3

Accessing and Using Health Care Services

The workshop’s second panel session focused on the theme of access and featured four presentations on approaches for improving access to and use of health care services for immigrant, refugee, and migrant populations. Nick Nelson, director of the Human Rights Clinic and associate program director of the internal medicine program at Highland Hospital in Oakland, California, spoke about delivering trauma-informed care and what practitioners need to think about and be aware of when interacting with immigrants, refugees, and migrants. Julia Liou, director of program planning and development at Asian Health Services and manager of the California Healthy Nail Salon Collaborative, described one innovative access point for reaching newly arrived populations. Jesús Quiñones, Guides for Understanding Information and Access (GUIA) program coordinator at Casa de Salud in St. Louis, Missouri, discussed approaches to establishing trust as the first step to bringing immigrants, refugees, and migrants into the health care system. Kari LaScala, health communications specialist with Wisconsin Health Literacy, gave the final presentation in this session on workshops her organization developed to help refugees and immigrants understand how to use their medications properly. An open discussion followed the presentations.

DELIVERING TRAUMA-INFORMED CARE TO IMMIGRANTS, REFUGEES, AND MIGRANTS¹

Nelson began his presentation by noting that there have been at least three observational studies in urban and coastal primary care clinics demonstrating that the prevalence of torture among all people born outside of the United States, including those from developed countries, is between 4 and 10 percent (Crosby et al., 2006; Eisenman et al., 2000; Hexom et al., 2012). He believes that the prevalence of torture in the populations this workshop is considering is considerably higher, as is the prevalence of less stringently defined forms of abuse and trauma, such as domestic violence, socioeconomic and ethnic persecution, and migration trauma.

Nelson illustrated the various aspects of the physical health, mental health, and socioeconomic and legal issues relevant specifically to the immigrant, refugee, and migrant populations with stories of some of the patients he and his colleagues have seen in their human rights clinic. The first story he told was of two young men who escaped forced military conscription in Eritrea, fled through Sudan to the Arabian Peninsula, and stowed away on freighters, one to Ecuador, the other to Brazil. These two men then walked from their respective landing points to Oakland, California, even though neither could read the Roman alphabet—their native language was Tigrinya—let alone speak English, Spanish, or Portuguese. In terms of their physical health, having been born and raised in Eritrea put them at risk of having HIV/AIDS, tuberculosis, and intestinal parasitic diseases such as schistosomiasis, while their treks from the Latin American tropics increased their risk of having other health issues. “The array of risks that people become exposed to is so diverse that even the CDC [Centers for Disease Control and Prevention] guidelines do not really cover them,” said Nelson, referring to the typical refugee health screening programs of the sort that Paul Geltman mentioned in the first panel discussion.

One clinical story illustrating how important it is to consider place of birth and think outside of the CDC guidelines involved a Vietnamese immigrant who had been a U.S. resident for some 20 years when he was hospitalized. This man had developed a primary brain tumor, and his oncologist had treated him with combination chemotherapy that included immunosuppressant drugs. When he came to the hospital, he was suffering from a fulminant multi-system illness characterized by renal failure, respiratory failure, and what Nelson called a bizarre rash. Test results revealed that parasitic worms, which had been living asymptomatically in the man’s

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¹ This section is based on the presentation by Nick Nelson, director of the Human Rights Clinic and associate program director of the internal medicine program at Highland Hospital in Oakland, California, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

colon, had disseminated throughout his body when he was immunosuppressed. “He died of this illness,” said Nelson, “but this could have been prevented with a simple stool examination or blood test when he arrived or at any time during the years he had been in the United States.”

Recently, Nelson’s hospital saw an outbreak of trichinosis, a disease he had never seen in his practice, in members of an extended social network. One family in this network had purchased a feral piglet on eBay, raised it in their backyard, and cooked it—incompletely—for a New Year’s celebration. “Both by virtue of in-country exposure and cultural practices once people are here, there are medical issues we need to be aware of,” said Nelson.

Mental health is another aspect of care that Nelson said he has learned about through his work in the human rights clinic. In medicine, he explained, there are various diseases such as tuberculosis and syphilis that are called great imitators because they present with symptoms that are easily confused with other illnesses. “Trauma is the great imitator in psychiatry,” he said. “Trauma can present with symptoms that are primarily anxiety, symptoms that are primarily depression or frank psychosis, and a huge variety of presentations rooted in the individual idiosyncrasies and in the cultures of the individuals in whom they develop.”

