and a social determinant of health. We discuss priorities for future research and policy to understand more fully and respond appropriately
to the health of the populations affected by this global phenomenon.
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INTRODUCTION
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Although immigration and immigrant populations have become increasingly important foci in
public health research and practice, public health scholars have seldom applied a social determinants of health approach in this area. A social determinants of health approach focuses on the
structural factors, aside from medical care, that are determined by social and economic policies
and inequalities and have important effects on health (22). This approach, as we define it, focuses
especially on upstream, macrolevel social factors. Social determinants are increasingly recognized
as central to health, as global patterns of morbidity and mortality follow inequities rooted in
conditions produced and reproduced by political economy, such as social structures, policies, and
institutions. There is growing acceptance by researchers and practitioners that they must understand how social and institutional contexts shape individuals’ lives and how factors such as
employment, housing and living conditions, access to food and social services, and legal status are
consequential for well-being. Immigration is a process that is both the result of these factors and
can result in changes in each of these areas.
As migration flows increase worldwide, the social determinants of health surround the many
individuals who choose to or are forced to leave their homelands for survival, work, safety, and,
in some cases, a new home in another land. Yet, these two profoundly related areas in public
health—social determinants of health and immigration—are not in sufficient dialogue with each
other. We argue that this disconnect has resulted in missed opportunities for research, practice,
and policy work. In this article, we examine the primary frameworks used in the recent public
health literature on the health of immigrant populations, note gaps in this literature, and argue
for a broad examination of immigration as both socially determined and a social determinant of
health. We close with a discussion of priorities for future research, practice, and policy to further
investigate and respond responsibly to the health of individuals and communities affected by this
global phenomenon. Such work is necessary for the field of public health to eliminate health
inequities and aid in the development of healthy societies for all people.
Immigration as a Public Health Challenge
According to recent World Health Organization estimates, there are at least one billion migrants
across the world (141), whose lives have been shaped by social determinants in their homelands
and who face new social, economic, and political conditions in destination countries. In the United
States, heightened immigration enforcement in recent years, including historic levels of deportation, has resulted in negative impacts on health and well-being (2, 47, 92), making immigration
policy a salient issue for public health that requires greater attention. As debates over new immigration policies continue, reforms to the current set of laws need to consider health impacts,
especially those on the 11 million undocumented people who live under discriminatory policies,
experiencing prejudicial attitudes, and lacking access to critical health resources.
An extensive literature examines specific health outcomes and issues among immigrant populations and, as a result, the overall immigrant experience. For example, past articles in the Annual
Review of Public Health have brought attention to the health status of immigrants broadly (61),
as well as to that of specific groups such as migrant and seasonal farmworkers (7, 134), along
with the impact of acculturation on health (69). Prominent public health organizations have also
recently commented on the impact of immigration policies on increasing stress and decreasing
access to health care (4–6, 93). However, this growing public health literature on immigration
and immigrants, as we illustrate below, has retained a relatively narrow focus on behavioral
and cultural topics such as the role of acculturation, adherence to treatment regimens, health
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screening, eating behaviors, and exercise behaviors, as well as culturally competent practices and
interventions.
Whether voluntary or involuntary, migration poses challenges to individuals and communities,
requiring an almost complete realignment of daily life that can have significant social, economic,
and health consequences (110). Although immigration is a consequence of social determinants,
such as poverty, occupational and educational opportunities, and political persecution, immigration must also be positioned as a social determinant in its own right. Lacking are studies that apply
a broad social determinants lens to understand immigrants’ experiences and how related policies
directly impact health. Without this perspective, the immigration experience is cast as secondary
to more proximal factors such as behavior, language, norms, income, or education, thus limiting
explanatory power and the capacity to create effective interventions that respond to some of the
root causes of ill-health in these communities. The enormous consequences of immigration on
daily life, and thus on broader health and well-being, cannot be reduced simply to a “protective
factor” or an acculturative “stressor” that affects health. Rather, immigration must be understood
as a broad social determinant of health and well-being. Examining immigration through a social
determinants of health lens provides a more holistic approach to allow greater understanding of
these complex, interrelated, and far-reaching impacts.
Social Determinants of Health
Research has increasingly identified ways in which social (including economic) inequality imposes
specific risks and constraints on choice (22). Critical public health approaches propose a broad
range of overlapping concepts for understanding and responding to the effects of social inequality:
These include social epidemiology (37, 43, 105), the eco-social or socio-environmental perspective
(23, 24, 65, 67, 115, 129), eco-epidemiology (128), and the risk environment framework (114, 113,
125). They call for a focus on social inequalities through concepts such as fundamental social causes
(73–75, 103), social stratification (78), social determinants of health inequality (63, 76, 78, 80, 125),
income inequality (63), webs of causation (65), higher-order causal-level structural factors (87),
upstream factors (86), discrimination, and racial disparities in health outcomes (42, 66, 71, 79,
123, 144). Drawing from the social sciences, frameworks have incorporated concepts related to
the importance of social structures and social inequalities, such as political economy and political
and economic determinants (94, 95, 121), structural violence (41), symbolic violence (19, 21,
54), structural vulnerability (29, 54, 111), conjugated oppression and hierarchies of embodied
suffering (20, 52), zones of abandonment (16), intersectionality (136, 139), and discourses of
deservingness (28, 53, 81, 119, 133, 143). Here, we do not explore each of these concepts in
depth because they overlap and together inform our understanding of the importance of the social
determinants lens for understanding the health effects of immigration. Rather, we utilize a broad
social determinants of health approach, focusing on the health effects of social structures, such as
economic inequalities, citizenship inequalities, ethnic hierarchies, and gender hierarchies, to name
a few.
