Immigrant and Refugee Experiences of Healthcare Access and Wellbeing During Covid-19 in Vermont: A Qualitative Evaluation

doi:10.21203/rs.3.rs-1975914/v1

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Research Article

Immigrant and Refugee Experiences of Healthcare Access and Wellbeing During Covid-19 in Vermont: A Qualitative Evaluation

https://doi.org/10.21203/rs.3.rs-1975914/v1

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Background

Refugee and immigrant communities all over the world have been historically underserved in health and social services and more negatively impacted by policies meant to address crisis rather than focusing on preventive care and culturally sensitive services. The lack of culturally responsive services coupled with systemic discrimination faced by refugee and immigrant populations are amplified during the Covid-19 pandemic. Perspectives from refugee and immigrant groups are often lacking in the published literature. This qualitative evaluation includes focus groups with five distinct refugee and immigrant communities who shared perspectives on their experiences accessing healthcare during the Covid-19 pandemic in Vermont.

Methods

A total of 114 participants who identify as refugees and/or immigrants, and who reside in Vermont, participated in 10 focus groups representing the following five different cultural groups of refugees and immigrants: Nepali/Bhutanese, Congolese, Somali/Somali Bantu, Burmese and Arabic. Cultural brokers or community case managers helped recruit participants and assisted in the focus groups providing interpretation and translation services. Focus groups took place remotely via online platforms. Although focus groups were conducted in English, interpreters were present and focus group guides were translated to the languages spoken by the aforementioned groups. Focus groups were audio recorded and transcribed with patient confidentiality maintained. Four themes were identified through a process of thematic analysis as identified by Braun and Clarke.

Results

Participants encountered several challenges in having meaningful interactions with health care providers and found it difficult to schedule appointments. Interpretation and translation services were also sporadic and inadequate. Interpretation was most reliable via Telehealth and Zoom calls, yet most participants did not experience this as an ideal format for health care. Participants shared their experiences with Covid testing and vaccination. Although some reported positive experiences, many participants communicated barriers in the process and shared experiences of discrimination. Although vaccine hesitancy was expressed by some participants, some also felt eager and hopeful about the Covid-19 vaccine.

Conclusions

Refugee and immigrant participants encountered many challenges in accessing health care during the Covid-19 pandemic. Discussions with the community and trusted cultural brokers created space for shared solutions and patient-driven ideas for care improvement.

Refugee

immigrant

cultural competency

healthcare access

equity

Covid-19

cultural brokers

When conducting research into Coronavirus related deaths in Great Britain, the Nuffield Foundation found that hospitalized Bangladeshi immigrants living in England have died at a rate twice that of white-British residents, while hospitalized Pakistani immigrants living in England died at a rate of almost three times that of white-British residents (1). Furthermore, the same research found that hospitalized black-Africans died at a rate nearly four times that of white-British residents in England, even though black-African persons living in England on a whole have a population of younger individuals, which should put them at less risk of complications leading to death from Covid-19 (1). While these statistics may present that health epidemics mainly affect historically vulnerable populations, the International Organization for Migration (IOM) suggests that a lack of quality services provided to immigrant and refugee populations can cause a greater risk of outbreak and sustained pandemic conditions for the larger population in which the underserved community cohabitates (2). Therefore, by providing inequitable services and treatment to traditionally underprivileged populations, there is a greater risk to the society at large for contracting illness and death, and the conditions of the pandemic will have greater chances of being prolonged.

Culturally humble, competent, relevant and sensitive care approaches are essential, and should include interpretation and translation services, and non-biased, patient-centered treatment (3). These practices are especially essential during Covid 19 and are critical in the prevention of Covid 19 transmission. Culturally humble and responsive care should ideally address barriers to care for the most marginalized. Access to mobile medical facilities for instance, is one approach for those with transportation challenges as well as telehealth service access complete with proper interpretation and translation support (2–4).