As an extreme example of this, Nelson told the story of a middle-aged information technology professional who had arrived from Yemen and had refugee status. This man came to the hospital complaining of precipitous weight loss over the preceding 2 months, symptoms that immediately raised concerns that the man had metastatic cancer. A $500,000 battery of tests, including endoscopy of his upper and lower gastrointestinal tract, found no trace of cancer or any other problem. Several months later, he returned to the hospital with the same complaint, and another $500,000 of clinical tests again revealed nothing. Several clinic visits later, someone in primary care asked him specifically if he had ever been tortured, and it turned out that 2 months prior to his initial visit to the clinic he had gone back to Yemen to prosecute a dispute with the government over some land his family owned. “They had imprisoned him and tortured him in ways that are too horrible for me to describe in mixed company, or just any company really,” said Nelson. “All of what he was experiencing represented the psychological residue of that torture.”

As an internist, Nelson said he has had a difficult time learning and understanding the socioeconomic aspect of the traumas his patients have experienced. “For me, the medical and psychiatric issues are pretty straightforward because as a physician, especially one who works in a county hospital, I am used to the fact that the prevalence of medical and psychiatric disease are differentially distributed in ways that systematically afflict people who are on the wrong end of power hierarchies, whether it is because you are part of an ethnic group or you are poor or whatever,”

said Nelson. “The intricacies of how that plays out in terms of access to services, to housing, to social support, have been a real eye opener for me over the years.”

In Oakland, for example, there are vibrant indigenous Guatemalan and Eritrean communities, and if someone from one of those two groups arrives in Oakland, there will be people who speak their language and who can help with assistance finding housing, employment, and other services. “But I think every urban community in the United States has people who came here under enormous pressure, possibly even because of a threat to their lives, and ended up in places where they do not have that kind of community and do not have access to services.”

Recently, Nelson examined a woman from Guinea who had the classic signs of female genital mutilation, which typically results in the San Francisco asylum court granting asylum, he explained. However, in this case the woman had married a South African who had abused her sexually and physically for 10 years in South Africa, which complicated the situation. Ultimately, however, the court did grant her asylum thanks to the efforts of her immigration lawyer, but until that happened she was not eligible for any support. “This poor lady mainly speaks French and has no contacts in the East Bay. During the coldest winter of the last 5 years, she was supporting herself exclusively with part time and totally unguaranteed work in an unheated African hair braiding salon, where she slept on the floor at night,” said Nelson. “Obviously, it was much worse for her than it was for me, but I felt terrible because here I am a doctor in a county hospital who has some kind of social justice mission and I am trying to marshal the resources that I usually have for patients like this, in terms of social workers and therapists, but the main barrier was that she was an asylum seeker in process and was just not eligible for anything.”

Fortunately, he added, this story ended well, but that is not always the case, particularly when these individuals are seen by primary care clinicians who do not have training or specific experience to imagine the extent of what immigrants, refugees, and migrants have to contend with in their daily lives. In that regard, perhaps the most important thing a clinician can do is be curious and ask people about their experiences. Nelson noted one study (Shannon et al., 2012) in which refugees were asked to identify the single greatest barrier to them divulging the history of their traumas. By a large majority, the refugees responded that the clinician had never asked.

The final story Nelson recounted spoke to the new set of difficulties that immigrants, refugees, and migrants face today. An undocumented Mexican woman with poorly controlled diabetes who he had been taking care of for many years came to urgent care three months ago with chest pain and changes in her electrocardiogram suggesting she might be having a heart attack. The Spanish-speaking resident who saw her called Nelson

because she refused to go to the emergency department for fear she would be arrested by Immigration and Customs Enforcement and deported, just as her son had been many years ago. Nelson told the resident to tell her from him that she would not be arrested and that she needed to be seen in the emergency department. However, when he arrived in the emergency department 2 hours later to see how she was doing, she was not there and he has been unable to contact her since then.

