Health Communication with Refugee, Immigrant, and Migrant Communities

Introduction

Recognizing the heterogeneity of refugee, immigrant, and migrant communities

Approximately 46 million people living in the United States were born in another country. Refugee, immigrant, and migrant communities, also known as RIM communities, are a heterogenous segment of the population representing many cultures, languages, regions of the world, immigration statuses, and motivations for migration to the United States. Individuals belonging to RIM communities have moved from one place to another; however, their reasons for leaving and the length of time they plan to stay in their new destination distinguish them (for definitions, see Pre-Arrival Medical Screening and Interventions for Newly Arrived Refugees, Immigrants, and Migrants chapter).

Some RIM communities are well-established in the United States, while others are still very new to the country. These communities represent a wide range of ages, socioeconomic statuses, educational attainment, English-proficiency levels, and occupations.

Health care access and community strengths

RIM communities face different barriers to public health and healthcare services. Some RIM communities are affected disproportionately by economic, social, and other obstacles to health, such as lack of health insurance, barriers to accessing quality health care, workplace conditions, education gaps, and low income. However, they may be resilient, with strong social networks that can be leveraged to improve individual and community health.

Establishing trust and safety

People in RIM communities have varied experiences with health systems in their home countries, while in transit, and after U.S. arrival. Each individual is affected by the unique circumstances of their migration. Factors to be aware of when providing health care to RIM communities:

• Each RIM community is unique, and variation may exist even within a single community. Being aware of and respecting different cultural and religious backgrounds improves communication.
• RIM communities may fear accessing healthcare services due to immigration status.
• Some people may be comfortable and trusting in healthcare settings, while others may not be.
• Some people have experienced violence before, during, or after migration, and this can affect the way they interact with health systems.
• Refugees and other forcibly displaced people may have lived experience or a family history that includes medical experimentation and/or unethical medical practice/research. This is also true for many people of color in the United States.
• After arriving in the United States, RIM communities may experience various degrees of racism, xenophobia, language-based discrimination, or other forms of discrimination on a daily basis, both internal and external to healthcare encounters. Given this, RIM communities may have an understandable distrust of health systems and healthcare professionals.

Healthcare professionals should be aware of how gathering history, demographic information, and medical documentation can be uncomfortable or perceived as threatening by people from RIM communities.

• Communicate directly about why information is elicited and how it will be documented and utilized for treatment plans.
• Ensure the patient is heard, the healthcare professional's role is clear, and patients are oriented to the expectations and limitations of the healthcare system.
• Offer a chaperone during certain encounters because sex concordance between patient and healthcare professional may be preferred in some cultures.

Improving communication with RIM patients

The quality of communication between healthcare professionals and patients influences patient outcomes. While true for all patients, there are additional considerations when caring for patients from RIM communities related to language and culture. Approximately 20% of the U.S. population speaks a language other than English at home and may prefer to speak a language other than English in healthcare encounters. Furthermore, 83% of the foreign-born population in the United States who are 5 years of age and older speak a language other than English at home, and 46% have limited English proficiency, indicating that language access is even more important for this group.

Professional interpretation (translation of spoken language) and culturally validated translated materials must be provided during clinical encounters when patients request communication in their primary language and for any important document provided to patients. Federal law mandates language services in healthcare settings under Title VI of the Civil Rights Act. The Affordable Care Act requires insurers and the healthcare industry to provide translation and interpreting services for individuals with limited English proficiency, but these services may be underutilized. Language preference for multilingual people from RIM communities may vary depending on the situation:

• Some may prefer English despite a different primary language.
• Some may be proficient in English but prefer to speak their primary language during healthcare encounters.
• Some individuals may read in 1 language and speak in another.

It is important to avoid assumptions about language preferences based on country of origin.

• Ask patients about their written and spoken language preferences and document this in their medical records so you can offer appropriate translation and interpretation services every time.
• Approach patients from RIM communities without assumptions about their level of health literacy or their comfort with and knowledge about U.S. health care, regardless of their English-language proficiency, race, ethnicity, or education level.