Immigrants and refugees experience challenges accessing health and mental health insurance due to limited health care access, often related to low wage incomes (2). Furthermore, vulnerable groups who are in the process of acquiring permanent residency and citizenship in countries in which they are new to are not always eligible to the same benefits of public assistance programs available to residents of a given country (2, 4). Lack of access to equitable and culturally competent care systems is associated with high infection rates in refugee and immigrant populations. Race, culture and ethnic is often “blamed” for high infections rates when in fact the reason for this is lack of access to quality healthcare. Public perceptions can then burden immigrant and refugee communities with experiencing higher rates of racism and discrimination as a result (5). The combination of racism and discrimination and lack of access to quality health thereby further marginalizes and harms individuals and communities already vulnerable to poor health outcomes. Providing optimal and quality care to immigrant and refugee communities can also mitigate the spread of Covid 19 to other communities.

Beyond access to healthcare services, immigrant and refugee communities face significant socioeconomic challenges. In many cases, both refugee and immigrant community members live in close quarters with one another, with many multigenerational individuals living together in single family homes, posing extreme challenges implementing social distance and self-quarantine protocols (1–3, 6–9). To further complicate matters for immigrant and refugee populations, federal and state mandates that shut-down work sectors tend to heavily target earners from vulnerable populations, causing additional income inequalities in a time when resources are limited (4).

Although immigrant and refugee populations face many challenges during a pandemic, including lack of culturally sensitive services, adequate financial resources, and access to essential housing and hygiene needs, additional barriers may yet supersede these issues that include clear communication between vulnerable groups and public service centers (3, 5, 7, 10). The timely delivery of accurate and understandable health information to the public is vital to any public health protocols yet those with limited English language proficiency an/or limited access to media are the most challenged in receiving in these messages (3, 5, 10). Unfortunately, in times of crisis, the most vulnerable populations who bear a disproportionate burden of health impacts as a result of Covid-19, are not involved with the planning and implementation of policies (3, 5, 11). Even in states such as Vermont, that at one point during the pandemic, were heralded by Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases as being examples of a successful COVID response, underrepresented groups are still disproportionately affected (10, 12). In 2020, Winooski, Vermont had a surge of COVID outbreaks in refugee and immigrant communities due to poor communication and education concerning the virus and contagion prevention strategies to populations of English learners. This was reportedly due to lack of proper information interpretation and translation and underfunding of services to vulnerable groups to assist with mitigating the spread of the virus to communities of non-native Vermonters.

In addition to improving communication and education for marginalized groups, organizations that both represent immigrant and refugee communities and are led by them need to be heavily involved in the planning and implementation stages of any policies or aid meant to mitigate risk of illness and promote mental health (5, 10, 11). There were two main objectives of this study: (1) to identify and address barriers to healthcare during Covid-19 for immigrant and refugee populations and (2) to involve community members to develop solutions to address barriers to care.

We conducted 10 focus groups comprised of individuals who self-identify as immigrant and/or refugee community members living in Vermont. This study was exempt from IRB review due to the focus on operational improvement. Five different refugee and immigrant communities were represented in the overall sample and included Nepali/Bhutanese, Congolese, Somali/Somali Bantu, Arabic Speaking and Burmese communities in Chittenden County, Vermont.

Study Design, Setting & Participant Recruitment

This was a cross-sectional, exploratory, qualitative study. Due to Covid-19 restrictions, focus groups took place remotely via online platforms. Cultural brokers and/or community case managers/interpreters recruited participants and assisted in the focus groups by providing interpretation and translation services (as required by state and federal laws). Focus groups ranged from 8 to 14 participants and participants were grouped into focus groups based on language preference and their cultural/ethnic group which they identified with. The Somali/Somali Bantu focus groups were scheduled with gender specific groups to respect cultural practices in those communities. The focus groups took place during the weekends at the request of the communities who participated in this study. Each focus group was recorded with participant consent and lasted approximately two hours. Focus groups were conducted first in English, with focus group guides having been translated in the languages spoken by each community group, and simultaneous interpretation took place at every session. Participants were compensated with a $50 gift card for their participation.