“We as clinicians have to be aware of those issues and find sensitive ways to inquire about them,” said Nelson. “One of the reasons that this discussion today is so helpful is because we have brought together people who know a great deal more than I do and have better ideas about how we might approach those difficult and sensitive issues without re-traumatizing or scaring people.” As a final thought, he added that he believes it vital to recognize how current changes in federal policy toward migrants, refugees, and asylum seekers affects the clinical encounter. “We all face an increasingly weighty burden of proof, which I think was discussed eloquently in the last panel, to demonstrate to these people that we are on their side, and we have a grave responsibility to advocate on their behalf.”

INNOVATIVE ACCESS POINTS CUSTOMIZED FOR NEWLY ARRIVED POPULATIONS²

In 2015, a New York Times article highlighted the health issues that nail salon workers experience because of their exposure to potentially toxic chemicals in nail care products. Liou explained that the reporter for this story spent a week at Asian Health Services to understand the issues confronting nail salon workers, who on average handle known carcinogens and reproductive toxicants such as benzene, bi-n-butyl phthalate, formaldehyde, glycol ethers, methylene chloride, and toluene on a daily basis for 8 to 10 hours per day. “For Asian Health Services, we are most concerned about the workers because of the cumulative and chronic exposures to these products that they handle so frequently,” said Liou.

Asian Health Services, said Liou, serves more than 27,000 clients in Alameda County (California) who speak 12 different Asian languages. She and her colleagues became aware of the occupational health problems facing Vietnamese nail salon workers when one of her organization’s community health workers, who was conducting outreach and education about diabetes, met one nail salon employee who kept complaining about how

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² This section is based on the presentation by Julia Liou, director of program planning and development at Asian Health Services and manager of the California Healthy Nail Salon Collaborative, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

she was having a hard time breathing while she was working and about a chronic rash she had developed. In relatively short order, more than 100 nail salon workers had reported similar stories, with some complaining about miscarriages or reporting they had developed breast cancer. “There were so many stories, not just one or two,” said Liou.

Talking with her clinical colleagues, she realized that they had been seeing patients who worked in the nail salon industry with similar complaints and pregnant workers who were concerned about the possible harm their babies could suffer from chemical exposure. “We started noting that this was an epidemic happening within this community that tended to be overlooked,” said Liou.

When the Asian Health Services team began looking into the issue, they found a study conducted among Vietnamese nail salon workers in Boston (Roelofs et al., 2008) that identified a constellation of acute health problems, such as asthma, headaches, and contact dermatitis plaguing these women. Another study of Vietnamese manicurists in California (Quach et al., 2015) found that these women were at greater risk of pregnancy complications, including gestational diabetes and placenta previa. They also heard concerns among nail salon workers about cancer, though there are no studies that have documented an increase in cancer rates in this population that totals at least 400,000 people nationwide.

Liou noted that some 58 percent of nail salon workers are of Asian descent, with the vast majority being female immigrants with limited English proficiency. Many of these workers, she added, are distrustful of the government because of their home country experiences. The average yearly income of a nail worker is less than $23,000.

Asian Health Services’ mission is to provide services to and be advocates for its community. “That means we are responsive to the issues we see in our patient population and we want to address health, not just within the clinic, but also looking at the social determinants of health,” Liou explained. This issue, however, is complex because the chemicals in nail products are there legally, and there is no independent third party that reviews these products for safety before they reach the consumer, she said. In addition, there is a paucity of research available on this particular population, and little had been done around outreach and education within this community.

She and her colleagues decided to start small, convening a gathering of six people. They secured seed funding from The California Endowment and the Women’s Foundation to hold an all-day meeting in 2005 on how to address the issue of nail salon worker health and safety. From this starting point, they established a research advisory committee to bring together researchers who were interested in studying this problem. They also formed policy and outreach working groups and a nail salon worker and owner

advisory group. Today, the California Healthy Nail Salon Collaborative includes more than 20 organizations statewide. It collaborates with experts in industrial hygiene and chemistry to think through some of the issues related to salon worker health and safety. Recognizing that the majority of nail salon workers have less than a high school education, the Collaborative has created educational materials written at a fourth-grade literacy level and rich with pictures and visuals. The Collaborative also formed focus groups to identify tips for workers that they could realistically use in their workplaces, such as wearing gloves to avoid dermal absorption of chemicals. “We have also worked with our partners and trained them on these topics so they could do these trainings as well,” said Liou.

