By NANCY FOWLER
Sept. 4, 2020
Last spring, as Avera Health ramped up to be a trusted source of COVID-19 information and help patients navigate care, the Sioux Falls, South Dakota-based health system paid particular attention to communications with non-English speakers.
Elena Cook, left, interpreter services supervisor, and Heather Armijo, a registered nurse, both with Avera McKennan Hospital in Sioux Falls, discuss a patient's status with a parent.
The system created printed materials in 10 languages including Spanish, Amharic and Korean. Nonprofit agencies tucked the guides into outgoing care packages for immigrants and refugees. After putting the same translated information on topics ranging from social distancing to coronavirus symptoms to testing availability online, Avera staff emailed links to individuals and families.
The system also assigned medical interpreters to areas of in-person contact such as emergency rooms and the bedsides of the hospitalized to communicate reliable and clear coronavirus information to non-English speakers.
The system's flagship facility, Avera McKennan Hospital & University Health Center in Sioux Falls, normally has three Spanish-speaking interpreters on staff. It also contracts with local agencies deaf-language services. Staffing was challenging because in March, before Sioux Falls had any confirmed coronavirus cases, some of the staff and contracted interpreters worried about exposure to the virus and left their jobs, according to Julie Ward, vice president of strategy and social innovation.
"They were afraid to come into the hospital and work," Ward said. "They didn't want to bring COVID-19 home to their families."
Fear and misinformation
Initially, having fewer interpreters wasn't a problem; hospital traffic was lower because non-essential procedures had been postponed to clear capacity for COVID patients. "But then we started to see an uptick of cases in our diverse communities in Sioux Falls," Ward said. "And we really needed to get creative and act quickly."
By April, in addition to using CyraCom, a company which provides phone and video interpretation in 200 languages, for hotline and inpatient communication, Avera McKennan had contracted with a total of eight interpreters who live in the Sioux Falls area. Most of them were native Spanish speakers. Every day, at least two of the interpreters staffed the systems busy COVID hotline. Two more interpreters worked at the hospital's COVID testing site and others worked in the emergency department. It became especially important to have in-person interpreters on hand in cases where literacy level was low and printed materials were of little use.
The April surge in positive coronavirus tests largely was tied to a single hot spot, according to Elena Cook, interpreter services supervisor at Avera McKennan. "We needed to be prepared," Cook said. As more non-English-speakers called Avera's COVID-19 information hotline, the hospital increased its reliance on CyraCom.
But a potential crush of serious COVID cases requiring hospitalization did not materialize, hospital officials said. Instead, many patients were able to be treated and convalesce at home.
The Sioux Falls Argus Leader newspaper reported in early June that while minorities, including Hispanics, Blacks, Asians, American Indians and others, accounted for 70 percent of South Dakota's coronavirus cases, they only made up roughly 17 percent of the state's population.
Masking facial expression
To reduce the risk of infection transmission, interpreters and other hospital staff will be required to wear masks for the foreseeable future. And while essential for safety, masks can interfere with non-verbal communication through facial expression.
"A lot of what an interpreter does is based on body language," Cook said. "Also, it can be a challenge when a person can't see the interpreter's mouth."
Wearing a mask all day can also make it difficult for the interpreter to be comfortable as they work. "It's easy to get overheated," Cook said. "And you have to speak much louder because you want people to hear you."
Misinformation was another communications hurdles. A common misconception among hotline callers early on was that if they didn't have symptoms, they couldn't have a positive test result.
"The interpreters had to work to make sure they knew that you could still have COVID-19 and be asymptomatic — and that that's why social distancing and masks are so important," Ward said.
Many were especially confused about how to react to getting a positive test result at a testing site or in the emergency room. "Some thought that they immediately needed to get in their car and drive to the emergency department," Ward said.
An unexpected benefit of bringing in the new interpreters from local agencies to boost staffing was that some turned out to be trusted members of their communities, which put callers at ease.
"There was an instant recognition factor that took calls from 45 minutes down to 15 minutes," Ward said.
Lifelines for immigrants and refugees
The Spanish-speaking immigrant community in the Canton, Ohio area has for 15 years looked to Mercy Medical Center as a resource for health and other concerns. The hospital's Immigrant Health Outreach and Language Assistance program provides in-person interpreters as well as a phone line that Spanish speakers and those who speak other languages can use to access health care information.
Callers began to ask about COVID-19 symptoms and testing in the spring, according to Sr. Carolyn Capuano, HM, vice president of the hospital's mission and ministry services. "Many were scared," Sr Capuano said. Mercy Medical Center is part of the Sisters of Charity Health System.
Thus far, those who've tested positive for COVID-19 have been spared serious complications, and none have been hospitalized, Sr. Capuano said. The immigrant outreach program continues to encourage mask-wearing and social distancing, but that can prove difficult for those living in crowded conditions.
Many of the program's participants are undocumented and wary of interacting with institutions, fearing deportation. But Mercy Medical has over the years built up trust within the community that has been helpful during the pandemic.
"We have been a kind of lifeline for them," Sr. Capuano said. "They know they can call up the coordinator of the program on her cell phone and ask her questions and tell her what's going on."
Changing social habits
In Phoenix, Dignity Health St. Joseph's Hospital and Medical Center and Catholic Charities' Refugee Resettlement Program are assisting hundreds of non-English speakers through an organization called the Refugee Health Partnership. The hospital is a member of CommonSpirit Health.
The Refugee Health Partnership – a collaboration between Dignity Health, Catholic Charities, the International Rescue Committee and the Arizona State University Morrison Institute for Public Policy -- helps refugees who have chronic or serious health issues. Working in conjunction with interpreters, the partnership ensures refugees can navigate the health care system. In the spring, the partnership also began to focus on making sure its clients understood about the importance of masks and social distancing to reduce their risk of contracting coronavirus, according to social worker Cheridy Clement.
Clement said it is common custom for multiple generations of immigrant families, or multiple families to dine together. "Ultimately, people are understanding the importance of social distancing."
Health care workers and refugee case managers rely on interpreters to assist when speakers of Swahili, Arabic, Farsi, Burmese, Spanish and other languages, express apprehension about COVID-19 testing procedures, particularly the use of the nasal pharyngeal swab. "Our providers and staff take the time to explain to the patients how the test works," Clement said.
Clement said there has been no tracking of COVID-19 cases among clients of the partnership. Joanne Morales, Catholic Charities' director of refugee programs, pointed out that "being socially and economically disadvantaged can put somebody at a higher risk for COVID."
Some of the families that the Refugee Health Partnership works with are suffering ripple effects of the pandemic, Morales said. Many who worked in manufacturing, at Amazon and in the hotel and service industries lost their jobs when the economy shut down.
"I really feel for those newly arrived refugees who had a lot of aspirations when they first came," Morales said. "The first thing they think of is education for their children and being able to work, to build a life and have opportunities here."
Some are back at work now, helping the local economy recover, Morales said.
"They're giving back, even at risk to their own health."
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