Data Analysis

Focus group discussions were audio recorded and transcribed (with the aid of interpreters). The interdisciplinary team conducted a thematic analysis informed by Braun and Clarke’s qualitative methodology (13, 14). Using an iterative process, we selected a primary coding schema, informed by our literature review, and independently coded transcripts. We then met in groups to discuss and reconcile codes, identify themes and came to a consensus. Through our iterative coding process, we identified four themes.

Participant demographics are summarized in Table 1. A total of 114 adults participated in the 10 focus groups conducted, which represent the following 5 community groups: Arabic, Nepali/Bhutanese, Somali/Somali Bantu, Central Africa/Swahili Speaking, Congolese/Swahili/Lingala Speaking. The ages of participants ranged from 20–66 years. Twenty participants identified as single parents. Qualitative results are presented below as four different themes.

Table 1

Sample Characteristics
Ethnic Community Represented	Sex		Age Range	Totals
Ethnic Community Represented	Female	Male	Age Range	Totals
Arabic	12	1	29–66	13
Nepali/Bhutanese	13	4	27–45	17
Somali/Somali Bantu	26	0	25–56	26
Central Africa, Swahili Speaking	18	17	20–55	35
Congolese-Swahili/Lingala Speaking	10	13	N/A	23
Total	79	35		114

Theme 1: Access to culturally sensitive healthcare during the COVID-19 pandemic.

When attempting to contact health care providers, many interviewees expressed difficulties, including with appointment scheduling, as described by one participant, “I have a problem…calling the [health center], two or three months they never answered me.” One major barrier is that many members in the community have limited English proficiency, and interpretation services are often unavailable to aid in communication with doctors and pharmacists, as one person stated, “during this COVID times it is difficult and challenging to reach out to doctors and pharmacies by calling over the phones especially for people who have no English or limited English.” Many focus group members reported calling several times to try and set up an appointment or be consulted on the next course of action if they needed testing or how to properly quarantine, but received no return calls, or would be transferred several times to make appointments or to follow-up on appointments that had been canceled due to the pandemic.

For example, as noted by a participant, “it was difficult to contact my doctor… I went there because there was [a] lot of misunderstanding as I was not able to contact… the hospital… I was totally confused what I should do… there wasn’t a response from the [health center]; I had left voice messages… 3 or 4 times a day but I did not get any reply. Finally, I went to the hospital… but they asked me to go back home and wait for them to contact me… it was a very difficult experience for me to contact the hospital.”

Participants discussed miscommunication between themselves and care providers; they also shared experiences where they made attempts to contact care providers who they felt were completely unresponsive, as expressed by one participant: “I didn’t know that the hospitals or clinics were closed so I tried to set up an appointment but… there was no response and they gave this number to call to schedule an appointment but there was no response so I didn’t end up setting up any appointment.” Poor communication has deterred community members from accessing care, as one person noted, “all three of us have not been able to contact our family doctor yet. I don’t know English and I don’t understand what they ask in English.”

This lack of timely communication caused interruptions in obtaining necessary prescriptions; such as one patient who was trying to refill a prescription for asthma, “I want a medicine from the doctor and I [had] been calling the hospital for a long time, at least a week, I wasn’t getting any answer.” The patient was informed by the hospital that they would contact the pharmacy to refill her prescription, but the patient was not contacted concerning the progress or process of refilling her prescription. During the focus group meeting, the interpreter for a participant stated, “she didn’t get a hold [of] the doctor so she went to the pharmacy… the pharmacist informed [her] she cannot get the refill until the doctor prescribed [it] for her… the pharmacy help[ed] her call the doctor… the doctor answer[ed]… ‘I cannot give you a refill because I haven’t seen you for… six months.’” This lack of timely communication caused the patient to experience considerable discomfort as a result of having asthma that went untreated, and inevitably, increased their risk for Covid-19. Community members shared that they continued to encounter barriers when attempting to contact health care professionals. Participants shared that there were sporadic interpretation services provided to patients when they were able to make an in-person appointments. Although, patients found more consistency with receiving guidance and language interpretation via interface programs such as Zoom, many participants expressed challenges with technology and with online platforms, as expressed by one participant:

“during the COVID-19 pandemic… the services are okay but it’s hard… with the Zoom or Telehealth services, I would rather have it in person… because it’s very challenging.”