One interesting finding from the focus groups was that the workers were interested more in learning how to speak English better than they were about their health. Another issue that arose was a concern about ergonomic health, so Liou and her partners created quick tips, for example how to avoid wrist pain. The Collaborative created cards for the workers with phrases they could use with their clients when their backs or wrists started hurting, such as “Excuse me, I need to stretch quickly. I have been in this position a long time,” and “Can I put this pillow under your wrist? This will help me see your hand better.”

The primary concern of business owners was avoiding fines, not health. “Unfortunately, a lot of health messaging was not getting through,” said Liou. What she and her colleagues realized, she said, was that they had to start with the basics, such as teaching them about the State Board of Cosmetology and its regulations and appeals processes. “We had to do that first before we could even get through to talk about health,” said Liou. “That was an important lesson for us.”

Those discussions, she said, helped build trust within that community, which then enabled Liou and her collaborators to conduct trainings, increase awareness and knowledge, and start thinking about how to change behavior and move people to take action. Through their trainings, they identified people who seemed committed to change and developed a leadership program for those individuals. They developed a curriculum that includes topics such as how to get people to share their stories in a safe space, how to take notes and report findings, and how to hold meetings away from work. “We started to see that folks were actually beginning to develop some leadership skills and feel a little more empowered,” said Liou.

Once they started building leadership in the community, the next step was to create a model for change that would include some solutions to address some of the social determinant factors that the workers might not necessarily control. To create the model, they held community meetings and asked workers and owners, most of whom also work in the nail salons, to comment on possible solutions. The idea of banning certain chemicals,

for example, was not favored because of the fear that doing so would hurt business. This led to the idea of rewarding salons that were doing right by their workers and to the creation of the Healthy Nail Salon Program (see Figure 3-1). The Collaborative worked with its policy members to identify champions in the San Francisco area and identify what defines a healthy workplace in a nail salon. “We were able to define a healthy nail salon as one that uses safer products that are available, uses ventilation, is able to train all of the workers, and has owners who invest in healthy and safe workplace practices,” said Liou. In 2009, the San Francisco Board of Supervisors unanimously approved the Nail Salon Recognition Program ordinance.

At that point, said Liou, the Collaborative realized it had a model and infrastructure by which nail salons could adopt the recommended solutions and salon workers could implement the health tips. Since then, they have identified additional partners who have replicated the Healthy Nail

Salon Program in four other cities and counties in California. Replication was important, she noted, because it created champions in the state legislature who could talk about nail salon worker safety. Replication also got the attention of the media. “We were able to tell the story of many of the workers and owners who did this,” said Liou. “We now have 143 Healthy Nail Salons throughout the state.” An early evaluation of San Francisco’s program (Garcia et al., 2015), funded by the U.S. Environmental Protection Agency, found that workers in Healthy Nail Salons had reduced chemical exposures and increased knowledge of healthy workplace practices. The California legislature has since passed the Healthy Nail Salon Bill to extend this program statewide, and the Collaborative is working with microloan partners to provide funds to nail salons in the state that want to become Healthy Nail Salons. Liou noted in closing that she is working with people in New York to build out the model and include labor rights as well. “We recognize this is an issue in addition to health that falls within the social determinants of health realm,” said Liou.

ESTABLISHING TRUST TO BRING INDIVIDUALS INTO PRIMARY CARE³

Casa de Salud—House of Health in Spanish—is a 501(c)(3) nonprofit health care organization that aims to provide high-quality medical and mental health services for the immigrant and refugee population in the St. Louis metropolitan area, which includes some 30 counties in Illinois and Missouri, explained Quiñones. A staff of 20 and about 60 volunteer providers conduct between 400 and 500 examinations per month and, in 2015, saw more than 2,100 patients. Knowing that it cannot provide all of the health care services its clients need, Casa de Salud works to facilitate access to the region’s health care infrastructure, coordinate referrals, conduct patient advocacy and navigation, and provide guidance about financial assistance and health education.

Casa de Salud’s main partner has been St. Louis University, which donated a building to the organization and allowed it to renovate it. Originally, the organization was founded to meet the needs of the Hispanic and Latino community, but as Quiñones explained, he and his colleagues realized quickly that there are many foreign-born communities in the St. Louis metropolitan area. “We have the International Institute of St. Louis, which is responsible for bringing immigrants and refugees to the city,” he said.