These concepts have both influenced and emerged from models that focus on the social
determinants of health with a focus on upstream fundamental causes, many of which are useful
for examining health issues in immigrant populations and for guiding related population-level
interventions. These approaches all emphasize the construction and impact of social structures
and the relative positions of individuals and communities in stratified hierarchies and power
relationships. In addition, these approaches share a concern with the interconnectedness of social,
structural, and/or ecological factors that affect health status. The analysis of disease causation,
as well as intervention strategies and policy changes to address it, requires an understanding
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of how social, physical, and biological phenomena interrelate and overlap. As a result, pathways
and interactions are understood as multicausal and complex, requiring attention to institutional practices and to the relationships between macrostructural processes and microlevel
behaviors.
Seeing Immigration through a Social Determinants of Health Lens
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We argue that if substantive changes in health outcomes are to be achieved, immigration must
be treated as a health determinant itself. Being an immigrant limits behavioral choices and, indeed, often directly impacts and significantly alters the effects of other social positioning, such as
race/ethnicity, gender, or socioeconomic status, because it places individuals in ambiguous and
often hostile relationships to the state and its institutions, including health services. How can
public health researchers and practitioners respond to the challenges posed by this complex social
determinant of health?
To delineate the advantages of a social determinants of health lens on immigration, we must first
review existing approaches in the public health literature. In the following sections, we summarize
the most common frameworks—which we denote as behavioral, cultural, and structural—that are
evident in the immigration and health literature published since 2000.
RECENT STUDIES OF IMMIGRATION AND HEALTH:
PRIMARY FRAMEWORKS
As a general pattern, most articles have focused on behavioral or cultural factors, whereas the
consideration of structural factors is more limited. Each of these frameworks for understanding
the relationship between immigration and health is explored more fully below through a summary
of the assumptions, topics, and outcomes most commonly considered and includes limitations
inherent to each framework. In the remainder of this article, we focus primarily on US-based
studies because of the unevenness of the literature on immigrant health in other countries, as
well as the very different circumstances internationally, including different systems of health care
and prevention; dissimilar notions of race and ethnicity in various countries; and unique national
developments in public health as a field of scholarship and practice.
Behavioral Framework
The behavioral framework is used most often in the current literature. In this approach, the
individual is generally the primary unit of analysis and intervention. As a result, the focus tends
to be on individuals’ behavioral choices, and thus the recommendations focus on individuals.
Although social or cultural factors influencing these choices are sometimes also recognized, these
factors tend not to be foci of the analysis.
The primary topics addressed by the behavioral approach to immigration and health include
health service utilization (44, 64), cancer risk behaviors and screening (18, 83, 146), chronic
disease (30, 60, 70), and mental health (10, 64). Most articles conduct analyses of immigrants’
health practices rather than of the social or economic contexts of these practices. Within this
literature, a primary area of focus involves identifying specific behavioral factors that may explain
the healthy immigrant effect or Latino health paradox, such as low prevalence of smoking (50, 120,
137). The healthy immigrant effect or Latino paradox refers to a common pattern in immigrant,
and specifically Latino immigrant, population health that appears to contradict expectations based
on the well-documented social gradient in health, in which individuals of higher socioeconomic
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status (SES) fare better than do those of lower SES. However, these paradoxes have long been
critiqued for their ambiguity of definition, limited empirical evidence, limited testability, and lack
of intervention application (1, 54).
In focusing primarily on individual health behaviors, researchers emphasize behavior change
theories to understand the causes of disease and design interventions. For example, a review article on breast cancer screening found that the most common theory underlying such programs is
the health belief model (100). These individually oriented theoretical approaches appear to arise
from this behavioral focus and subsequently perpetuate the primary focus on personal responsibility, self-esteem, and self-efficacy as opportunities for changing health behavior within the
existing context, rather than investigating contextual drivers of behaviors and the possibility for
upstream change. The centrality of personal responsibility within the immigrant health literature
is highlighted in work on nutrition within maternal and child health. Most studies in these areas
emphasize parental responsibility for child well-being, calling for programs aimed at improving
parenting skills or modifying parenting practices or attitudes (32, 84, 99) as a primary intervention
strategy. And yet, most of these studies fail to recognize social determinants such as neighborhood
access to healthy food, differential pricing correlated with nutrition, and labor system hierarchies
that complicate certain groups’ ability to afford healthy food or to expend energy obtaining it.
In general, a narrow focus on individual behaviors or outcomes is likely to be inadequate for
explaining the origins of community-level inequities.
The use of health behavior change theories in understanding immigrant health leads to an individualization of responsibility and risk and assumes individual choices are largely unconstrained
by social structures, policy environments, and economics (54). Although many authors acknowledge structural factors when introducing their studies (e.g., 55), these tend to be overlooked when
analyzing the data and identifying opportunities for interventions. Thus, this framework has several limitations. First, it is largely deficit based, viewing health behavior as the result of a lack of
personal education, motivation, readiness, or self-efficacy. Second, it places accountability for behavior change on the individual, rather than locating accountability within the social systems that
drive poor health outcomes. In the case of immigration, phenomena such as labor policies and immigration enforcement create systems of prejudice and fear that impinge on health behavior. This
focus results in a narrow range of proposed interventions because it cannot sufficiently account for
the historical, political economic, and societal processes associated with certain health behaviors.
Without addressing larger contextual factors, recommendations fall back on interventions that
place the responsibility on the individual.
One area in which behaviorally focused research and interventions begin to expand past individual health behaviors in the literature on immigrant populations is the use of acculturation
frameworks. However, many current theories and definitions of acculturation and “culture” in
general focus on the individual level. Acculturation is often cited as one of the drivers of individuallevel behavioral choices, thus linking behavioral frameworks with cultural ones and making them
difficult to disentangle. Such writing may reinforce perspectives on immigrants that may not be
empirical, useful, or effective, as we discuss in the following section.