Another participant agreed, “I wish they would allow at least… the kid and one guardian… go in person to do the checkup because through Zoom, how do I know if my child’s vision is good or like hearing well.” One participant expressed concerns with doctors not being able to treat her mother’s health issue properly over a Zoom call, “my mother-in-law had [a] throat problem, and when she tried to connect with [the] hospital, they just did Zoom… but how can you show your throat in Zoom?” In each focus group, there was an overwhelming concern that needs were not being met when communicating over Zoom, both because of technology barriers, especially for elderly or non-literate members of the community, and because patients did not feel that their symptoms and ailments could be fully expressed without an in-person meeting. One participant stated, “are the doctors going to see this report and see the recommendations that Zoom is not working, so would they stop using Zoom?” This sentiment was shared by another participant, “with Zoom it’s really hard for people in our community especially who don’t read or write. The instructions… how to do Zoom meetings or appointments… but it’s still hard to follow the instructions.” The English only availability of Zoom instructions further complicated this issue for participants. One participant summed up their feelings about using Zoom for healthcare:

“We don’t know anything about Zoom; we don’t know how to open the Zoom, how to use the Zoom; we know nothing about the Zoom. There can be many individuals who are like me who do not know anything about Zoom and how to use it.”

Theme 2: Quality of Health Services in Vermont and Partnerships with Immigrant and Refugee Communities.

All focus groups reported long wait times, whether they were being seen at a health care facility or at a Coronavirus testing center, as one person noted, “I felt very sick and… went to the emergency, and… stayed 4 hours without help. There [were] so many people in the waiting area, no masks.” This sentiment was echoed by another participant who stated, “I have a challenge at the hospital, waiting time, 3 to 4 hours.”

Focus group members did report positive experiences at the testing centers both with interpretation services and in obtaining help with filling out forms. An interpreter from one focus group offered, “the testing site… for them… was well done, [there] was an interpreter there.” Other focus group members praised the conduct of the testing sites, stating, “this is the best thing… making… testing sites available to everyone, with or without registration, it was very comfortable.” Also, one participant shared, “there’s an interpreter on site, so the interpreter helps us with filling out the forms.” For most Somali community members, the entire testing process was very successfully handled, as noted by a participant who stated, “For me going to the testing site I didn’t have any problem, I went there and there [was] a Translator that helped me with the application and testing.” Another Somali community member added: “I didn’t have any problem… everything was smooth… after four days [I had] a letter translated [in] Somali and English saying the testing was negative.”

The most significant issues presented were the amount of paperwork that needed to be filled-out for each family member for Covid-19 testing (many participants, as mentioned, have large multigenerational family units), together with limited English-language proficiency, added more challenges to the process, as noted by one participant, “there’s a lot of paperwork… like three-four forms. And I think it’s very difficult when you don’t speak English to fill all those forms.” Another participant stated, “I went to the testing site and… [it] was all in English… They should have someone there to translate but they didn’t have anyone there to translate.”

Some participants expressed a possibility that translation and interpretation services became less reliable later into the pandemic timeline, for example, one participant shared, “we had interpretation… from the beginning to the middle… I don’t know what happened [in the] last two months but before… they had interpretation.” While most reports on the testing centers were positive, some focus group members from the Nepali community had very negative experiences, as shared by a participant who stated that:

“I also went two times for the corona testing…interpreter was there, still we don’t understand a lot. I had a good experience the first time, but the second time, I felt that we were treated differently than the local American people…when they direct[ed] us to come this or that way, they did it in a disrespectful way, their disposition was bad…they did test…on me…also…not gently…blood came out of my nose…since then, I stopped going for the testing.”

