of asian immigrants by huabin luo and bei wu found that longer residencies in the united states and english proficiency were correlated with more regular visits to dental clinics. another cross-sectional study among chinese immigrants has shown that english proficiency as well as print health literacy is crucial in determining immigrants' health status. in addition to language barriers, some asian subgroups emphasize a higher level of trust between health care practitioners and patients, and as a result, may feel alienated using the more formalized american health care system. africans a study by jacqueline lucas, daheia barr-anderson, and raynard kington indicates that black male immigrants demonstrate better health outcomes than us-born black men. this finding comports with the "healthy immigrant effect," which describes the idea that those who immigrate to 'developed countries' tend to enjoy better health than the native-born populations. multiple studies also demonstrate that black immigrants are less likely to have insurance than us-born black and white counterparts. insurance rates of black male immigrants do not significantly vary with income, employment status, or health status. foreign-born black men also use physician and hospital services less frequently than us-born black and white men. project muse's report on african refugee and immigrant health needs reveals that african immigrants struggle with accessing health care services due to lack of information concerning providers, costs, and unfamiliarity with the u.s. health care system. communications with health care providers are also complicated by language barriers, differing degrees of english literacy, and immigration status. mental health services tend to be less frequently utilized due to stigma concerning mental health disorders and social pressures to characterize mental and emotional struggles as offshoots of stress. homer venters and francesca gany found that cultural perceptions of disease models and illness can impede effective communications between african immigrants and health care providers. specifically, hypertension, diabetes, coronary artery disease, and other chronic conditions are considered to be less understood due to their relative greater prevalence in nations such as the united states. women studies have found that immigrant men demonstrate greater health outcomes than immigrant women; gendered health disparities are observed to be greater among immigrant populations than u.s. citizens. whether an immigrant woman is legally document or not, there are many constituents in laws that prevent immigrant women from qualifying for health insurance that can intercept them from getting standard medical services and causing the negative outcomes. immigrant women who become ill in the united states face multiple levels of marginalization from their immigration status, health status, and gender status. in a survey by carol pavlish, sahra noor, and joan brandt, somali women in minnesota reported encountering obstacles with unfamiliar healthcare systems, inefficiencies of diagnosis and treatment processes, and ineffective communication with medical professionals. religious beliefs and practices of immigrant women may also play a role on the medical decisions of immigrant women and their families which can affect their health. there are instances when health care professionals might think that a mother or a woman is well-rounded on personal health, which may lead to the lack of giving supplemental or further information to the patient when there is a possibility that many immigrant women are not educated enough on medicine. scientific or medical myths may also influence the opinions of immigrant women, mothers in particular, that may be the cause of their decisions regarding health that can lead to mistreatment or undiagnosed illnesses. some immigrant women may find themselves struggling to balance their health with their culture and traditions that may dictate what they want to decide for their health, while also learning american health culture. compared to women born in the united states, immigrant women do not have the same access to health care services and insurances. without these, this puts immigrant women at a higher risk for health complications and illnesses, particularly in the area of sexual and reproductive health. whether immigrant women have medical insurance or not, immigrant women are reluctant to seek help because some might fear that it may negatively affect their immigration status. immigrant women are less likely to get mammograms, pap tests, and other sexual and reproductive health services. there are about one in five immigrant women who have medical insurance but do not utilize it. statistical data from kaiser family foundation and national immigration law center in 2018 shows that 34 states have permit lawfully residing immigrant children without 5-year wait (medicaid or children's health insurance program/chip), 25 states permit lawfully residing pregnant women without 5-year wait (medicaid or chip), and 16 states permit pregnant women regardless of status (chip). current research also indicates that one's immigration status in the united states affects all aspects of sexual and reproductive health of a woman. for example, the risk for postpartum depression in women is twice as high for u.s. immigrant women than in their birth country. it is a factor to consider that other countries might not recognize postpartum depression or mental health as an important area of health and wellbeing compared to the united states, so it may be unreported in other countries. immigrant women who endure intimate partner violence (ipv) may encounter difficulties in obtaining medical help. in a focus group by heidi bauer and her colleagues, abused asian and latina immigrant women expressed hesitance to seek health care. due to linguistic obstructions, lack of kinship and social networks, and fear of jeopardizing their relationship or their children's safety. immigrants coming from english-speaking countries such as the united kingdom, canada, or australia may face less issues in the health care system because the language barrier is not as wide compared to countries whose primary language is not english. many studies on immigrant women in the united states conclude that advanced research and studies are needed to be done to obtain more statistical data on immigrant women's health. the missing substantial evidence can be linked to immigrant women's reluctance to finding health care and the insufficient and unavailable services that are difficult to acquire. without evidence and statistical data, it is difficult to track and label the reasons for the higher health complications of immigrant women compared to women born in the united states. barriers to care lack of health insurance lack of health insurance has been cited as a major