People who suffer from chronic kidney disease (CKD) are twice as likely to have self-reported fair or poor health status compared with those without CKD (1). The World Health Organization defines “mental health” as a state of well-being that enables people to cope with the stresses of life, realize their abilities, learn and work well, and contribute to their community (2). The mental health of marginalized groups, particularly undocumented immigrants, is further strained by cultural systemic barriers to their mental health including language barriers, health care coverage, disease characteristics, differences in beliefs, and trust with the health care team. Practicing cultural sensitivity with undocumented immigrants can give health care professionals a better idea of how to provide better care to patients with CKD (3).
Language barriers
Undocumented immigrants often face a language barrier to care, with nearly 50% reporting a lack of English proficiency (4). This challenge compounds the stress of expressing health concerns during vulnerable moments, contributing to mental health strain. This may erode trust with primary care physicians or the nephrology care team. Using a medical interpreter during conversations may improve care.
Residency status and health care coverage
Undocumented immigrants are often excluded from government, state, or employer-based insurance plans, which may limit access to affordable and preventive health care (4, 5). Undocumented immigrants residing in states that do not provide scheduled dialysis rely on emergency dialysis treatments; this is known to increase anxiety, morbidity, and mortality (5–7). Undocumented immigrants with kidney failure report an exceptionally low quality of life when surveyed using the validated Kidney Disease Quality of Life survey (8, 9). Physicians should be familiar with resources that support mental health and well-being for undocumented immigrants. One example is El Futuro, a nonprofit organization that provides advice, education, and support groups in the Latinx community (10).
Disease characteristics
CKD is a silent disease. Diagnosis requires laboratory testing, and symptoms manifest only in late stages. Nephrology care teams should acknowledge limitations such as medication costs and access to primary care that disproportionately affect undocumented immigrants. These limitations may accelerate progression of diabetes mellitus and hypertension, the leading causes of CKD.
Addressing beliefs
Discussions around diet and medications often overlook cultural preferences, such as fasting or dietary restrictions, leaving patients feeling overwhelmed rather than empowered. Kidney care practitioners should inquire about patients’ cultural or religious preferences as they relate to treatment, and customize treatment plans to fit their patients’ unique needs. We note that this is not unique to undocumented immigrants and should be considered for all patients.
Next steps
A viable approach to address mental health in undocumented immigrants with CKD might mirror strategies studied to improve mental health for patients with kidney failure. This includes establishing a patient-navigation program tailored to meet the cultural and linguistic needs of a patient. A portion of the clinical visit should be dedicated to discussing this patient population's unique mental health challenges. Nephrologists should also familiarize themselves with resources offered on a community and state level to alleviate the mental health burden of chronic health conditions on the undocumented immigrant population. These strategies, along with use of a multidisciplinary team, can be utilized to provide high-value care to undocumented immigrants.
Footnotes
References
- 1.↑
Nguyen HA, et al. The association between depression, perceived health status, and quality of life among individuals with chronic kidney disease: An analysis of the National Health and Nutrition Examination Survey 2011–2012. Nephron 2017; 136:127–135. doi: 10.1159/000455750
- 2.↑
World Health Organization. Mental health. June 17, 2022. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response
- 3.↑
Kaihlanen A-M, et al. Increasing cultural awareness: Qualitative study of nurses’ perceptions about cultural competence training. BMC Nurs 2019; 18:38. doi: 10.1186/s12912-019-0363-x
- 4.↑
Budiman A. Key findings about U.S. immigrants. Pew Research Center. August 20, 2020. https://www.pewresearch.org/short-reads/2020/08/20/key-findings-about-u-s-immigrants/
- 5.↑
Raghavan R. Caring for Undocumented immigrants with kidney disease. Am J Kidney Dis 2018; 71:488–494. doi: 10.1053/j.ajkd.2017.09.011
- 6.
Cervantes L, et al. Patient navigation: Addressing social challenges in dialysis patients. Am J Kidney Dis 2020; 76:121–129. doi: 10.1053/j.ajkd.2019.06.007
- 7.↑
Rizzolo K, et al. Access to kidney care for undocumented immigrants across the United States. Ann Intern Med 2023; 176:877–879. doi: 10.7326/m23-0202
- 8.↑
Hogan AN, et al. Emergent dialysis and its impact on quality of life in undocumented patients with end-stage renal disease. Ethn Dis 2017; 27:39–44. doi: 10.18865/ed.27.1.39
- 9.↑
Mapes DL, et al. Health-related quality of life as a predictor of mortality and hospitalization: The Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Int 2003; 64:339–349. doi: 10.1046/j.1523-1755.2003.00072.x