Other Nepali participants expressed similar sentiments, as stated by one participant, “While testing, people bled sometimes… we fear that maybe they will hurt us more… and cause more infections. So, because of such fear, we did not go to the testing sites.” Another Nepali participant shared that, “People mistreated us, humiliated us and even at [the] hospital they would ask if we were corona positive before or not and if yes, they would ask ‘what did you do that time?”

Another obstacle was getting children to get tested as the swabbing process could be quite painful, as one participant noted, “we had to hold our daughter real tight and fight to do the test… when she was sick the second time… she did not want to go to see the doctor… she was impacted psychologically due to her COVID test experience.” For some families, the long line for Covid-19 testing was in itself a barrier, as one participant shared that “I’ve been to the testing site… a couple times-the first time was in the summer, it was very hot, and the line was very long… I couldn’t get tested that day because my kids were in the car and it was very hot that day.” Another participant shared that, “I never went to the testing site because the wait is long.” A participant who identifies as Congolese shared that “sometimes when they [have] symptoms, they want to get tested, they don’t know where to go. Even [if] they give them the address… they don’t know… that place.”

Some focus group members expressed challenges with how they were treated in seeking health care, and shared experiences of either not being able to get tested or being refused an in person visit because of unreasonable suspicion of acquiring Covid. As one Arabic speaking participant noted:

“I have to beg care providers… to… test me… they said I do not have high temperature and I did not have the regular COVID symptom[s], even the doctor was examining me without [a] mask… I begged them… To test but they were refusing, and after walking in at a testing site, I ended up being positive.”

An interpreter from the Somali focus group explained that one community member had issues with constant itching on her hand and simply wished to try a different topical cream to alleviate the itching. When she called to make an appointment with a doctor to update the prescription the following happened: “she said that I want to set an appointment and… the person who was… [on] the phone said… ‘I cannot make… an appointment because you sound like someone with COVID-19 and you cannot come here.” Although many community members reported positive experiences with the testing centers, and there were a few members of the focus group who stated that they were well cared for at their health care facilities, several reports suggest a lack of interpretation and quality care practices that leave community members with a poor impression of the kind of care they can expect to receive. This is discouraging, especially in the time of a pandemic when there is a great deal of uncertainty and anxiety surrounding health issues and weighing the risks of getting tested against the risk of infection by spending long hours at a health care facility.

Theme 3: Health Behaviors Surrounding the Pandemic, Causal Challenges and Vaccines

Although each focus group professed that there are a multitude of preexisting health conditions that increase risk of acquiring COVID within their communities, they mentioned high blood pressure, diabetes, heart conditions, asthma, allergies, cancer and especially irritable colon syndrome for the Arabic communities; asthma and diabetes was prevalent for the Congolese community, who also shared that HIV is a concern within their community.. Focus group members reported that high blood pressure continued to be a concern after the pandemic was in effect due to the stress and lack of exercise as many community members did, in fact acquire Coronavirus and had to self-quarantine, not leaving the house for work or physical activity, as one person shared, “I had tested COVID positive and also my mother-in-law was COVID positive… I was a new mom with just [a] one-month-old child when I was affected by Coronavirus. I was in [a] lot of stress.” Additional stress may have been a factor in personal health as many infected members had to quarantine in a house with non-infected family members, which made quarantining difficult.

Other community members reported mental health strains due to isolation, as one participant stated, “we were isolated in our house for more than 5 months; we are seeking therapy because no one asked about us and no one contacted us. No provider called us; no social worker checked us.” Another Arabic participant stated that due to the new living conditions in a pandemic, “I am using sanitizers all the time until I have allergy now. I have anxiety. Depression… media has [a] very big role in destroying our psychological condition hearing about death rate every minute in the news.” Although, many of the immigrant and refugee communities admitted high rates of COVID infection, many of them seemed to have a basic understanding of the vital precautions to take to stay safe during the pandemic, such as, “washing hand[s]… and sanitize the mask… observe the social distancing, because in our culture we are always close to each other.”