reason behind immigrants' low usage of the united states health care services. the survey of income and program participation (sipp) indicated that in 2002, 13.4% of native-born citizens were not insured compared to 43.8% of foreign-born adults. reasons for lack of insurance vary, but the findings of a 2005 study suggest that personal characteristics as well as the types of jobs immigrants have factor largely into the lack of coverage. there is a high concentration of immigrants in low-paying jobs and other jobs that do not offer health insurance. personal characteristics that stem from structural obstacles include education; both immigrants and native-born citizens who have lower levels of education tend to be uninsured. high uninsured rates are also often correlated with greater difficulties in accessing and retaining insurance. undocumented immigrants and those with deferred action for childhood arrivals (daca) deferments are not eligible for many of the coverage options offered through the patient protection and affordable care act. citizenship status many immigrants report that distrust prevents them from actively seeking out health services. although the immigration and naturalization service has stated that receiving medicaid or schip benefits (with the exception of long-term care) does not jeopardize residency status, many lawful permanent residents are unaware and perceive otherwise. the new york times reported that fear of deportation or detention causes immigrants, especially those who are undocumented, to refrain from seeking medical care. this includes screenings, picking up prescriptions, and participation in federal nutrition programs. a study by russell toomey and his colleagues similarly confirmed that mexican-born teenagers and mothers decreased their usage of preventive health care and public assistance programs after the implementation of sb 1070 in arizona. prolonged fear of deportation has also been observed to exacerbate mental health conditions such as stress, depression, and anxiety. overall, undocumented immigrants are likely to be uninsured due to lack of employer-sponsored insurance and ineligibility for medicare, medicaid, chip, and ppaca marketplaces. health benefits are largely contingent on immigrant parents in that although a child may be born in the u.s., the naturalization process for adults can take between 5 and 10 years. since welfare reform initiatives like the personal responsibility and work opportunity reconciliation act have been enacted, states have seen an overall decline in the number of children being vaccinated. in august 2019, the united states citizenship and immigration services announced the discontinuation of the medical deferred action policy that grants temporary protection from deportation to immigrants undertaking major, life-saving procedures. however, in september 2019, this decision was reverted after drawing substantial criticisms from advocacy groups. financial costs financial costs of health care are also cited as a barrier to access, especially as they can be complicated by immigration status. a study by nathan gray and his colleagues found that immigrants who cannot access hospice care often must rely on more expensive choices such as hospitalization or emergency services instead. additionally, bureaucratic procedures, such as extensive paperwork, may deter immigrants from seeking health care due to both the cost of completion and lack of familiarity. the financial costs of health coverage are also often correlated with lack of insurance. studies have shown a connection between the lack of coverage and higher poverty rates. in their research, julia prentice, anne pebley, and narayan sastry reported that immigrants are less likely to be insured than native-born citizens. prentice, pebley, and sastry also found that immigrants tend to share more characteristic qualities of those who are uninsured and often of lower socioeconomic status. these include lower levels of education attainment, income, and ownership of non-housing assets. additionally, lack of enrollment in public programs or health plans has been observed to disproportionately affect those in low-income families. low-income immigrants are over two times more likely to lack health insurance than low-income citizens. language a study by janice tsoh reported that immigrants with limited english proficiency (lep) and health literacy were more likely to rate their health status as poor. lep is often correlated with experienced discrimination in medical care, as well. studies have found that perceptions of discrimination have decreased among immigrants with lep from the early 2000s to 2017. however, lep patients may experience greater difficulties than english-proficient patients with communicating information with their practitioners. furthermore, language proficiency can determine the types of treatments, exams, and other health services that latino immigrants receive. studies demonstrate that latina patients were more likely receive recommendations for pap smears and similar screenings from their doctors if their level of english proficiency was higher. linguistic difficulties can prevent immigrants from completing health insurance and medical forms. a study of korean immigrants demonstrated that language barriers and uninsured status were major obstacles to utilizing healthcare in the united states. additionally, lep can limit employment to a small range of certain jobs, often those that are less likely to provide job-based insurance. social and cultural familiarity unfamiliarity with the u.s. health care system has been repeatedly cited as a barrier to health care for undocumented immigrants. hesitance to seek health services may also result from the perceived stigma associated with immigrants' utilization of welfare. a 2003 study found that asian and latino immigrants who seek healthcare are more likely to report discrimination than u.s. nationals, even when adjusted for ethnicity. additionally, some research indicates that barriers may exist according to a group's cultural beliefs. for example, a 1992 study of southeast asian refugees revealed that participants tended to be less forthcoming in seeking health care due to perceived relative urgencies of pain and discomfort. values of stoicism and differences in disease etiology were also considered as potentially in conflict with perceptions of practicality of western health care. additionally, in a 2016 study of asian immigrants, luo huabin found that participants with higher levels of acculturation were more likely to seek routine oral health care. health care in immigration detention centers according to a 2018 report by the american immigration council, the number of immigrants detained by u.s. immigration and customs enforcement (ice) has increased by over five times within twenty years. immigration detention has been cited for repeated