Recommendations for Health

This recommendation also appears under Navigators and as Recommendation 2 under Translation and Interpretation

One of the most imposing barriers facing residents of this region is the challenge of navigating support systems. Understanding what step to take next, how to fill out a form correctly, or who to call for help can be extremely difficult for many people, and especially lower income individuals.[1] For immigrants these problems may be compounded by a lack of familiarity with local systems, language challenges, and a cultural or societal fear of being seen as causing problems. Some immigrants may simply avoid seeking services instead of dealing with the potential for failure and humiliation.

The addition of navigators can be a major benefit for helping resolve these issues. Navigators are individuals employed or utilized by service providers to help assist community members with accessing services. The best navigators are those that are both trained in the requirements of service systems and come from the communities they serve, providing them with the language and cultural knowledge to effectively help. These navigators can leverage trust and relationships within immigrant communities to make sure that a greater number of people are able access important services. Hiring additional navigators, especially at organizations or government departments that regularly serve immigrant communities, can be an extremely beneficial way to improve engagement with local populations.

Excellent examples of valuable immigrant navigators already exist within Dubuque. These include community health workers at Crescent Community Health Center, paraprofessionals at the Dubuque Community School District, family navigators at Child Health Specialty Clinics, and staff at the Northeast Iowa Community College. Many other organizations, such as institutes of higher education, also have staff that, while not navigators, may frequently serve a navigator role. Several navigator positions were also created as a result of collaborations connected with this research, including the Guatemalan Mentor program and the Marshallese community connector at the Visiting Nurse Association (see Projects and Accomplishments Connected with the Community Assessment for more information). This is by no means an exhaustive list of navigators in the region, but is meant to be provide examples of existing navigators who are members of local immigrant communities.

However, while hiring navigators is an undoubtedly powerful tool for helping improve access to services for immigrant populations, it should not be seen as a substitute for capacity and power building. Navigators can serve an important role, but still are meant to move forward the mission of the organization they work for and follow the direction of their (usually non-immigrant) managers and bosses. This is a very valuable and necessary part of how service organizations in this region work, and navigation plays a critical role in helping to provide equitable access to systems. But it should still not be seen as a replacement for advocacy and power building within immigrant communities.

The role of navigators is especially important in healthcare. Health services can be an intimidating experience, especially if there are language and cultural barriers. Misinformation about medical issues can be common, especially during a health crisis like the Covid-19 pandemic. Understanding what information is correct or how to best engage with complex systems like insurance or medical billing can be very difficult for community leaders and volunteers that are supporting immigrant families. Having a trusted individual who is knowledgeable about health-care systems and paid to assist members of their local community can be a huge asset. Health-care providers and related organizations should consider creating more navigator positions staffed by members from immigrant communities, such as community health workers or community connectors.

An example of previously recommended program that can fulfill some of the roles of a navigator position is the Natural Helper program. While this is not a substitute for having a paid staff position dedicated to navigation, training and compensating immigrant volunteers to help members of their communities navigate systems can increase access to services. The Natural Helper program is described in more detail in Capacity and Power Building section.

The expansion of Medicaid has done a lot to help cover medical expenses, and there are other existing systems for helping with uncovered costs. Hospitals often provide significant financial support to uninsured individuals, providing care even if there is no expected payment. And many nonprofits and government offices provide additional funding to help with medical bills, often raised through grants, donations, or the allocation of government funding. This means that there are many existing services that can support individuals with uncovered medical costs.

However, many of these services have specific requirements and limitations, and understanding which are applicable can be challenging. Funding sources may not be available due to:

The nature of the cost (if it was a cost like transportation that came outside of the hospitals system),
The residency status of the individual (only green card holders or U.S. citizens are eligible for some funding),
The income level of the individual,
Whether the individual had any outstanding bills or had been helped by the program before,
If the procedure is considered “necessary” (for example, Dubuque for Refugee Children has needed to raise money from supporters for clients to have their wisdom teeth removed); and
Other considerations that might determine whether an individual is qualified for that funding.

Due to the confusion that exists around these different support services, having trained navigators available to help immigrant families can be very important for ensuring that funding is accessed regularly and efficiently (see the previous recommendation, 1. Hire Additional Navigators).