Many participants were most concerned for the elderly and children in their community, as one person noted, “for the adult, the prevention education is pretty clear… But for the elderly, it might be difficult, but it is especially harder for young kids… someone says… ‘you cannot give a hug…’ he wouldn’t listen.” Another member of the Burmese focus group agreed, stating, “it is really hard for younger children to follow social distancing… their masks are going down when they talk, and… we have to remind them ‘pull your mask up.” Another Burmese community member added, “with the younger kids, it’s really hard for them… they have to stay home and [can’t] play with friends… from their point of view, their stress level is very high and they are getting depressed at the same time.”

Community members worry that the isolation inside the home and lack of social time for their children is having serious effects on their mental health, as one person shared that “the issue of stress and depression is very present for the young people… they… always used to go out and play… but now… They are just in [the] house.” For the elderly, “because of COVID-19, my mom’s stress level is very high because she gets really scared… and she’s been staying home and… not been going outside.” Additionally, a participant stated that the “elderly got very scared and stressed when they heard they are the most vulnerable.” Many community members have had their physical activity, (a natural stress reliever), reduced greatly due to the pandemic.

Community members also experienced higher levels of stress and risk of mental disorders without their usual coping mechanisms to remedy these issues, as one participant noted that “to… play soccer… together that’s how we actually… talk and it’s… our own way of counseling each other.” Arabic community members expressed concerns for becoming obese due to their current living conditions, stating, “the problem is eating too much and gaining lots of weight… and this increased obesity.” Loss of work and income insecurity compounded an already stressful situation for many community members as well, as one person shared that “it was a challenging time for me too. I am a single mom; my two kids were sick; there was no job due to the pandemic; I pay rent by myself only… I had to apply for a food stamp.” Unsurprisingly, community members added that, “they are confused… too much fear… and a lot of stress because they are alone.” Community members also stated, “we are feeling very miserable. Because of the social isolation. We are almost getting crazy, not able to socialize with anyone.”

Theme 4: Vaccine Hesitancy

Concerning the Covid-19 vaccine, most community members were optimistic about taking it, stating, “many people are looking forward to it.” Other focus group members insisted that, “if the government can bring out vaccines for this virus and provide us as soon as possible, it would be great.” Another participant stated that, “I will take the vaccine if it becomes available,” a sentiment shared by another participant, “I will take it and give the vaccine to my family.” Of course, the majority of focus group members from all the communities asserted that they needed be sure that the vaccine was safe for use, and many inquired about possible side-effects, especially for persons with asthma or allergies, as stated, “I’m concerned for my children… for vaccine when they get it, can they get… side-effects… if someone has asthma, can they get the vaccine, or will it make it worse?” Understandably, community members experienced limited or confusing messaging concerning the vaccine, as one participant stated, “the media, they are contradicting each other about vaccines making some people sick… Are they going to work or make me sick? I am really worried and confused.” Another participant shared that, “I would love to have information about the vaccine before you take a shot because that vaccine could… make you sick or something.” The most resistant arguments against the validity of the vaccine came from the Congolese focus group, as one participant shared that “People… are not supposed to get the vaccine. They will take this vaccine only if they know that this vaccine cannot… change the DNA for people… most people are opposed to this vaccine… It is a problem of trust.” The interpreter for the focus group added, “they don’t trust the vaccine because they don’t know exactly if [it] is the right vaccine or not.” Although, most community members are hopeful that the vaccine will bring an end to the pandemic and the stress and isolation that come with it, others are hesitant to trust a vaccine because of fears of being targeted by institutions that have proven to act against underprivileged populations in the past.

Participants encountered several challenges having meaningful interactions with health care providers and found it difficult to schedule appointments. Interpretation and translation services were also sporadic and inadequate. Documents and forms were mostly sent to individuals in English, while many patients have English literacy challenges, creating further burdens when attempting to receive care. Interpretation was most reliable via Telehealth and Zoom calls, but due to technology proficiency inconsistencies and access to technology for vulnerable groups such as the elderly, the community insisted that Zoom not be the main form of health care interaction. Participants did not see the value of such interface systems for proper check-ups or diagnosis. Because of many of the above issues, some community members experienced interruptions in receiving vital prescriptions.