Cultural Framework
The cultural framework is the second most common approach to understanding immigration and
health in the public health literature. Articles in this framework emphasize the role of assumed
group traits, shared beliefs, values, customary practices, or traditions, which are often linked
explicitly to race, ethnicity, or national origin. These are understood to influence behaviors, shape
choices, and affect perceptions of health-related risk.
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The cultural framework is used in relation to topics and outcomes such as acculturation (e.g.,
31, 76, 132, 145), mental health (e.g., 9, 33), chronic disease (11, 38, 122), health care access (e.g.,
31), maternal and child health (26, 104, 145), substance use (132), physical activity and obesity (76),
and social capital (3, 15, 14). Most outcomes within this framework are captured as individuallevel behaviors. Thus, this framework tends to presume that cultural or ethnic group membership
becomes a major—even primary—determinant of health-related individual behaviors and tends to
assume that the responsibility for adopting healthy cultural practices lies with individuals. Thus,
the studies in the cultural framework share many assumptions with the studies in the behavioral
framework discussed above. Some studies within this framework acknowledge social factors such as
social networks, ties, or social capital (e.g., 15, 14) and the health effects of stress or allostatic load
(e.g., 101). Within this framework, although the data imply political, economic, and historical
realities related to race and ethnicity, the primary focus remains on how race and ethnicity—
through culture—affect individual health-related behaviors.
One primary assumption within this framework is that immigrant or minority groups are
“acculturating,” or moving toward behaviors that are more in line with the mainstream group.
Typically, this process is found to impact health negatively (31, 62, 76, 132, 145), with level of
acculturation directly corresponding with individual-level health risk behaviors, especially diet,
smoking, and use of health services. Meanwhile, the mainstream population is not defined or
described in terms of cultural traits or behaviors (57). The practice of assuming a mainstream
population toward which other groups are presumed to be acculturating is often subtly and dangerously ethnocentric. In other cases, researchers emphasize resiliency and the protective factors
associated with biculturalism or the maintenance of cultural patterns (e.g., 9). This emphasis is
especially true for the healthy immigrant or Latino paradox, where interventions focus on maintaining positive cultural practices. Although this reframes culture as a positive factor, it also risks
implying homogeneity or a permanence of traits or behavioral characteristics. Indeed, the use
of acculturation in health research has been critiqued because of its use of poorly defined and
operationalized variables for culture and largely unexplored underlying assumptions (57, 89, 107,
136, 135). Indeed, few articles in this framework define culture or provide empirical backing for
their representations of culture (57).
Studies may rely on superficial or stereotyped notions of culture and present a static view of
intergroup relations and a belief that acculturation is more or less uniform across populations.
Culture and ethnicity are often conflated: Cultural groups are generally defined by ethnic groups
(e.g., Hispanics, Asians) regardless of sociohistorical and geographic differences. Researchers may
view Latino immigrants, for example, largely as a homogenous group instead of accounting for
different histories and contexts of migration, class, legal status, SES, and the large nonimmigrant
Latino population in the United States. Although much of the acculturation and healthy migrant
paradox literature focuses on the potentially protective factor of individual behaviors linked to
cultural practices, a wide body of literature focuses on negative cultural narratives of immigrant
populations. Of particular concern are simplified notions of gender, family relations, and cultural
values such as “fatalism” and “machismo” (e.g., 26). This practice produces an essentialization of
culture, which implies that underlying, socially shared dispositions give rise to behavioral characteristics of specific racial/ethnic groups. Thus, such studies ultimately revert back to an apolitical
and ahistorical understanding of differences between populations that eschews social inequalities
and social determinants of health. Related to the behavioral framework, the logic remains that
if beliefs and attitudes explain differences in behaviors, then behavior-based interventions can be
made more effective if they are more culturally relevant. Again, however, studies in this framework
largely tend to assume that the responsibility for adopting the desired cultural values and practices
lies with individuals.
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The overreliance on cultural explanations for immigrant health outcomes obscures the impact
of contributing structural factors, such as poor access to transportation, elevated health care costs,
changing access to healthy foods, or differences in labor practices (136, 135)—factors that affect immigrant communities disproportionately regardless of their cultural, racial, or ethnic background.
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Structural Framework
The third but least common framework employed in recent scholarship on immigration and health
is the structural framework. This framework interprets health outcomes through understanding
and accounting for the large-scale social forces that impact health. Research utilizing this approach
tends to focus on either (a) access to health care or (b) the health outcomes directly associated with
immigration status, including living and working conditions and the impact of deportation and
detention.
The most common structural factor explored in the literature is access to health care. Although
access varies among immigrant populations (e.g., 36), immigrants, and especially undocumented
immigrants, clearly experience limited access to health care (e.g., 6, 97). Scholarship in public
health that takes a structural approach to understanding limited health care access among immigrant communities includes analyses of the social and policy determinants, such as the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) (e.g., 17, 45, 77), a
pattern that is expected to continue for many immigrants under the Affordable Care Act of 2010.
This analysis of the structural factors impacting access to health care is the largest focus within
the structural framework; however, access is often one of the downstream results or products of
larger structural conditions.
The second, less common area in this framework explores the general impacts of immigration
status, specifically how immigration status impacts immigrants’ ability to access health-protective
resources. Status-related impacts include social, economic, and political factors that are external
to immigrant bodies and that are shaped by local and national policies, such as housing conditions,
neighborhood safety, and labor protections. For a few of these factors, immigrants are explicitly
excluded from resources that other US residents receive (e.g., preventive care, certain labor protections). For other factors, immigrants experience challenges similar to those of other low-income
communities of color (e.g., poor housing quality, poor neighborhood safety). The additional burden that immigrants face, however, is that they often choose not to interact with government
services that could provide some relief to their situations out of fear that the interaction could
lead to deportation or family separation. Some articles provide reviews focused on subpopulations
of immigrants, including farmworkers (134), women (91), and children (91, 118), whereas others
examine how the stress of racial discrimination, lack of legal status, and general exclusion affects
mental health (27, 127, 148), and specifically depression (46, 51, 72). Many immigrant groups
experience discrimination that exacerbates the challenges of living as immigrants (117, 148) or
results in lower self-worth (111). Other articles discuss workplace issues, specifically violation of
labor rights (34, 35, 130). This focus on the health effects of immigration status fits more squarely
with a broad, macrostructural social determinants of health lens. Finally, an important minority
of articles discusses the direct impact of legal status, including the health effects of immigration
enforcement actions such as detention, deportation, and family separation (47, 48, 85, 92, 116,
126, 131, 138). Other articles focus on the stress and other impacts resulting from losing a family
member through deportation (2, 85, 126, 131, 138). This focus on legal status is congruent with
a social determinants of health lens.