In addition, the gaps in funding mean that there are many expenses that regularly go uncovered within this region. These outstanding costs can create serious problems for immigrants such as delayed treatments or rising medical debt. Many nonprofit organizations, such as the Presentation Lantern Center, raise funds to help provide emergency support for medical needs. However, these funds are often limited and cannot cover all costs. Communities should consider creating pools of collective funding designed as a funding option of last resort for immigrant medical costs. Allowing nonprofit organizations and other service providers to apply for these funds on behalf of immigrants could improve access to care and reduce medical debt. It is important than any collected funding option is designed in a way that it does only cover those uncovered costs, as otherwise it would be simply replacing the work of already existing funding sources, instead of its intended purpose of benefiting immigrant families.

Models to consider:

The Marshallese Health Fund at the Community Foundation of Greater Dubuque provides funding to help cover otherwise uncovered costs incurred by Marshallese families related to the Covid-19 pandemic. The Fund provides support with medical bills, housing and utility assistance, and other important costs through partnership with trusted nonprofit organizations. The Fund was launched by Dr. Mark Janes, a local pulmonologist concerned about the toll Covid-19 was taking on members of the Marshallese Community.
- https://dbqfoundation.org/giving-center/dubuque-marshallese-health-fund

While this region has made significant progress in providing health-care services to immigrant populations, one area where major gaps still exist is with brain health services. A recent Brain Health Needs Assessment, commissioned by Dubuque County and the Mental Health and Disability Services of the East Central Region and conducted by the Community Foundation, found that:

There was a significant lack of counseling services within Dubuque County, leading to few available slots and long wait times throughout the region; and
An even larger gap exists for immigrants and individuals whose primary language is not English.[2]

Counseling is a very personal and sensitive practice, requiring trust between the counselor and the patient. This means that many practitioners in the area are understandably uncomfortable with holding counseling sessions across languages and cultures. Advocates and nonprofit organizations struggle to find brain health services for immigrant individuals, even when they are able to provide translation. This lack of services is in addition to the cultural taboos around brain health in some immigrant populations, where counseling and treatment for brain health needs are seen as something a “crazy” person would do, and not as a legitimate issue requiring medical diagnosis. This means that for many immigrants, challenges like stress, anxiety, and depression often go untreated due to either an unwillingness to seek treatment or because of insufficient available services.

Being able to fully address the brain health needs of immigrants would necessitate addressing the larger challenges around a lack of general capacity. This would require a significant increase in resources and effort, and is outside the scope of this research. However, there are several potential programs that can help address some of the needs around brain health for immigrants through more targeted interventions:

Recruit additional practitioners serving immigrant communities. The most straightforward way to address this gap is to increase the number of practitioners that serve immigrants. Hiring additional counselors with language skills and the cultural competency to work with individuals from other populations will increase the availability of services for immigrants. Hiring counselors that look like or come from the same background as immigrant populations can also provide value, as it can help immigrants feel more comfortable accessing services.
Train existing practitioners. There are a number of brain health practitioners in the region who can provide training to improve local capacity to serve immigrants. Dr. Naomi Ford at the Iowa Refugee Counseling Center in Iowa City has offered to provide training to interested practitioners, and other trainings may help provide additional capacity.
Group Brain Health Sessions. Due to the reluctance of some immigrants to seek formal brain health services, holding free group sessions focused on trauma or other issues may be a more accessible option. Providing a less formal, free group session in the individual’s first language can help address some brain health needs and serve as an onramp to more extensive services. For an example, see the Beyond Trauma program under “Models to consider.”
Additional support to students. The region’s local schools have been doing an impressive job in offering additional brain health support to students in the wake of the Covid-19 pandemic. It is important the school officials make sure that these services are accessible and usable by immigrant students, and that those students feel that the services are available to them.

Models to consider:

The Iowa Refugee Counseling Center in Iowa City, which is housed by the nonprofit organization IC Compassion, provides both individual and group counseling services for immigrants and refugees. They also provide additional counseling and immigration related services such as assessments for asylum proceedings.
- https://www.iccompassion.org/refugeecounseling
The Beyond Trauma (also known as ESPERE) program uses a restorative justice model to help adult immigrants who have experienced trauma. Beyond Trauma classes, which are conducted by the group Adelante Mujeres in Oregon, use a group model that works with individuals over a series of sessions. There are individuals in Dubuque with experience providing this service in Spanish to Latino men and women.
- https://www.adelantemujeres.org/beyond-trauma

This recommendation also appears as Recommendation 6 under Translation and Interpretation

One significant gap in this region is for licensed medical interpreters and translators, especially for languages like Marshallese that are not commonly spoken throughout much of the United States. Many health-care providers require certified medical translators to make sure that they can correctly translate the technical terms used by staff. However, in many instances these interpreters are not available, and so the providers rely on untrained community members for interpretation. At times, young children have been asked to provide translation when there is no other readily available option. Not only is this potentially inappropriate and could lead to significant mistranslations, but in many cases health-care providers are unable to compensate non-certified interpreters.