Clinical encounters

Identifying language preferences

Providing language services for effective communication with healthcare professionals minimizes the potential for miscommunication about important information needed for diagnosis and to communicate treatment recommendations to patients. When the patient is a child, the language needs of the caregivers should be determined. Avoid assumptions about English proficiency based solely on duration in the United States. Consider asking the following questions:

• How well do you speak English? (Not at all / Not well / Well / Very well)
• In what language would you prefer to speak to your healthcare professional?
• In what language would you prefer to receive written health information?
• Would you like to use a medical interpreter for today's visit?

Working with professional medical interpreters

Medical interpretation is the accurate, complete, and objective transmission of oral messages between healthcare professionals and patients who do not share a language. This can be done in person, by phone, or via video. Working effectively with professionally trained medical interpreters is a skill set required for timely and effective communication that can minimize poor health outcomes.

• Provide patients with professional interpretation services even if they have a friend or family member with them who can help communicate. Never use a child as an interpreter.
• Make patients aware of their right to professional medical interpreters free of charge with the assurance of confidentiality in the healthcare encounter.

Consider creating specific resources, like glossaries, to improve cross-cultural communication of standardized health terms through a rigorous translation and cultural validation process, such as this resource created for sexual and reproductive health for Afghan newcomers. Other best practices include:

• Always confirm the language and dialect when arranging for an interpreter. People who speak 1 dialect of a language may not understand an interpreter using a different dialect.
• Prepare for extra time. Interpreted encounters tend to take more time than when the healthcare professional and patient speak the same language. Remember that each statement is uttered twice through interpretation, and clarification may be needed.
• Allow interpreters to introduce themselves and explain their role in a brief statement to both patient and provider.
• Position yourself physically to speak directly to the patient, not the interpreter. Even with a phone interpreter, speak directly to the patient. Remind the interpreter to encourage the patient to address you directly.
• Do not use medical jargon or acronyms.
• Speak in a clear, normal voice. It is not necessary to speak louder.
• Speak in short simple sentences and pause to give the interpreter time to relay the message accurately, especially when working with a phone interpreter.
• Minimize gestures to convey meaning as these may not be universally understood.
• Ask only 1 question at a time, and make sure only 1 person is talking at a time. This is particularly important for phone interpreters because they do not have contextual physical cues to assist them.
• Allow your interpreter to ask for a clarification, definition, or repetition if some information has been missed or if a particular term is unfamiliar. Expect the interpreter to interrupt when necessary for clarification.
• Be prepared to repeat your message in different words if your message is not understood.
• Confirm understanding by asking the patient to repeat key information back to you.
• For longer appointments, check in with your interpreter to see if they need a break to ensure that they can continue their work at the highest possible standard.
• For phone or video interpretation, it can be helpful to provide brief background information or context to the phone interpreter about the purpose of the visit, for example, emergency room evaluation or hospital discharge instructions.
• If speaking over the phone, using a landline rather than a cellphone will ensure you have a stable connection for the entire appointment.
• Do not say anything in the encounter that you do not intend for the patient to hear. For example, do not speak about the patient to the interpreter in their presence. If it is necessary to explain something to the interpreter, ask the interpreter to explain to the patient why this is being done.

Cultural awareness in nonverbal communication

Meaning and expectations derived from nonverbal communication are not universal and may differ based on culture (Table 9.4.1). Nonverbal communication norms may vary based on age or male/female dynamics and can include:

• Body posture
• Hand gestures
• Eye contact
• Physical touch
• Facial expressions

Healthcare professionals should become familiar with norms for the communities they care for to demonstrate respect and cultural awareness. Healthcare professionals can best familiarize themselves with norms for specific communities through:

• Engagement with multicultural staff from RIM communities who can share specific insights
• Learning about a community's practices through local cultural organizations
• Asking individual patients about their preferences, as variability can occur within cultural practices

Although it is impossible to know all cultural variations in nonverbal cues, a general familiarity with variability can inform healthcare professionals' intercultural interactions.

Table 9.4.1: Nonverbal Communication Domains

Family and community involvement

Certain RIM communities may involve family or community members to various degrees in shared decision-making around health care. This may include bringing several family members to clinical appointments.

• Inquire about the family unit and who the patient desires to involve in healthcare decisions.
• Bridging Western medical treatment plans with traditional medicine practices may offer an opportunity to increase trust in the healthcare system.