Scholarship utilizing a structural framework frequently conceptualizes and measures social
position through variables such as income or highest education level. However, in applying this
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approach to immigrants, social position should also include examination of the institutional practices and policies that limit rights, resources, and sense of security in navigating everyday life.
While an analysis of the impact of these forms of exclusion is critical to understanding the larger
context, most articles within this framework limit themselves to explaining access to care rather
than addressing the broader impacts of other public policies in the inclusion and exclusion of
immigrant populations or the impact of ethnic/racial hierarchies. Overall, we see inadequate attention to the various social and policy-related factors that affect immigrant health outside of
health care access, even though such structural approaches have the most potential to engage with
the laws, policies, and enforcement activities that define the health landscape that immigrants must
navigate. An explicit commitment to the social determinants of health lens can aid researchers,
practitioners, and policy makers in addressing these gaps.
ADDRESSING THE KNOWLEDGE GAPS
Priorities for Future Research
Given the limitations of the dominant behavioral and cultural frameworks in immigration and
health, as well as the potential of structural frameworks to provide greater insight into practice
and policy opportunities, we delineate a number of conceptual and topical gaps in the current
public health literature on immigration and health.
We take the strengths and relatively unharnessed potential of the structural framework as our
point of departure, arguing that these should be further developed within a social determinants
approach to immigration and immigrant health. The structural framework, as noted above, has
been applied primarily in research on access to care; this scope must be expanded significantly to
include economic and social opportunities and resources, as well as other specific structural factors,
such as access to legal support, housing, food security, and living and working conditions. Conceptually, these specific factors and related policies should be employed to explore and intervene on
the structural factors that affect immigrant population health. Such a focus would better integrate
and emphasize nonmedical factors that influence health, especially upstream determinants such
as living and working conditions.
Furthermore, the broader historical context of migration must be more explicitly considered
in scholarship on immigrant health. This focus should include attention to the political economic
circumstances that produce the motives for migration. Scholars often strive to distinguish between
voluntary and forced migration because each produces different consequences in host countries.
Voluntary migrants are often assumed to choose to cross borders in search of economic opportunity, whereas involuntary migrants (or refugees) are forced by circumstances to flee their home
countries in search of physical security. However, the conventional understanding of active choice
in the migration decision has been contested. People can be driven out of their home countries
by economic desperation—that is, forcibly displaced by material factors aside from war and natural disasters—and some have argued that the idea of voluntary migration ignores the realities of
structural violence that push people out of their home countries (see, e.g., 54, 108, 147). Immigration is fundamentally determined by social, economic, and political inequalities. This reality is
particularly important because when immigrants’ circumstances are viewed as a choice, they are
less likely to be viewed by policy makers as inherently deserving of social and health services, as
we discuss in the section on deservingness below.
Although many of the studies reviewed here examine immigration as a critical variable in
the experience of health and sickness, they have a heavy focus on health behaviors, health care
interactions, and access. Research questions should be expanded to consider the policies that shape
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the broader health landscapes in which immigrants live. The ability to document measures such
as leading health indicators is necessary to highlight where immigrants deviate from national
populations (61); however, we also need further explanations of the root causes that lead to harsh
conditions for immigrants by acknowledging the damage of structural conditions and related
policies. Immigration and immigration status affect health through many mechanisms, including
fear, stress, differential access to resources, experiences of prejudice and violence, and differential
access to safe work and housing. In addition, immigration impacts the health of nonimmigrants.
For example, most children living in 2.3 million mixed-status families are US citizens by birth.
They are directly affected by the undocumented status of their family members; they access health
care benefits at a lower rate or receive delayed treatment (49, 56), experience greater developmental
risk in childhood (12, 98, 149), and experience higher levels of family conflict and stress (131),
including the effects of deportation of individual household members, often parents (2, 47, 48, 92,
116, 131). In addition, children are often left in the community of origin and experience negative
effects of familial separation. These situations underscore that immigrants are embedded in social
units, creating a cumulative ripple effect on households and communities that must be considered.
Immigrant legal status must be understood as a fluid characteristic that can change—often
multiple times—over the course of an individual’s lifetime owing to personal circumstances (e.g.,
marriage) and shifting policy environments (e.g., legalization). Some examples include the relief
provided under the Immigration Reform and Control Act of 1986, which allowed some 2.7 million
migrants to gain legal status, and the deferred action for childhood arrivals (DACA) program
announced in 2012, which has provided semilegal status to more than a half-million undocumented
youth for a renewable period of two years. In both of these examples, the variable of legal status
changed virtually overnight, but the lifelong experiences that affect health status may remain.
Thus, legal status should not be viewed simply as a dichotomous variable; in addition to a number
of ambiguous situations [such as DACA and temporary protected status (TPS)], federal policies
stratify the relationships between various statuses and access to services and programs. The 2010
Affordable Care Act, for example, draws on federal eligibility categories that distinguish between
“qualified” and “nonqualified” immigrants as well as “lawfully present immigrants” (which includes
both “qualified” and some “nonqualified” categories) and “not lawfully present immigrants.”