This region, and especially locations like Dubuque where languages are commonly spoken that do not have readily available translators, should work to develop the support process and funding to help interested community members become certified for medical interpretation. Courses and tests can be expensive and take extensive time, so it will be important to have individuals who can assist with navigating systems and funding to help cover costs. While the best process and programs may vary from area to area, the following is an option that communities could consider:

The Certification Commission for Healthcare Interpreters (CCHI)[3] offers several accreditations that are accepted by many health-care providers.
- For Spanish, Mandarin, and French, CCHI offers its Certified Healthcare Interpreter (CHI) certification.
- For other languages (such as Marshallese), CCHI offers its Core Certification Healthcare Interpreter (CoreCHI) certification. Due to the big lack of interpreters for less commonly spoken languages, this report will primarily discuss the CoreCHI.
Applicants for the CoreCHI and CHI certification must meet the following requirements:
- Be at least eighteen years of age.
- Have received a high school diploma or equivalent from any country.
- Be able to demonstrate proficiency in both English and the language of interpretation. This can be done with:
  - A high school diploma or equivalent from a country that teaches in the language;
  - Successfully passing a language proficiency test from a reputable testing organization;
    - A list of suggested English language testing options are available at the CCHI site.[4]
      - The TOEFL Essentials test provided by ETS allows for remote testing online.[5]
    - Sites such as Language Testing International (LTI) offer widely accepted language proficiency certificates.[6]
      - LTI does not currently appear to offer language testing in Marshallese. For Marshallese, the Avant STAMP WS test is available and accepted by CCHI.[7]
  - Other options are listed in the CCHI Candidate Examination Handbook.[8]
- Completion of a minimum of 40 hours of training (not experience) in health-care interpreting.[9] See “Models to consider” below:
The CoreCHI examination includes $210 worth of fees. The CHI Examination includes an additional $275 of fees.

Models to consider:

Heartland Regional Genetics Network provides a medical interpretation training for Marshallese interpreters that fulfills the 40-hour requirement. Several community members have taken part in this training.
- https://www.heartlandcollaborative.org

This recommendation also appears as Recommendation 3.6.7 under Translation and Interpretation

Separate from medical interpretation and translation, brain health[10] or counseling interpretation requires additional training and commitment for an interpreter. Due to the personal nature of counseling services, an interpreter may become a major participant in any session. Any interpreter would need to have additional training on how to properly participate in counseling sessions, how to correctly interpret for the brain health specialist, and how to operate ethically and confidentially during the sessions. Trust is a key component of this kind of interpretation, so finding the correct, committed interpreter can be challenging. It is recommended that any effort to recruit translators for counseling sessions be coupled with training and a very thoughtful recruitment process. For more on brain health services for migrants and immigrants, see 3. Provide Brain Health Services.

Models to consider:

The Iowa Refugee Counseling Center in Iowa City holds counseling sessions for refugees and other immigrants. As part of their counseling sessions they use interpreters who are trained by the Center. Dr. Noemi Ford, who runs the Center, is able to provide trainings for interpreters on how to be successful interpreters for brain health sessions. Dr. Ford could be contracted to provide training sessions for community members who are interested in serving as translators.
- This training should be accompanied by a training of counselors or brain health providers as well. Both the counselor and the interpreter should understand their roles and how to work cross culturally.
- https://www.iccompassion.org/refugeecounseling
The Marjorie Kovler Center, a Chicago-based program providing trauma-informed care to survivors of torture, has previously offered training sessions for interpreters.
- https://www.heartlandalliance.org/program/marjorie-kovler-center/
The National Council on Interpreting in Health Care has produced a working paper titled “A National Code of Ethics for Interpreters in Health Care.” This document provides useful information for potential translators and service providers regarding interpretation for brain health.
- The manual can be accessed at: https://www.ncihc.org/assets/z2021Images/NCIHC%20National%20Code%20of%20Ethics.pdf.

Here for you. Alex Baum Director of Advocacy, Data and Learning alex@dbqfoundation.org 563-588-2700

Recommendations for Health

1. Hire Additional Navigators

2. Provide Funds for Uncovered Medical Expenses

3. Provide Brain Health Services

4. Offer Training for Medical Translation and Interpretation

5. Offer Training for Brain Health Translation and Interpretation

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