Module #4: Migration  1
Module #4: Migration
Overview: This training is designed to help health professionals better understand how
migration and status as a migrant affect health, as well as the obstacles their immigrant
patients and clients face when living in South L.A. This module challenges participants to
come up with strategies to help immigrant patients meet their physical, social, mental, and
legal needs.
Objective:
By the end of the workshop, participants will:
 Understand different legal statuses that immigrants may have.
 Understand how legal status as an immigrant affects health and access to services:
o Being undocumented severely limits access to opportunities that affect
health
o Undocumented immigrants experience discrimination because of their legal
status, which contributes to stress and poor health outcomes
 Be aware that immigrants are more likely to reside in larger households, live in
poverty, and lack a high school education compared with persons who are born in
the U.S.
 Cultural sensitivity and awareness by health care providers can improve
appropriate care for immigrant patients.
Module Schedule At-a-Glance:
Time
Topic
Method
Resources needed
1 week
prior
Pre-Readings/PreEvaluation Questionnaire
See reading list below.
Can use a relevant
subset of these readings
as needed
Photocopies or
electronic versions of
reading
3 min
Welcome/Introduction
7 min
Icebreaker: The mapping
exercise
Participants take 5 pins
(3 different colors) and
place pin where they
were born and where
their parents and
grandparents were
born
World map, push pins
10 min
Video: Unnatural Causes
(migration section)
Watch video
DVD player and dvd,
projector
None
Module #4: Migration  2
20 min
Small group exercises: The
Cruz Nava family
Break into small groups, Handouts of clinical
each group discusses
vignettes and questions
one aspect of migration
and health
15 min
Discussion
Re-group and discuss
each small group’s
findings
None
5 min
Post-Evaluation
Questionnaire
Administer and collect
post-evals
Evaluation questions
Section Breakdown:
Preparation
(In advance)
Distribute the pre-evaluation questionnaire and any reading
materials at least one week in advance.
Welcome/Introduction (3 min.)
1. Have students drop off their pre-evaluations as they come in.
2. Once people are seated, introduce the day’s topic and briefly run
through the objectives for the workshop.
Icebreaker
The mapping game (7 min.)
Materials/Supplies
Large world map; push pins (3 colors- one color represents
participants, one their parents and one their grandparents.)
Procedure
Ask participants to select 5 pushpins and define which color
represents the person, which color represents a person’s parents,
and which represents a person’s grandparents. Participants place
push pins on the map to indicate where they were born and where
their families were born (one pin for each person’s mother, father,
grandmother, grandfather). Explain it is ok to leave something out if
they do not know where a person was born.
Discussion
After 5 minutes, bring group back together
Ask one person to describe the patterns seen on the map.
Module #4: Migration  3
Transition
Facilitator links the personal migration journeys to the context of
South LA:
 99% of US residents are migrants or descendents of migrants
 Birthplace and ancestry are many things, not just about someone’s
genes
 It is hard to generalize about the diversity of Americans and
where they are from, but almost all of us connect with our
ancestry in some way
Video
Unnatural Causes: Is Inequality Making Us Sick? (10 min.)
Materials/Supplies
An internet-connected laptop and a projector (or a DVD player)
Procedure
Transition
Pop-ed Exercise
 Use the projector to show 10 minutes of Migration portion of
Unnatural Causes (Discussion at end of module) .
Now we’re going to put ourselves in the shoes of the Cruz Nava
family of South LA resident and explore the realities immigrants face
on a daily basis.
The Cruz Nava family (20 min.)
Materials/Supplies Clinical vignettes and questions for each activity
(All materials can be found in the appendix and should be printed and
prepared before the workshop.)
Procedure
 Divide the participants into groups of 2 or 3, each with an assignment on
the connection between migration status and: work, access to health
services, education, and human rights
 Instructions:
o The goal of the activity is to put ourselves in the shoes of our
patients, and to think through some of the tough decisions that
South LA residents have to make as they navigate the community
from the perspective of an immigrant.
o Each participant should take a clinical vignette and discuss the
questions in each activity and be prepared to report back at the end .
o After small group discussion, bring group back together and each
group reports its findings (last section, see below).
Module #4: Migration  4
Document 1
(Note: this material is also found in the appendix in handout form)
Education:
Clinical vignetteMaria and Elena Cruz-Nava are sisters. Maria is 18, was born in Mexico and
came to the U.S. with her parents when she was 9 months old. Elena is 17,
and was born in South Los Angeles. Maria has just graduated at the top of
her class in high school, and wants to become a doctor. However, since she is
undocumented, she cannot afford to go to college.
Elena is also a good student. She wants to be a lawyer, to help her sister and
others who have been raised in the U.S. but have no path to citizenship. Elena
has applied to UCLA, UC Berkeley, and Cal State Long Beach and is waiting to
be accepted. She is a citizen of the U.S.
Questions:

Describe the different obstacles faced by Maria and Elena on their
journey towards a higher education.

Describe how education level affects health status.

What is the DREAM Act? How would this affect Maria’s journey to
become a doctor?
Take home points:

Immigrants, especially recent immigrants, have lower education
levels compared to U.S. born persons.
o 58% of non-elderly Mexican adults in the United States do
not have a high-school degree

Undocumented persons are not eligible for public financial
assistance for higher education. AB 540 allows a subset of students
to pay in-state tuition if they are undocumented.

The DREAM Act would allow undocumented persons living in the
U.S. to build a path to citizenship and allow them to attend U.S.
colleges and universities. It was reintroduced for vote in May 2011,
but did not win approval by the U.S. Senate.

The California Dream Act will take effect January 2013, which will
allow a subset of undocumented students to qualify for (some) state
Module #4: Migration  5
financial aid.

There is an under-representation of Latino health care professionals
and culturally sensitive professionals in general.
Resources:
Dream Resource Center (www.dreamresourcecenter.org)
College Board’s Repository of Resources for Undocumented Students
(http://media.collegeboard.com/digitalServices/pdf/diversity/RepositoryResources-Undocumented-Students_2012.pdf)
Work:
Clinical vignetteIrma and Jose migrated to the U.S. from Mexico in 1992. Jose is from El
Salvador, and left his country to escape the civil war. Irma is from Mexico.
When they came to the U.S. with their newborn daughter they had visas, but
because of the economic hardships in Irma’s hometown after NAFTA was
passed, they decided to stay in the United States, and are now without status.
Irma is 46 and works as a janitor at Elena’s school. She has a second parttime job as a kitchen worker at a local restaurant. Despite being
undocumented, she is in SEIU, a worker’s union. Through Irma’s union, she
has health insurance. Prior to migrating to the U.S., Irma had a master’s
degree in history and politics.
Jose is 48 and works in the construction industry. He works 60 hours a week,
without retirement or health care benefits. Prior to his current job, he was
fired from his other construction job when he had to take a day off to go to
the doctor after breaking his ankle falling off a scaffolding at work. When he
was fired, he did not get his last two weeks of pay.
Questions:

What kinds of difficulties do Irma and Jose face in their work
environments (the toll of low-paid work, not getting paid enough to feed
your family, physical, psychological aspects, cycle of poverty, lack of
worker’s rights)?

Describe the relationship between work and health (Hint: Remember
Whitehall studies).

Does Jose have a right to get his last two weeks of pay?
Take home points:
Module #4: Migration  6







Approximately 16% of the U.S. labor force is foreign-born, both
documented and undocumented, working predominantly in
agriculture, the restaurant industry, and construction.
The primary cause of low rates of health insurance among
immigrants is the lack of employer-based insurance
o Low-paying industries are less likely to provide health
insurance coverage and other employer-sponsored benefits
for their employees.
o Low incomes make it difficult, if not impossible, for
individuals to purchase private health insurance.
Over 4 million migrant and seasonal farm workers work in
agriculture, 90% of which are Latino.
Migrant agricultural workers are at risk for work-related illnesses
such as musculoskeletal and traumatic injuries, respiratory
diseases, pesticide exposures, dermatitis, eye problems, etc.
Undocumented immigrants employed in illegal and hidden
operations are often engaged in low skilled, low paid, temporary
employment and routinely lack supervision, training, and benefits.
o For example, the agricultural industry employs 3% of the U.S.
workforce but is responsible for 13% of workplace fatalities
In many instances, undocumented workers may be afraid to ask
questions or risk job loss if they complain about unsafe work
conditions
Undocumented workers may have rights they are unaware of, such
as the right to get paid.
o Clinicians and social workers can help patients advocate for
workers’ rights .
Resources:
Legal Aid Foundation of Los Angeles (LAFLA)
www.lafla.org
Access to care:
Clinical vignetteMrs. Rosas is Irma’s mother. She has not seen her daughter in over 20 years.
Eventually she is able to come from Mexico with Irma’s sister Norma on a
tourist visa. This is the first time she has met her two granddaughters, now
age 17 and 18. Unfortunately, while visiting her family in South LA, she
suffers a debilitating stroke.
Questions:

Discuss the barriers to access to care faced by immigrant patients
(undocumented, visa restrictions, recent immigrants [less than 5
Module #4: Migration  7
years], vs. long term legal immigrants).

What is the human right to health care?

How does the Affordable Care Act limit access to healthcare for
immigrants? How is this different than the current situation?
Take home points:


Despite widespread misperceptions, immigrants use public
resources at lower rates than native-born U.S. citizens.
Approximately 7 million undocumented persons lack health insurance
(15% of total uninsured population).
o 56% of the Mexican immigrant population lacks any kind of
health insurance coverage.
 Among the undocumented, women, those with less education,
immigrants from Latin America (versus other countries) and those
with limited English language skills are more likely to lack health
insurance.
 Undocumented immigrants may not seek needed medical care as a
result of their legal status. For example, undocumented immigrants
from Mexico are 27% less likely to visit a doctor and 35% less likely
to have a usual source of care compared to documented Mexican
immigrants.
 Denying coverage to undocumented immigrants is not costeffective. In 2008, the uncovered cost of healthcare for the
undocumented was estimated at $2000/person or about $14.2
billion nationwide, higher than the standard Medicaid rate.
Inclusion of coverage for the undocumented would cost less if
people were able to enroll in federal and state programs.
Resources:
Legal Aid Foundation of Los Angeles (LAFLA)
www.lafla.org
St. John’s Well Child and Family Center
www.wellchild.org
Human rights and migration status:
Clinical vignetteRosa Veliz is Irma’s cousin. She is 36, in good health, and came to urgent care
today complaining of chest pain for the last two months, with palpitations
and trouble breathing during these episodes. She has been to three other ERs,
and had multiple lab tests and EKGs, and a CT scan of her chest. She was told
each time the tests were “normal”. When asked, she said her chest pain began
Module #4: Migration  8
when she discovered that her 5 year old had been sexually abused by a
teacher’s aid at school. Although her daughter is a U.S. citizen, Rosa is
undocumented and has been afraid to contact authorities.
Questions:

What are some of the hardships endured by immigrants during their
migration journey or after their arrival from another country?

What is a refugee? What does it mean to seek asylum?