Similarly, we must investigate and respond to the impacts of specific, and often local, immigration, labor, and education policies. Doing so is especially important for undocumented people; for
example, the vulnerabilities associated with deportation and family separation remain understudied, even though undocumented status is associated with socioeconomic indicators known to affect
health. Recent studies have begun to examine the interaction between deportation and well-being,
for example on mental health (2), drug use (116), and HIV risk (92). A recent systematic review
of the health impact of immigration policies found that the majority of policies focused on the
impact on access to health care rather than on specific health outcomes (82). In addition, research
is needed into specific labor and education policies: for example, states adopting explicit rights for
farmworker organizing (142), adopting equal minimum wages for restaurant workers and other
workers, changing identification card or driver’s license eligibility, and implementing policies for
educational access for immigrant children. Often, these are state-level changes that affect only
some populations, such as those in new settlement areas facing a large influx of immigrants for
the first time without an infrastructure established to serve them (102). Studies should account for
such localized circumstances, striving for deeper understanding of a policy’s impact rather than
seeking to make broad generalizations for all immigrant populations.
Although arguably very important, deservingness of immigrant populations has been a relatively
neglected area. Deservingness refers to how some groups, but not others, are considered worthy
of attention, investment, and care, particularly against the backdrop of the retrenchment of the
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welfare state and increasing health care costs (28, 53, 81, 90, 109, 119, 133, 143). Conceptions
of deservingness are distinct from formalized entitlements as well as from pragmatic questions of
access. However, “although we have well-developed analytic toolkits for investigating questions of
both entitlement and access, the subtler moral positions that undergird them—identified here as
local ways of reckoning health-related deservingness—remain conspicuously underinvestigated”
(143, p. 805). Given the many ways in which assumptions about deservingness affect public opinion,
elections, and allocation of social and health resources, this is an especially important area of future
study related to immigration and health. Indeed, deservingness may be inflected by immigration
status, language use, accent, perceived ethnicity or race, and many other factors.
Despite the relatively common focus on ethnicity and “culture” in the literature on immigration
and health, there is a lack of discussion of the role of discrimination, including racism and antiimmigrant prejudice. We know from public health research that forms of racism and prejudice
affect health significantly (59, 68, 71, 144), likely through factors such as stress, violence, and
exclusion from resources. These factors are likely very important in the experiences and health
outcomes of immigrants (54) and should receive more research and political attention.
Finally, we recommend increasing the focus on resiliency. Resiliency, or the ability of a population to respond positively despite factors challenging its health (140), represents a strengths-based
research approach as opposed to the more common deficit and sickness focus in health research.
This type of approach related to immigration and health is found primarily within the focus on
the Latino paradox or the immigrant health paradox. However, given critiques of these frameworks, especially in clumping together people with diverse experiences, histories, and statuses
(1), researchers must explore resiliency in other ways among immigrant individuals, families, and
communities. This expansion may include analyses of such positive aspects as social capital and
informal care networks as well as community organizing and resistance to policies and practices
detrimental to health. Taking seriously the resiliency of immigrants suggests a commitment to
working with communities not only to understand their needs but also to identify and build on
their strengths. Thus, research with this focus may benefit especially from a community-based
participatory framework (8, 88).
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Policy Implications
The social determinants approach to immigrant health compels public health practitioners to
support specific policy and programmatic interventions, in addition to attending to the future
research priorities discussed above. Despite the considerable health effects of migration, there is a
lack of coordinated policy and program efforts to address these effects. Policy making on migration
has been conducted generally by institutions composed of international aid, security, immigration
enforcement, trade, and labor, which rarely include the health sector and often have incompatible
goals (e.g., 150). And even though the hallmark 1978 Declaration of Alma-Ata expressed the
need for action by governments and health and development workers to protect and promote
the health of all people, it is apparent that such action—not to mention its accomplishments—
has been woefully inadequate for immigrants among many other populations. Equity remains
the chief human rights dilemma in health in the twenty-first century (40, 39). Taking seriously
immigration as a social determinant of health in its own right requires policy efforts that emphasize
the following:
1. Equal access to health care for im/migrants. Access to prevention and treatment (39) should
be “in proportion to need without discrimination” (112); yet, as evidenced by the Affordable
Care Act of 2010, the current system continues to exclude many immigrants, often based
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on assumptions of deservingness. The Affordable Care Act has expanded health insurance
and access to many immigrants. For example, lawfully present noncitizens can purchase
subsidized private insurance plans through the health insurance exchanges. However, many
lawful permanent residents are excluded from accessing Medicaid because of a five-year
residency requirement. Undocumented immigrants are excluded entirely from the ACA’s
various individual insurance provisions, as are some individuals with temporary status (e.g.,
TPS or DACA) (96). Thus, there is significant policy work to be done to expand access
to all immigrant groups. In addition, there are not enough community health centers to
serve the intended population (124). Contrary to popular perceptions, immigrants use fewer
health services (13, 25, 106) and tend to rely more on local community health centers and
their programs. Community health centers will continue to be a vital health care source
throughout most of the country for immigrants without coverage and should be supported
to decrease the negative health effects of immigration, not only on immigrants but also on
nonimmigrants in their communities and societies.
2. Improved enforcement of existing labor laws and protection of immigrant workers’ right to
organize. Despite the existence of many labor laws, immigrant workers around the world are
often mistreated (58, 88). Labor protections for immigrants are limited owing to their lack
of political power, language differences affecting access to power, and, for some immigrants,
fear of retaliation and potential deportation. For these reasons, it is important not only
to increase enforcement of existing labor laws but also to protect the rights of immigrant
workers to organize to protect themselves collectively on the job.
3. Fair immigration reform that includes a path to citizenship. Given that immigration functions as a social determinant of health, the best way to address that determinant is to reform
the immigration system itself. In the United States, a fair and comprehensive policy change
is necessary and should focus on a path toward citizenship and a worker permit that would
not undermine workers already present nor deepen power differentials, as guest worker programs often do. These changes could significantly improve the health of immigrants and
should be promoted and subsequently tracked when implemented. One significant aspect of
immigration reform is the commitment to fair and more equitable economic development
globally so that many people would no longer be forced to leave their homes in the first
place.