The GUIA Program that Quiñones oversees is a social work and case

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³ This section is based on the presentation by Jesús Quiñones, GUIA program coordinator at Casa de Salud in St. Louis, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

management program that assists Casa de Salud’s clinical program. “We operate in a case management model that aims to facilitate access to the health care infrastructure, both at the systems level and the patient level,” he said, noting the importance of being part of systems-level processes in addition to the political process. “My supervisors, our president, and I focus on systems-level access by building relationships with health care organizations in the St. Louis area. This is done to ensure that there are referral pathways that we can use for our patients and also to overcome the unique barriers that our population faces resulting from their lack of access to public assistance programs,” said Quiñones. Some 70 volunteer providers—physicians, internal medicine providers, specialty care providers, mental health providers, nutritionists, and dieticians—provide services contingent on their ability to make time. “When we are unable to meet a patient’s needs, we refer them externally,” said Quiñones.

Case managers, acting as community health workers, provide patient-level access, which includes referral coordination or appointment setting and evidence-based education on chronic illness management. The GUIA Program has an appointment reminder system that uses whatever means are necessary to reach its clients, and it coordinates a home visit program to address chronic illnesses, primarily diabetes and hypertension, that includes three home visits over 6 months and monthly calls between visits. During each home visit, the case manager, acting as a community health worker, provides chronic illness education, and a volunteer nurse assesses the client’s health and administers specific interventions. The goal of the home visit program is to empower patients using a patient-centered model, said Quiñones.

Quiñones said his program has developed its own tools, using published studies as a guide, to measure program efficacy, both so that it can report to its funders and to determine if any interventions are not working. For example, Casa de Salud developed its own diabetes curriculum when it found that its clinics were not using existing written materials consistently. “We wanted to be consistent across all levels of the clinic and we wanted the curriculum to be accessible to low literacy and low numeracy patients.” The new evidence-based, culturally competent program is delivered verbally, with patient understanding assessed using teach-back methods. For example, instead of the existing example of a healthy meal that included pictures of mashed potatoes, chicken, and salad, Casa de Salud’s diagram has beans and rice. Another tool the diabetes curriculum uses is a set of what he called “glucose wands” instead of showing them pictures of what arteries look like in a diabetic and non-diabetic patient. The wands contain beads representing red blood cells. One wand contains a viscous fluid, the other a less-viscous liquid, and clients can easily see the difference in the way the beads can move in the two wands.

With regard to evaluation, the program uses a teach-back tool administered on the first and last visit and a simple self-efficacy scoring tool. At one time, the program also included a 24-hour diet and physical activity recall instrument used by dieticians and nutritionists, but this was not the best tool for this population. Quiñones explained that since some of their clients are in the food service industry, home visits are usually scheduled for Monday, which is a common day off in that industry. The problem was that in many of the communities Casa de Salud serves, Sunday is a day of church parties, so the results of the diet and physical activity recall activity were providing a skewed picture of dietary and physical activity behaviors. “That was a lesson we learned recently,” he said.

As part of its trust-building activities, Casa de Salud does not ask clients specifically about their insurance or documentation status. “We simply do not ask,” said Quiñones. He noted that all nonprofit health care organizations in the St. Louis region need to have community benefit programs, which includes financial assistance processes. “Our case managers have extensive experience guiding patients through that process, which is extremely lengthy,” he explained. Another way in which Casa de Salud has been able to build the community’s trust in it and the health care system at large is to assist them in accessing all aspects of the health care system, including specialist and other forms of care. “You cannot just tell them to go see a neurologist, because they do not know where to go,” said Quiñones, “and when they go they may face discrimination. Having someone assist them in the continuum of care has really helped to establish trust.”

In closing, he noted that in 2016, the GUIA Program sent 1,322 referrals outside of Casa de Salud, and 6 case managers were able to schedule 1,500 appointments in primary and specialty care. “We really do think that a trusting relationship with the case manager is what is driving these interventions,” said Quiñones.

LET’S TALK ABOUT MEDICINES: WORKSHOPS FOR REFUGEES AND IMMIGRANTS⁴

The goals of the Let’s Talk About Medicines project, explained LaScala, was to help refugees and immigrants gain a better understanding of how to more safely and effectively use their medications and develop a comfort level around asking questions of their doctors and pharmacists. This 2-year project, she added, was a spinoff from a similar project Wisconsin Health Literacy had developed for seniors, and it features 20 workshops each year.