What would you do if your patient was a victim of torture?
Take home points:
Increasing anti-immigrant sentiments and policies in the United States are
further limiting the resources available to noncitizens, and at the same time
making people more fearful of seeking healthcare and other social services.
Resources:
Coalition for Humane Immigrant Rights of Los Angeleswww.chirla.org
National Economic & Social Rights Initiative- Immigrants and the Human
Right to Health Care: A Perspective on the Federal Health Reform Law (see
appendix).
Transition
Now we are going to join together in one large group and talk about our
cases and what we discovered.
Discussion/Closing
(15 min.)
Materials/Supplies
None
Procedure
Encourage sharing and active participation in this section.
This was a discussion about a family from Mexico, with some
members from Central America.
 Do you think this is an accurate portrayal of an immigrant family
network? Why or why not?
 What would be different if the family was from Korea?
Phillipines? Russia?
 Shift the discussion to doctors and patients:
Module #4: Migration  9
o How might these sorts of situations affect our patients week
after week?
o Has anyone encountered scenarios where migration status
has affected health or health outcomes in our patients?
o What resources are available to our immigrant patients to
help them deal with the work, education, healthcare, and
other issues they face?
o What obstacles keep people from accessing those resources,
and how can we help them overcome those obstacles?
Post-Evaluation
(5 min).
Materials/Supplies
Post-evaluation questionnaire (one per participant).
List of resources (one per participant).
Procedure
1. Ask everyone to take two minutes to think about what they’ve
learned about challenges facing their immigrant patients, and to
write down one outstanding question and one concrete action they
will take.
2. Hand out the post-evaluation questionnaire and the list of
resources.
3. Ask students to complete the questionnaire and drop it off as they
leave. They can keep the list of resources.
Resources
How you can use it (eg background info;
community resource; way to take action)
Coalition for Humane Immigrant Rights of
Los Angeles (CHIRLA)
www.chirla.org
2533 W 3rd St, Suite 101
Los Angeles, CA 90057
888-6CHIRLA
213-353-1333
CHIRLA advances the human rights of
immigrants and refugees in LA; promotes
harmonious multi-ethnic and multi-racial
communities; legal advice and education about
matters important for immigrants
Legal Aid Foundation of Los Angeles (LAFLA)
www.lafla.org
(800) 399-4529
South LA Office:
7000 S. Broadway
Los Angeles, CA
90003
(213) 640-3950
Legal services that address problems faced by
poor and low-income people in LA, including
employment law/worker’s rights, wage claims,
immigration law, housing and eviction
defense, government benefits, etc.
LAFLA Self-Help Legal Access Centers:
Inglewood, Torrance, Long Beach
http://www.lafla.org/service.php?sect=muni&
Module #4: Migration  10
(213) 640-3988 (Fax)
sub=selfhelp
http://www.chirla.org/sites/default/files/A
GUAS%20booklet%20ENGLISH.pdf
A Know-Your-Rights guide for immigrants
Video: Unnatural Causes- Is Inequality
Making Us Sick?
From California Newsreel (www.newsreel.org)
Episode 3 “Becoming American” about the
experience of immigrants across generations
in the US. Can check out from UCLA Library
Readings
Where you can get it
(See appendix for some)
Mohany et. Al. Health Care Expenditures of Immigrants in the Pubmed; UCLA Medical Sciences
United States: A Nationally Representative Analysis. American Library
Journal of Public Health (2005) Vol 95; N8
Summary:
Health care expenditures are substantially lower for
immigrants than for US-born persons. Refutes the
assumption that immigrants represent a disproportionate
financial burden on the US health care system
Immigrants and the Human Right to Health Care: A
Perspective on the Federal Health Reform Law (2010)
Summary:
From National Economic and
Social Rights Initiative
(www.nesri.org)
The new federal health law excludes many people who cannot
afford insurance or are unable to prove their eligibility for
public programs or the new insurance marketplace. Addresses
the 18 million who will still be left out from a human rights
framework.
Migration and Health: Latinos in the United States
University of California, Los Angeles, School of Public Health
Center for Health Policy Research Steven P. Wallace,
Associate Director (2008)
Summary: A comprehensive view of the health status of
Latino migrant groups in the United States.
Pacheco, et Al. Policy Barriers to Health Care Access Fuel
Discriminatory Treatment: The Role of Promotoras in
Overcoming Malos Tratos. Journal of Ambulatory Care
Management (2012) V35, N1
UCLA Center for Health Policy
Research
http://www.healthpolicy.ucla.ed
u/pubs/Publication.aspx?pubID=
274
Pubmed; UCLA Medical Library
See appendix
Module #4: Migration  11
Summary: Systemic barriers to access (malos tratos)
reflected on personal barriers such as affordability of care.
Promotoras help participants overcome barriers but do not
change the policies determining access and procedures
Module #4: Migration  12
Pre-Evaluation Questionnaire
Module: Migration
Please fill out these 10 questions to the best of your ability. All feedback is appreciated and
used to improve future iterations of this module. Turn in completed questionnaire at the
beginning of module.
1. The module is relevant to my clinical work:
Strongly Disagree
Disagree
Agree
Strongly Agree
Agree
Strongly Agree
2. The assigned readings were informative:
Strongly Disagree
Disagree
3. I feel knowledgeable and comfortable with this module topic and know how to respond
in these situations:
Strongly Disagree
Disagree
Agree
Strongly Agree
4. I am open to training and guidance on this module topic to change how I conduct my
work where applicable:
Strongly Disagree
Disagree
Agree
Strongly Agree
5. I know how to address health inequity in our hospital system:
Strongly Disagree
Disagree
Agree
Strongly Agree
6. Migration status affects what health insurance a person qualifies for in the US.
Strongly Disagree
Disagree
Agree
Strongly Agree
7. Migrants, especially recent immigrants, have lower education levels than persons born
in the United States.
Strongly Disagree
Disagree
Agree
Strongly Agree
8. The primary cause of low rates of health insurance among immigrants is the lack of
employer-based insurance.
Strongly Disagree
Disagree
Please write comments on the back.
Agree
Strongly Agree
Module #4: Migration  13
Post-Evaluation Questionnaire
Module: Migration
Please fill out these 10 questions to the best of your ability. All feedback is appreciated and
used to improve future iterations of this module. Thank you for participating.
1. The module was relevant to my clinical work:
Strongly Disagree
Disagree
Agree
Strongly Agree
2. The format/style of the presentation was effective; I gained new insights about the issue
in relation to my work:
Strongly Disagree
Disagree
Agree
Strongly Agree
3. After participating in this module, I feel knowledgeable and comfortable with this topic
and know how to respond in these situations:
Strongly Disagree
Disagree
Agree
Strongly Agree
4. As a result of this module, I am likely to change how I conduct my work where
applicable:
Strongly Disagree
Disagree
Agree
Strongly Agree
5. As a result of this module, I am likely to begin to address or change how I address health
inequity in our hospital system:
Strongly Disagree
Disagree
Agree
Strongly Agree
6. Migration status affects what health insurance a person qualifies for in the US.
Strongly Disagree
Disagree
Agree
Strongly Agree
7. Migrants, especially recent immigrants, have lower education levels than persons born
in the United States.
Strongly Disagree
Disagree
Agree
Strongly Agree
8. The primary cause of low rates of health insurance among immigrants is the lack of
employer-based insurance.
Strongly Disagree
Disagree
Agree
Strongly Agree
Module #4: Migration  14
Please write comments on the back.
Module #4: Migration  15
Appendix: Migration Health
MIGRATION AND HEALTH WORKSHOP
----------------------------------------------------------------------------------------------------------------Education:
Clinical vignetteMaria and Elena Cruz-Nava are sisters. Maria is 18, was born in Mexico and came to the U.S.
with her parents when she was 9 months old. Elena is 17, and was born in South Los Angeles.
Maria has just graduated at the top of her class in high school, and wants to become a doctor.
However, since she is undocumented, she cannot afford to go to college.
Elena is also a good student. She wants to be a lawyer, to help her sister and others who have
been raised in the U.S. but have no path to citizenship. Elena has applied to UCLA, UC Berkeley,
and Cal State Long Beach and is waiting to be accepted. She is a citizen of the U.S.
Questions:



Describe the different obstacles faced by Maria and Elena on their journey towards a
higher education
Describe how education level affects health status.
What is the DREAM Act? How would this affect Maria’s journey to become a doctor?
Take home points:





Immigrants, especially recent immigrants, have lower education levels compared to
U.S. born persons.
o 58% of non-elderly Mexican adults in the United States do not have a highschool degree
Undocumented persons are not eligible for public financial assistance for higher
education. AB 540 allows a subset of students to pay in-state tuition if they are
undocumented.
The DREAM Act would allow undocumented persons living in the U.S. to build a path
to citizenship and allow them to attend U.S. colleges and universities. It was
reintroduced for vote in May 2011, but did not win approval by the U.S. Senate.
The California Dream Act will take effect January 2013, which will allow a subset of
undocumented students to qualify for (some) state financial aid.
There is an under-representation of Latino health care professionals and culturally
sensitive professionals in general.
Module #4: Migration  16
---------------------------------------------------------------------------------------------------------------Work:
Clinical vignetteIrma and Jose migrated to the U.S. from Mexico in 1992. Jose is from El Salvador, and left his
country to escape the civil war. Irma is from Mexico. When they came to the U.S. with their
newborn daughter they had visas, but because of the economic hardships in Irma’s hometown
after NAFTA was passed, they decided to stay in the United States, and are now without
status.
Irma is 46 and works as a janitor at Elena’s school. She has a second part-time job as a
kitchen worker at a local restaurant. Despite being undocumented, she is in SEIU, a worker’s
union. Through Irma’s union, she has health insurance. Prior to migrating to the U.S., Irma
had a master’s degree in history and politics.
Jose is 48 and works in the construction industry. He works 60 hours a week, without
retirement or health care benefits. Prior to his current job, he was fired from his other
construction job when he had to take a day off to go to the doctor after breaking his ankle
falling off a scaffolding at work. When he was fired, he did not get his last two weeks of pay.
Questions:



What kinds of difficulties do Irma and Jose face in their work environments (the toll of lowpaid work, not getting paid enough to feed your family, physical, psychological aspects,
cycle of poverty, lack of worker’s rights)?
Describe the relationship between work and health (Hint: Remember Whitehall studies).
Does Jose have a right to get his last two weeks of pay? (YES!)
Take home points:




Approximately 16% of the U.S. labor force is foreign-born, both documented and
undocumented, working predominantly in agriculture, the restaurant industry, and
construction.
The primary cause of low rates of health insurance among immigrants is the lack of
employer-based insurance.
o Low-paying industries are less likely to provide health insurance coverage
and other employer-sponsored benefits for their employees.
o Low incomes make it difficult, if not impossible, for individuals to purchase
private health insurance.
Over 4 million migrant and seasonal farm workers work in agriculture, 90% of
which are Latino.
Migrant agricultural workers are at risk for work-related illnesses such as
musculoskeletal and traumatic injuries, respiratory diseases, pesticide exposures,
dermatitis, eye problems, etc.
Module #4: Migration  17



Undocumented immigrants employed in illegal and hidden operations are often
engaged in low skilled, low paid, temporary employment and routinely lack
supervision, training, and benefits.
o For example, the agricultural industry employs 3% of the U.S. workforce but
is responsible for 13% of workplace fatalities.
In many instances, undocumented workers may be afraid to ask questions or risk
job loss if they complain about unsafe work conditions.
Undocumented workers may have rights they are unaware of, such as the right to
get paid.
o Clinicians and social workers can help patients advocate for workers’ rights.
----------------------------------------------------------------------------------------------------------------Access to care:
Clinical vignetteMrs. Rosas is Irma’s mother. She has not seen her daughter in over 20 years. Eventually she is
able to come from Mexico with Irma’s sister Norma on a tourist visa. This is the first time she
has met her two granddaughters, now age 17 and 18. Unfortunately, while visiting her family
in South LA, she suffers a debilitating stroke.
Questions:



Discuss the barriers to access to care faced by immigrant patients (undocumented,
visa restrictions, recent immigrants [less than 5 years], vs. long term legal
immigrants)
What is the human right to health care?
How does the Affordable Care Act limit health establish access to healthcare for
immigrants? How is this different than the current situation?
Take home points:


Despite widespread misperceptions, immigrants use public resources at lower rates
than native-born U.S. citizens.
Approximately 7 million undocumented persons lack health insurance (15% of total
uninsured population).
o 56% of the Mexican immigrant population lacks any kind of health insurance
coverage.

Among the undocumented, women, those with less education, immigrants from Latin
America (versus other countries) and those with limited English language skills are
more likely to lack health insurance.
 Undocumented immigrants may not seek needed medical care as a result of their
legal status. For example, undocumented immigrants from Mexico are 27% less
likely to visit a doctor and 35% less likely to have a usual source of care compared
to documented Mexican immigrants.
Module #4: Migration  18

Denying coverage to undocumented immigrants is not cost-effective. In 2008, the
uncovered cost of healthcare for the undocumented was estimated at $2000/person
or about $14.2 billion nationwide, higher than the standard Medicaid rate. Inclusion
of coverage for the undocumented would cost less if people were able to enroll in
federal and state programs.
----------------------------------------------------------------------------------------------------------------Human rights and migration status:
Clinical vignetteRosa Veliz is Irma’s cousin. She is 36, in good health, and came to urgent care today
complaining of chest pain for the last two months, with palpitations and trouble breathing
during these episodes. She has been to three other ERs, and had multiple lab tests and EKGs,
and a CT scan of her chest. She was told each time the tests were “normal”. When asked, she
said her chest pain began when she discovered that her 5 year old had been sexually abused
by a teacher’s aid at school. Although her daughter is a U.S. citizen, Rosa is undocumented and
has been afraid to contact authorities.
Questions:



What are some of the hardships endured by immigrants during their migration
journey or after their arrival from another country?
What is a refugee? What does it mean to seek asylum?
What would you do if your patient was a victim of torture?
Take home points:
Increasing anti-immigrant sentiments and policies in the United States are further limiting
the resources available to non-citizens, and at the same time making people more fearful of
seeking healthcare and other social services.