4. Inclusion of immigrant communities through collaboration and participation. Public health
practitioners and researchers should reconsider how the field approaches immigration and
work more closely and directly with immigrant communities. Such participatory planning
of public health research and responses could increase sustainability of programs and tailor
programs to the needs and realities of specific immigrant communities.
CONCLUSION
Although the focus on social determinants of health is growing in public health research and
practice, this understanding has not made significant headway into the field of immigration and
health. Public health research on immigration and health is dominated by three primary frameworks. The most common framework focuses on individual health behaviors and neglects broader
social, economic, and political forces. The second most common framework focuses on the culture of immigrants, moving beyond the level of the individual to some degree, yet still neglecting
many of the larger forces affecting immigrants. And finally, the third framework focuses on social,
economic, institutional, and political structures as they affect immigrant health. However, most
of the research in this third framework is limited to access to health care for immigrants and
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rarely addresses the many other ways in which such structures affect health. A structural approach
requires acknowledgment of the host of social factors and forces that affect health and operate
to either include or exclude individuals and communities from adequate health care as well as
from resources and experiences that foster health. We suggest expanding research in this structural framework as one important way to engage in research and practice related to immigration
utilizing a social determinants of health lens.
Immigration involves challenging adaptations that are more than processes of individual adjustment to new environments or cultural assimilation or acculturation to new sociocultural contexts;
it is also a complex and often protracted process of negotiation with social structural, political,
and economic forces. Thus, we recommend that, to make substantive improvements in health
outcomes, immigration must be understood as a key social determinant of health in its own right.
Immigration influences all other social relationships and is a lived experience that directly affects health and well-being. A serious consideration of immigration in this light is consistent
with and advances public health as a science that examines and responds to causes of disease on
a population level. Treating immigration as a social determinant of health poses challenges to
conventional understandings and practices because it requires going beyond the hold of individualism and behaviorism in public health and instead requires tackling a wider sphere of upstream
structural factors affecting health. These include more inclusive health care practices, engagement
with immigrant communities, and advocacy for fair immigration, economic, and health policies.
A concerted effort to understand the effects of immigration as a social determinant of health holds
the potential to position public health as a key actor in the development of a truly healthy global
society, inclusive of those compelled to cross international boundaries.
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DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.
ACKNOWLEDGMENTS
The authors thank Thomas A. Arcury, Paula Braveman, Sara A. Quandt, S. Leonard Syme, and
Priscilla Young for their comments and recommendations. The authors also thank the immigrant
populations with whom they have been privileged to work.
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Contents
Annual Review of
Public Health
Volume 36, 2015
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Symposium: Strategies to Prevent Gun Violence
Commentary: Evidence to Guide Gun Violence Prevention in America
Daniel W. Webster p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
The Epidemiology of Firearm Violence in the Twenty-First Century
United States
Garen J. Wintemute p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 5
Effects of Policies Designed to Keep Firearms from High-Risk
Individuals
Daniel W. Webster and Garen J. Wintemute p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p21
Cure Violence: A Public Health Model to Reduce Gun Violence
Jeffrey A. Butts, Caterina Gouvis Roman, Lindsay Bostwick, and Jeremy R. Porter p p p p p39
Focused Deterrence and the Prevention of Violent Gun Injuries:
Practice, Theoretical Principles, and Scientific Evidence
Anthony A. Braga and David L. Weisburd p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p55
Epidemiology and Biostatistics
Has Epidemiology Become Infatuated With Methods? A Historical
Perspective on the Place of Methods During the Classical
(1945–1965) Phase of Epidemiology
Alfredo Morabia p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p69
Statistical Foundations for Model-Based Adjustments
Sander Greenland and Neil Pearce p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p89
The Elusiveness of Population-Wide High Blood Pressure Control
Paul K. Whelton p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 109
The Epidemiology of Firearm Violence in the Twenty-First Century
United States
Garen J. Wintemute p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 5
Focused Deterrence and the Prevention of Violent Gun Injuries:
Practice, Theoretical Principles, and Scientific Evidence
Anthony A. Braga and David L. Weisburd p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p55
vii
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Unintentional Home Injuries Across the Life Span:
Problems and Solutions
Andrea C. Gielen, Eileen M. McDonald, and Wendy Shields p p p p p p p p p p p p p p p p p p p p p p p p p p p p 231
Sleep as a Potential Fundamental Contributor to Disparities in
Cardiovascular Health
Chandra L. Jackson, Susan Redline, and Karen M. Emmons p p p p p p p p p p p p p p p p p p p p p p p p p p p p 417
Annu. Rev. Public Health 2015.36:375-392. Downloaded from www.annualreviews.org
Access provided by George Mason University on 09/22/22. For personal use only.