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⁴ This section is based on the presentation by Kari LaScala, health communications specialist with Wisconsin Health Literacy, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

During the first year, project staff facilitated workshops for refugees and immigrants in the community, while staff from the sponsoring community organization observed the workshop. “For sustainability purposes, they are now implementing the workshops themselves in year two,” said LaScala. The 90-minute workshops include interpreters and translations when needed. The goal is to have 15 to 30 participants per workshop, with each participant receiving a pillbox. LaScala and her colleagues conducted preworkshop and 60-day post-workshop assessments.

When Wisconsin Health Literacy staff was developing the workshops for seniors, they spoke with doctors and pharmacists to identify trouble spots that served as the main workshop topics. The workshop topics include

• The main parts of a medication label,
• Dosage instructions: determining how much medicine to take and when,
• Basic storage techniques,
• Strategies to remember to take medications, and
• The importance of asking the pharmacist questions.

While the topics remained the same for the refugee and immigrant workshop, LaScala and her colleagues modified the content based on feedback from community health educators at Wisconsin’s refugee organizations. For example, the workshop for seniors includes a discussion about when not to take certain over-the-counter medications with prescription medicines. This was extended in the refugee and immigrant workshop to include herbal preparations and other cures from their home countries. The refugee and immigrant workshop also includes a discussion about the differences between a pharmacist and doctor and what happens at a pharmacy. “Some of the refugees, depending on where people are from, might have gotten their medicines directly at the doctor’s office and not had to go to a pharmacy. Other times, they could just go to a market,” LaScala explained. “Often, they are not aware that to get a prescription medicine you first have to see a doctor, who writes the prescription, and then go to the pharmacy to get it.” The workshops also featured sample medications so that the participants could see, for example, what an inhaler looks like and how to measure a liquid medication.

There were many challenges to delivering this content to refugees and immigrants, particularly around language and interpretation. “We had interpreters at our workshops and that works out great, especially if it is just one language or two languages and two interpreters,” said LaScala. “But we did have one workshop where we had six different languages and six different interpreters. I left with a little bit of a headache after that workshop.” Among the languages spoken by attendees at the first year

of workshops were Arabic, Burmese, French, Hmong, Somali, Spanish, Swahili, and the Sgaw dialect of Karen (a language spoken by people from Myanmar and neighboring parts of Thailand).

Written translations were also problematic with some of the less common languages, she noted. At first the idea was to rely solely on interpreters and not have any written materials at all. However, the health educators at the refugee organizations said it would be helpful to have any kind of translations, so LaScala worked with those organizations to identify either a staff member or a community member who could be trusted to translate materials into the less common languages. In one case, the individual translating materials into Karen had to handwrite the translation because there was no keyboard she could use that would produce the right symbols. In another instance, the pre- and post-workshop questionnaires for Arabic speakers had to be adjusted to reflect the fact that Arabic is read from right to left.

Working with English language learners was also a challenge given that there were usually people at the workshops with different levels of English proficiency. When the workshops were held in conjunction with an English class, the tutors or even other attendees were often helpful. The diverse background and culture of the participants also presented challenges. Some people, for example, had been in refugee camps for years, while others were coming in as immigrants. Education and literacy levels varied widely, too, as did the experiences participants had with doctors and pharmacists in their countries of origin. The important points for dealing with the fact that every participant is different, said LaScala, is to be prepared for this diversity and to encourage workshop participants to ask questions.

Working with the 13 sponsoring community organizations was not without problems, said LaScala, though she called them “phenomenal partners.” Some of the organizations were reluctant to renew their participation in the second year given the time and effort involved in recruiting participants and organizing the workshops, the difficulty in predicting the number and language of the participants at a given workshop, and the challenge of conducting the 60-day post-workshop surveys. At least one of the partner organizations told her that they have to prioritize what they are able to do today given the current climate around refugees and immigrants. She did note, though, that she has been able to locate replacements for those organizations that were not onboard for the second year of the project.

From the questionnaires LaScala and her colleagues learned to keep explanations as simple as possible, to allow for questions along the way, and to keep the workshops interactive. Remaining flexible was important, as was remembering that a simple smile and a hello go a long way. She noted that as the participants became more comfortable in the workshops, they began asking questions and having fun. “These are serious topics, and

some of these people are suffering or have come from serious trauma or tough backgrounds,” said LaScala. “Just to have fun in the workshop is a really nice way to go.”