Health communications for RIM communities

Selecting high-quality materials

When sharing health communication materials with patients, carefully select materials that are culturally and linguistically appropriate and that have been developed using translation best practices. High-quality materials are those that:

• Use plain language
• Reflect community perspectives
• Use images that are clear and culturally appropriate for the community
• Use formats (written, audio, or video) that are appropriate for the community's needs and preferences
• Align with guidance from trusted sources like the Centers for Disease Control and Prevention (CDC), state health departments, or international sources like the World Health Organization
• Have been rigorously translated and proofread by a professionally trained translator
• Have undergone cultural validation with community members

There are several organizations that offer translations of health education materials, including:

• CDC
• Medline Plus
• Multilingual Health Exchange
• Migration Health Initiative

Even organizations that have health communications materials that are based on reliable sources may not necessarily offer high-quality translations. The best way to assess a translation for cultural and linguistic relevance is to involve the community in your selection process.

The importance of plain language

Plain language is an important component of high-quality health communication materials (Table 9.4.2). The Plain Language Act requires federal agencies to use clear communication that the general public can understand and use. This practice makes communication easier, and also makes materials easier to translate. Some common techniques to ensure that writing is in plain language include (Plain Language Action and Information Network):

• Using "you" and other pronouns
• Using active voice rather than passive voice
• Writing in short sentences and paragraphs
• Avoiding jargon by using common words
• Including layouts such as lists, headers, and tables

By using plain language, you can ensure that all patients, regardless of the language they use, understand health communications better and can make informed decisions about their healthcare needs. This will benefit people who communicate in English as well as those who use other languages. Plain language also makes English-language materials easier to translate into other languages.

Table 9.4.2: An example from the CDC's everyday words for public health communication

Notes

More information and strategies on plain language can be found on the U.S. General Services Administration website.

Involving the community

Translation best practices involve community members to ensure accuracy and cultural relevance. While machine translations (e.g., Google Translate) can be helpful in saving time and money, they should never be used without the review of a qualified translator. In healthcare settings in particular, the use of machine translations can be dangerous to a patient's health. Unlike automated translators, professional translators can:

• Convey tone, urgency, and intention
• Explain acronyms and colloquial expressions
• Provide culturally necessary context

Community members are uniquely positioned to judge a translation for its ability to go beyond translating words to instead translate the concepts behind the message and can ensure that your health material achieves its intended impact. After the material has undergone professional translation, bilingual and bicultural community members should review it to ensure accuracy, relevance, as well as cultural appropriateness, particularly for people who speak different dialects or have different levels of education. More information and examples are available on Migration Health Initiative.

Using multiple formats

Some communities rely on oral traditions which can be leveraged to ensure effective communication. Different cultures have varying relationships with the written word, and it is important to be as inclusive as possible by responding to community needs. Think creatively about solutions to overcoming barriers to communicating with patients:

• Many refugees, immigrants, and migrants benefit from audio and video resources.
• Even people who can read in their language sometimes prefer other formats. By pairing written communications with video or audio messages, you can ensure that everyone has their needs met.
• Creating short video messages and sharing them on social media platforms common with your intended audiences, as well as sharing audio and video messages on WhatsApp or other messaging apps popular with the community, can go a long way.
• Some community members may benefit from QR codes on written materials that link them to alternative ways of receiving information. Even if a particular patient is not familiar with this technology, they may have family members, friends, trusted messengers, or community navigators who can help them access it.

Disseminating health communications

Partnerships and trusted messengers

Some people from RIM communities may have lived experience or a family history that includes medical experimentation or unethical medical practice and research. Given this, some people may have a well-founded mistrust of healthcare professionals. Collaborating with trusted messengers and community organizations is a way to deliver health information in a culturally relevant manner. Some partnership ideas include:

• Faith-based organizations
• National, regional, and local RIM-serving organizations
• Social media influencers
• Public libraries
• Refugee resettlement agencies
• Consulates
• Youth groups
• K–12 schools
• Community leaders
• Community health workers
• Employers
• Federally Qualified Health Centers
• State Refugee Health Coordinators
• Local radio stations

Community-led Initiatives

Not all health initiatives are led by health departments or health systems. RIM communities have the wisdom, experience, and desire to influence systems to serve their communities better. Healthcare professionals and public health professionals should look to what is already working well within communities for ideas on how to support or partner with community-led initiatives.