Translating Evidence into Population Health Improvement:
Strategies and Barriers
Steven H. Woolf, Jason Q. Purnell, Sarah M. Simon, Emily B. Zimmerman,
Gabriela J. Camberos, Amber Haley, and Robert P. Fields p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 463
Environmental and Occupational Health
Fitness of the US Workforce
Nicolaas P. Pronk p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 131
Food System Policy, Public Health, and Human Rights in the
United States
Kerry L. Shannon, Brent F. Kim, Shawn E. McKenzie, and Robert S. Lawrence p p p p p p 151
Regulating Chemicals: Law, Science, and the Unbearable Burdens
of Regulation
Ellen K. Silbergeld, Daniele Mandrioli, and Carl F. Cranor p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 175
The Haves, the Have-Nots, and the Health of Everyone: The
Relationship Between Social Inequality and Environmental Quality
Lara Cushing, Rachel Morello-Frosch, Madeline Wander, and Manuel Pastor p p p p p p p p p 193
The Impact of Toxins on the Developing Brain
Bruce P. Lanphear p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 211
Unintentional Home Injuries Across the Life Span:
Problems and Solutions
Andrea C. Gielen, Eileen M. McDonald, and Wendy Shields p p p p p p p p p p p p p p p p p p p p p p p p p p p p 231
Public Health Practice
Cross-Sector Partnerships and Public Health: Challenges and
Opportunities for Addressing Obesity and Noncommunicable
Diseases Through Engagement with the Private Sector
Lee M. Johnston and Diane T. Finegood p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 255
Deciphering the Imperative: Translating Public Health Quality
Improvement into Organizational Performance Management Gains
Leslie M. Beitsch, Valerie A. Yeager, and John Moran p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 273
viii
Contents
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Identifying the Effects of Environmental and Policy Change
Interventions on Healthy Eating
Deborah J. Bowen, Wendy E. Barrington, and Shirley A.A. Beresford p p p p p p p p p p p p p p p p p p 289
Lessons from Complex Interventions to Improve Health
Penelope Hawe p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 307
Trade Policy and Public Health
Sharon Friel, Libby Hattersley, and Ruth Townsend p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 325
Annu. Rev. Public Health 2015.36:375-392. Downloaded from www.annualreviews.org
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Uses of Electronic Health Records for Public Health Surveillance to
Advance Public Health
Guthrie S. Birkhead, Michael Klompas, and Nirav R. Shah p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 345
What Is Health Resilience and How Can We Build It?
Katharine Wulff, Darrin Donato, and Nicole Lurie p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 361
Effects of Policies Designed to Keep Firearms from High-Risk
Individuals
Daniel W. Webster and Garen J. Wintemute p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p21
Cure Violence: A Public Health Model to Reduce Gun Violence
Jeffrey A. Butts, Caterina Gouvis Roman, Lindsay Bostwick, and Jeremy R. Porter p p p p p39
Focused Deterrence and the Prevention of Violent Gun Injuries:
Practice, Theoretical Principles, and Scientific Evidence
Anthony A. Braga and David L. Weisburd p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p55
Regulating Chemicals: Law, Science, and the Unbearable Burdens
of Regulation
Ellen K. Silbergeld, Daniele Mandrioli, and Carl F. Cranor p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 175
The Response of the US Centers for Disease Control and Prevention
to the Obesity Epidemic
William H. Dietz p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 575
Social Environment and Behavior
Immigration as a Social Determinant of Health
Heide Castañeda, Seth M. Holmes, Daniel S. Madrigal,
Maria-Elena DeTrinidad Young, Naomi Beyeler, and James Quesada p p p p p p p p p p p p p p p p 375
Mobile Text Messaging for Health: A Systematic Review of Reviews
Amanda K. Hall, Heather Cole-Lewis, and Jay M. Bernhardt p p p p p p p p p p p p p p p p p p p p p p p p p p 393
Sleep as a Potential Fundamental Contributor to Disparities in
Cardiovascular Health
Chandra L. Jackson, Susan Redline, and Karen M. Emmons p p p p p p p p p p p p p p p p p p p p p p p p p p p p 417
Contents
ix
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Stress and Type 2 Diabetes: A Review of How Stress Contributes to
the Development of Type 2 Diabetes
Shona J. Kelly and Mubarak Ismail p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 441
Translating Evidence into Population Health Improvement:
Strategies and Barriers
Steven H. Woolf, Jason Q. Purnell, Sarah M. Simon, Emily B. Zimmerman,
Gabriela J. Camberos, Amber Haley, and Robert P. Fields p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 463
Annu. Rev. Public Health 2015.36:375-392. Downloaded from www.annualreviews.org
Access provided by George Mason University on 09/22/22. For personal use only.
Using New Technologies to Improve the Prevention and Management
of Chronic Conditions in Populations
Brian Oldenburg, C. Barr Taylor, Adrienne O’Neil, Fiona Cocker,
and Linda D. Cameron p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 483
Commentary: Evidence to Guide Gun Violence Prevention in America
Daniel W. Webster p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
The Haves, the Have-Nots, and the Health of Everyone: The
Relationship Between Social Inequality and Environmental Quality
Lara Cushing, Rachel Morello-Frosch, Madeline Wander, and Manuel Pastor p p p p p p p p p 193
Cross-Sector Partnerships and Public Health: Challenges and
Opportunities for Addressing Obesity and Noncommunicable
Diseases Through Engagement with the Private Sector
Lee M. Johnston and Diane T. Finegood p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 255
Lessons from Complex Interventions to Improve Health
Penelope Hawe p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 307
What Is Health Resilience and How Can We Build It?
Katharine Wulff, Darrin Donato, and Nicole Lurie p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 361
Health Services
Assessing and Changing Organizational Social Contexts for Effective
Mental Health Services
Charles Glisson and Nathaniel J. Williams p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 507
Policy Dilemmas in Latino Health Care and Implementation of the
Affordable Care Act
Alexander N. Ortega, Hector P. Rodriguez, and Arturo Vargas Bustamante p p p p p p p p p p p 525
Tax-Exempt Hospitals and Community Benefit: New Directions in
Policy and Practice
Daniel B. Rubin, Simone R. Singh, and Gary J. Young p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 545
The Prescription Opioid and Heroin Crisis: A Public Health Approach
to an Epidemic of Addiction
Andrew Kolodny, David T. Courtwright, Catherine S. Hwang, Peter Kreiner,
John L. Eadie, Thomas W. Clark, and G. Caleb Alexander p p p p p p p p p p p p p p p p p p p p p p p p p p p p 559
x
Contents
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The Response of the US Centers for Disease Control and Prevention
to the Obesity Epidemic
William H. Dietz p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 575
Mobile Text Messaging for Health: A Systematic Review of Reviews
Amanda K. Hall, Heather Cole-Lewis, and Jay M. Bernhardt p p p p p p p p p p p p p p p p p p p p p p p p p p 393
Annu. Rev. Public Health 2015.36:375-392. Downloaded from www.annualreviews.org
Access provided by George Mason University on 09/22/22. For personal use only.