As a final thought, LaScala stressed that this work is important. She recounted a story from one of the one workshops. After the workshop, one of the refugee medical liaisons told her that a client she was seeing had multiple medications to manage. The liaison asked him if he could handle doing so and he said that he could because he had just attended the workshop and had his pillbox to help him organize his medications. “That was great to hear,” said LaScala. She also noted that she is working with a pharmacist in Milwaukee to create a video to provide tips on how pharmacists can communicate better with refugees and immigrants in their communities.

DISCUSSION

Earnestine Willis asked Quiñones if some of his program’s volunteers were legal experts, and he replied that the program used to hold a once-per-month law clinic in partnership with St. Louis University that brought a law firm to the health clinic to screen patients for legal assistance problems. However, the clinic recently ended that program because many of its patients reported that it was a waste of time to see someone who would tell them what they needed to do, and then tell them that they had to go see someone else to take care of their problem. “It was putting up an additional barrier,” said Quiñones. Now, the clinic recommends that its patients go directly to one of the legal assistance organizations in the St. Louis area. Still, there are significant barriers, he added. “For example, most law firms or legal assistance places, you have to call and no one picks up—it is more like leave a message and someone will call you back in English,” he explained. “Very few organizations have bilingual options. That is our experience.”

Robert Logan commented that the panelists had all spoken eloquently about person-to-person, person-to-group, and group-to-group efforts. He wondered if social media or other types of media have been helpful to any of their projects. Liou responded that using ethnic media was helpful, in part because simply posting a small advertisement gave the program legitimacy in the eyes of a salon’s employees and owner. Ethnic media also served as a useful conduit for messaging to the community at large. She and her colleagues also held press conferences for the ethnic and mainstream media to capitalize on the local champions they had developed relationships with and to get the message out to the broader community about the importance of worker health.

Quiñones said that when Casa de Salud was founded, the majority of outreach was done at health fairs and via word of mouth. For the past

4 years the organization has not had an outreach person on staff. “The majority of our patient referrals are done by friends and family, which is something unique to our Hispanic and Latino community,” he said. However, Casa de Salud is having trouble with outreach to other foreign-born communities in the St. Louis region, so the organization has redeveloped its website and Facebook page so that people can request an appointment directly from those locations.

LaScala said her program does not usually promote its workshops using social media because the sponsoring community organizations have better ways of reaching the people who would benefit from the workshops. Nelson noted that he used to worry about using social media to bring more clients into his clinic because hospital administration might question how busy the clinic was if it had to resort to advertising to drive traffic. Now Nelson said his concern is that using social media would create a repository of information about individuals that might put them at risk with regard to immigration enforcement. “I do not know what to do at this point,” he said.

Alicia Fernandez commented that the community organizing that Liou and her colleagues at Asian Health Services has done is unique, noting that even progressive institutions such as San Francisco General have not been able to duplicate the type of work Liou’s organization has accomplished. She asked Liou if she could speak about how her position is funded, how her program is funded, and how Asian Health Services sees her work as fitting into their strategic vision. Liou replied that Asian Health Services has always seen advocacy as a key piece of its mission, so there is a commitment to this particular issue because of its advocacy component. Financial support comes from foundation grants and federal education and training funds, and she noted, there is leadership commitment at the highest levels to her program.

Bernard Rosof asked Liou if she has worked with anyone outside of San Francisco. She replied that she has been in touch with a coalition in Seattle and King County, but that coalition is working from a regulatory agency model. She is also aware of smaller groups outside of San Francisco that are working on something similar.

Ruth Parker asked Nelson if the term human rights clinic helps or hurts the core mission of providing health care services. Nelson said the only time it causes an issue is when he is asked to testify as an expert witness at immigration hearings. Some government attorneys, he said, will claim he is partisan because he works at a human rights clinic. The fact is, he said, the name of the clinic puts it in harmony with its national organization, Physicians for Human Rights, which provides forensic evaluations through a volunteer network. “The way they would put it, and the way I put it, is the fact that I work in an emergency room does not make me partisan in

diagnosing pneumonia,” said Nelson. “I diagnose people with pneumonia when they have pneumonia. If someone is a traumatized refugee, I diagnose their PTSD [posttraumatic stress disorder]. If they do not have PTSD, I do not diagnose it.”