Although, most community members acknowledged that testing centers provided far better service and were more reliable for interpretation and translation assistance, there were instances where some community members experienced disrespectful treatment. This finding is significant in that it corroborates other scholars who have also found that discrimination is health care is prevalent, and harmful to the health and wellbeing of refugee and immigrant communities (2, 15). Nearly all participants shared that most visits to health care providers or testing centers had extremely long wait times. Participants did state instances where they were receiving aid such as food supplies and stimulus checks, but there were several reports suggesting that when seeking support from local and state officials, little assistance was given, and communication was largely non-existent. The community also voiced that reliable, accessible information was slow to reach them, and they heavily relied on community leaders in the form of cultural brokers or case managers to disseminate useful information in a method that they could easily understand for multiple language and literacy proficiency levels and technology aptitudes. There were also cultural and trust concerns that needed to be adhered to that the cultural brokers could navigate them better than authoritative organizations or officials.

The participants from these communities had several useful suggestions to improve care for themselves, and potentially for the general public in the near future or should another pandemic occur. One such suggestion is having easily accessible forms available either online or in a public space where community members can obtain them and complete them before going to a testing center or health care facility. This will also give community members ample time to seek assistance with translation. Also, the community has expressed a desire for reduced paperwork when seeking services, especially for occasions when multiple members of the same family are being tested or treated. Perhaps the guardian could fill-out a family form if much of the information is the same for most or all of the family. Furthermore, care facilities need to improve their ability to provide interpreters and translated documents as required by law3. Having easily accessible files in multiple languages that all employees are well trained to access and navigate is vital as the region is increasingly diversifying and failing to properly serve any community, puts the general population at greater risk during a health epidemic. The community also strongly opposes organizations’ sole reliance on Telehealth and Zoom. Community members with limited access and proficiency with technology may require more traditional forms of interaction such as phone conversations and in-person treatment when possible. Automated Alert Systems that leave phone messages or texts to the public similar to those used for at-home school announcements was another feasible suggestion by community members. Furthermore, the hospital should create an assessment policy that inquires whether patients’ needs were met during their visit prior to discharging them. Perhaps the patient should be asked to explain back to the health care professional what they understand about their condition and how both parties will take actions to remedy the patient’s illness. There were multiple reports of community members or their family members seeking treatment and not being able to recall information given to them, diagnosis, therapies, references, or medications.

Communities also need supports to recruit and retain community leaders or cultural brokers from their respective communities, who can build trust and who are versed in a similar language and cultural background in order to effectively advocate for their communities. Community members also need to have more of a partnership role and presence in care facilities and government roles to build trust and engagement between underrepresented populations and the organizations that are meant to serve them. The community also expressed a desire for more direct engagement with them from public officials through refugee and immigrant serving organizations and/or programs. For persons who have either acquired COVID or have been tested, follow-up communication and check-ins would be extremely helpful, especially consultation follow-up that includes mental health services and recommendations.

Ethics Approval and Consent to Participate

This study was deemed exempt from Institutional Review due to the quality improvement goals of this research by the Institutional Review Board of the University of Vermont.

Availability of Data and Materials

The datasets used and/or analyzed during this current study are available from the corresponding author on reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Funding

This project was funded in part by the Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB) grant number T7300039. The views presented in this article are those of the authors and do not necessarily represent those of the funder.

Authors Contributions

CV (corresponding author) contributed to the analysis, writing, editing and revisions of this manuscript. MA contributed to the design and methodology of this study, including data collection, analysis, and writing of this manuscript. SD and TC contributed to design, data collection, analysis and writing of this manuscript.

Acknowledgements

We wish to acknowledge and thank members of the refugee and immigrant communities that participated in this project and who shared their experiences and knowledge with us.

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Immigrant and Refugee Experiences of Healthcare Access and Wellbeing During Covid-19 in Vermont: A Qualitative Evaluation

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