Using New Technologies to Improve the Prevention and Management
of Chronic Conditions in Populations
Brian Oldenburg, C. Barr Taylor, Adrienne O’Neil, Fiona Cocker,
and Linda D. Cameron p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 483
Indexes
Cumulative Index of Contributing Authors, Volumes 27–36 p p p p p p p p p p p p p p p p p p p p p p p p p p p 597
Cumulative Index of Article Titles, Volumes 27–36 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 603
Errata
An online log of corrections to Annual Review of Public Health articles may be found
at http://www.annualreviews.org/errata/publhealth
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Communities in Action: Pathways to Health Equity
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James N. Weinstein, Amy Geller, Yamrot Negussie,
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Title: Communities in action : pathways to health equity / James N.
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Description: Washington, DC : National Academies Press, 2017. | Includes
bibliographical references.
Identifiers: LCCN 2017005055| ISBN 9780309452960 (paperback) | ISBN
0309452961 (paperback) | ISBN 9780309452977 (pdf)
Subjects: | MESH: Health Equity | Healthcare Disparities | Community Health
Planning | Health Promotion | Socioeconomic Factors | United States
Classification: LCC RA418 | NLM W 76 AA1 | DDC 362.1—dc23 LC record available at https://lccn.loc.gov/2017005055
Digital Object Identifier: 10.17226/24624
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways to health equity. Washington, DC: The
National Academies Press. doi: 10.17226/24624.
Copyright © National Academy of Sciences. All rights reserved.
Communities in Action: Pathways to Health Equity
The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution
to advise the nation on issues related to science and technology. Members are
elected by their peers for outstanding contributions to research. Dr. Marcia
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The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering
to advising the nation. Members are elected by their peers for extraordinary
contributions to engineering. Dr. C. D. Mote, Jr., is president.
The National Academy of Medicine (formerly the Institute of Medicine) was
established in 1970 under the charter of the National Academy of Sciences to
advise the nation on medical and health issues. Members are elected by their
peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau
is president.
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Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org.
Copyright © National Academy of Sciences. All rights reserved.
Communities in Action: Pathways to Health Equity
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please visit nationalacademies.org/whatwedo.
Copyright © National Academy of Sciences. All rights reserved.
Communities in Action: Pathways to Health Equity
COMMITTEE ON
COMMUNITY-BASED SOLUTIONS TO PROMOTE
HEALTH EQUITY IN THE UNITED STATES
JAMES N. WEINSTEIN (Chair), Dartmouth-Hitchcock Health System
HORTENSIA DE LOS ANGELES AMARO, University of Southern
California School of Social Work and Keck School of Medicine
ELIZABETH BACA, California Governor’s Office of Planning and
Research
B. NED CALONGE, University of Colorado and The Colorado Trust
BECHARA CHOUCAIR, Kaiser Permanente ( formerly Trinity Health
until November 2016)
ALISON EVANS CUELLAR, George Mason University
ROBERT H. DUGGER, ReadyNation and Hanover Provident
Capital, LLC
CHANDRA FORD, University of California, Los Angeles, Fielding
School of Public Health
ROBERT GARCÍA, The City Project and Charles Drew University of
Medicine and Science
HELENE D. GAYLE, McKinsey Social Initiative
ANDREW GRANT-THOMAS, EmbraceRace
SISTER CAROL KEEHAN, Catholic Health Association of the
United States
CHRISTOPHER J. LYONS, University of New Mexico
KENT McGUIRE, Southern Education Foundation
JULIE MORITA, Chicago Department of Public Health
TIA POWELL, Montefiore Health System
LISBETH SCHORR, Center for the Study of Social Policy
NICK TILSEN, Thunder Valley Community Development Corporation
WILLIAM W. WYMAN, Wyman Consulting Associates, Inc.
Study Staff
AMY GELLER, Study Director
YAMROT NEGUSSIE, Research Associate
SOPHIE YANG, Research Assistant (from June 2016)
ANNA MARTIN, Senior Program Assistant
ALINA BACIU, Senior Program Officer (from October 2016)
MICAELA HALL, Intern (from June 2016 to August 2016)
HOPE HARE, Administrative Assistant
ROSE MARIE MARTINEZ, Senior Board Director
DORIS ROMERO, Financial Associate
v
Copyright © National Academy of Sciences. All rights reserved.
Communities in Action: Pathways to Health Equity
National Academy of Medicine/American Academy of Nursing/American
Nurses Association/American Nurses Foundation Distinguished Nurse
Scholar-in-Residence
SUZANNE BAKKEN, Columbia University School of Nursing
James C. Puffer, M.D./American Board of Family Medicine Fellowship
KENDALL M. CAMPBELL, East Carolina University, Brody School of
Medicine
Consultants
ARIEL COLLINS, The City Project
DEBORAH KIMBELL, The Dartmouth Institute for Health Policy and
Clinical Practice
NANCY NEGRETE, The City Project
RON SUSKIND, Harvard Law School
MAKANI THEMBA, Higher Ground Change Strategies
CESAR DE LA VEGA, The City Project
SUNMOO YOON, Columbia University
vi
Copyright © National Academy of Sciences. All rights reserved.
Communities in Action: Pathways to Health Equity
Reviewers
This report has been reviewed in draft form by individuals chosen
for their diverse perspectives and technical expertise. The purpose of this
independent review is to provide candid and critical comments that will
assist the institution in making its published report as sound as possible
and to ensure that the report meets institutional standards for objectivity,
evidence, and responsiveness to the study charge. The review comments
and draft manu…
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