Parker then asked all of the panelists if they had any specific requests for the roundtable with regard to specific areas for engagement or action. Nelson responded that it is his sense that clinicians need more and broader education, even at the level of medical school and residency, about the issues he raised as far as talking to their foreign-born patients about torture and other traumas they may have experienced. He also said that the types of programs that the other three panelists discussed were excellent examples of how to respect an individual’s background, culture, and language skills. “I would love to have my residents rotate through all of these programs,” he said.

Liou wondered if the roundtable could help spread the word about a tool her team has developed for clinicians that aims to help them identify patients who work in the nail salon industry and then provide tips to protect their health. Quiñones said that there is currently little conversation regarding integration of physical and mental health for immigrants and refugees, and he thought a more detailed discussion on that topic and on funding opportunities for nonprofits would be useful.

Michael Villaire, chief executive officer at the Institute for Healthcare Advancement, commented that trust and engagement have to occur before addressing health literacy and asked the panelists to talk about the challenges of earning trust and engaging immigrant, refugee, and migrant communities. Quiñones replied that his organization does this in part through its advocacy activities, particularly with regard to getting medically necessary services for its patients who do not have access to public assistance programs and therefore do not have insurance.

Liou said that she and her colleagues had to step back and think about where nail salon workers and owners are coming from with regard to their fears that wearing masks and gloves will scare off their customers and put them out of business. Her approach was to hold workshops and make them fun. These workshops were not framed as health workshops, but rather as community gatherings, she explained. In one instance, her program held a Lunar New Year celebration and then started infusing some ideas about health. They also held community forums at which workers and owners could express their concerns. She noted that her program has also been building relationships with other trusted community and social services organizations.

Community organizations are where LaScala starts establishing trust. “They know they can trust us to get workshop materials to them on time, that we will respond to their questions, that we will work together to

develop a great workshop because the refugees and immigrants already have a trusted relationship with them,” she explained. She said that she can feel trust building between the community and her program over the course of a single workshop, fostered by the openness with which workshops are run and the freedom of the community members to ask questions and share their stories. Nelson agreed that partnering and working with community organizations is key and that his clinic would not survive otherwise. “We take forensic referrals and referrals for complicated, traumatized, medically complex, decompensated PTSD patients,” said Nelson, who added that the only reason these individuals will come to his clinic is because a trusted staff member at a community organization referred them. “The community organizations are where the magic happens for us,” said Nelson. The interpreters at Highland Hospital, who serve a dual role as cultural ambassadors, also play a major role in building trust with the community, he added.

Umair Shah, executive director at Harris County Public Health in Houston, Texas, remarked that the refugee health clinics run by the county health department often double as de facto community centers and provide the opportunity to engage the community in ways that go beyond providing health care. Nelson responded that he, in fact, had a meeting later today to figure out how to do just that with Highland Hospital’s refugee clinic, which is a separate entity from his clinic that serves asylum seekers. He commended the community organizations whose primary mission is to do legal advocacy for acting as de facto community centers that also provide case management services and psychological services. “These places serve as vital nuclei for those communities,” said Nelson.

Imelda Plascencia, health policy outreach manager with the Latino Coalition for a Healthy California, asked how the threat of increased immigration enforcement has affected use of services and enrollment at Nelson’s clinic, noting that her organization has heard many stories of people intentionally disenrolling from health clinics. Nelson said that the federally qualified health centers in the region and the University of California, San Francisco, have done a good job developing clear policies about who is allowed where in a facility and which areas are restricted, and in training staff about how to respond to incursions by immigration enforcement officials. LaScala said that given the current circumstances, refugee organizations are having to prioritize what they can work on with regard to the most important needs of the communities they serve.

Liou said Asian Health Services has been developing policies around the issue of private space in its clinics and training staff about how managers can respond when dealing with an immigration enforcement official. She said her organization has had patients who want to disenroll from Medi-Cal even when not warranted and is trying to encourage patients to get the services they need. It is also developing a role-play for its provid-

ers to help them answer their patients’ questions. Quiñones said that as of January 2, 2017, Casa de Salud’s policy is to cooperate fully with agents in accordance with the law. “We already have a policy in place and staff has been trained,” he said.