Institutionalizing Communication Standards with Limited English Proficient Populations Sara Chute, MPP, International Health Coordinator Alexa Horwart, Graduate Fellow Minnesota Department of Health

Overview Background/Need for project Promising practices at MDH Institutionalizing the model Challenges and Lessons learned Next steps

Setting Decentralized public health infrastructure – 87 counties – 10 tribal health jurisdictions Eight public health regions Statewide videoconferencing capacity Multi-cultural communication venues exist

Distribution of Foreign-Born Populations by Region of Origin, U.S. and MN 2010 United States N = million (12.5%) Minnesota N = 357,561 (6.8%) Source: Migration Policy Institute, Minnesota Fact Sheet

Refugee Arrivals to MN by Region of World Refugee Health Program, Minnesota Department of Health

Primary Refugee Arrivals, Minnesota 2012 N=2,264 Refugee Health Program, Minnesota Department of Health “Other” includes Belarus, Cameroon, China, DR Congo, Cuba, Eritrea, Guatemala, Indonesia, Iran, Ivory Coast, Kenya, Laos/Hmong, Liberia, Mexico, Moldova, Nepal, Russia, Sudan, Tanzania, and Ukraine

Foreign-Born Population Minnesota, 2011 In 1960, more than 50% of of foreign-born Minnesotans were from Europe. In 2008, just 13.8% of foreign-born Minnesotans were from Europe. Source: 2011 ACS

Key Assumptions Health disparities exist LEP populations are at risk Communication barriers such as language, trust, culture, and low literacy levels exist There are champions of work in this area and best practices across MN and the USA

Project seeks to address: How do LEP groups learn about health issues? How to break thru barriers like language/culture? What are creative ways to deliver health messages?

Project Background and Need H1N1 Accreditation Demand within MDH

Examples of Promising Practices Local Media and Health Promotion

Lessons learned from H1N1 Created during H1N1 to aid in prioritizing communities for audio/written/video translation Potential use beyond emergency preparedness Language Prioritization Grid

Example: Minnesota’s Grid created during H1N1 Lesson learned: MDH needs more than a static grid and ‘top 10 list’ Hence project was born

Examples of Data Sources used Census 2010 – American Community Survey 5, 3, and 1 year estimates Minnesota Department of Education – Student Survey Minnesota Department of Health – Refugee Health Program data – Birth Registry data Minnesota State Demographic Center

LEP Communication Needs Examples: Hmong, Somali and Karen communities Lesson learned: one ‘health literacy’ size does not fit all

Demand within the department implementing federal and state grants conducting research projects disease outbreak calls/investigations emerging health issues

Often includes: Health education Promotion activities Resources MEASLES BED BUGS Skin-lightening Creams AUTISM RHP works with refugee communities to develop appropriate response Goal: To create healthier, happier refugee communities and help promote healthier lifestyles. HEALTH ISSUE EMERGES

Promising Practices Continued Community-Led Health Education

Institutionalizing the model throughout the department What elements are needed?

Element #1: Develop Sustainable Framework Evolution of statewide grid Lessons learned: Evaluation of key data indicators is critical Graduate students are key to success with limited $/staff County demographic “mini-reports” or dashboards LEP group demographic “mini-reports” Larger city demographic “mini-reports” Community survey creation and analysis MDH survey creation and analysis MDH case studies creation Community conversations MDH stakeholder conversations User Guide for MDH staff

Element #2: Creating a Shared Space Online ‘intranet/web’ resource hub Lesson learned: Need communications support early on How to identify LEP populations How to gain a deeper understanding of LEP groups Available resources for reaching LEP groups – Existing materials – MDH champions – Community outreach How to implement your idea (tools and templates)

Online Tool: MDH Intranet Page

Identifying LEP communities

Gaining deeper understanding LEP group backgrounders List of organizations representing communities List of trusted messengers by group* Effective format information by group* Lesson learned: It’s easy to create beautiful workplans and project documents, but the reality is that compiling this information will take longer than your Phase I, II or 3 * This information will come from community surveys, community conversations, and past focus groups

No need to reinvent the wheel! Identify existing materials – Refugee Health Information Network – Healthy Roads Media – MDH (existing fact sheets, videos, etc.) – Health Exchange Look to MDH Champions Links to national ‘best’ practices for how to co- create and collaborate directly with LEP groups Listen to Community Advisors

Element #3: Gain Internal Support from Leadership, Managers and Staff

Work across silos! Partners and advisors at MDH Refugee Health Program LEP Communications workgroup Health Communicators workgroup Public Health Infrastructure Initiative Center for Health Promotion Office of Minority and Multicultural Health Office of Emergency Preparedness Office of Performance Improvement Office of Health Statistics Communications Lesson learned: need to integrate into existing workgroups rather than start from scratch

Example: In 2012, MDH commissioner called for a new Public Health Infrastructure Initiative, with cross-divisional representation whose charter included eliminating health disparities and achieving health equity In 2013 a Health Equity workgroup was created out of this, with key objectives including : -define key disparity terminology -set performance baselines for MDH programs -collection of race, language, ethnicity data -trainings for staff (on racism, social determinants of health, etc.) Meets monthly to keep work moving forward *** Health Literacy Project*** Health Equity efforts

LEP Health Communicators Workgroup In Fall 2012, a 12-person workgroup from the MDH health communicators group was created to work together on improving communications projects with LEP and low- literacy communities. Meets monthly to discuss potential projects and to work on creating an intranet site where resources can be shared. Cross-divisional representation

Element #4: Create Mechanism for Ongoing Evaluation & Continuous Improvement Example: MDH Survey (Dec 2012) 63 total participants 82% had been a part of a communications/outreach project with LEP/low literacy communities Top communities served: Hmong, Spanish- speaking (Hispanic and Latino), Somali, African American

MDH Budgets and Timelines

MDH Projects involving translation

Take home message: You are not alone! Main challenges Working with community partners Navigating the translation process Understanding and bridging cultural barriers Finding time/managing time Lack of internal support within section or program Lack of internal communication/resources at MDH Budget Tailoring messages to specific communities Evaluation Knowing who to communicate to – demographic information for the state or specific regions

Element #5: Seek Community Involvement and Feedback on a regular basis Examples of potential partners/advisors: Community based organizations Diverse community media Community health coalitions

Example: Community survey (Dec 2012) Purpose: How do communities access health information? How can MDH more effectively community with LEP/low-literacy communities? Total of 253 participants from community based organizations and diverse community media

Community themes identified in survey Trust– insiders, long-term relationships, building capacity, history of mistrust Accessibility-- language, convenience, culturally appropriate Cultural relevance/cultural responsiveness Importance of ‘bridgers’ and navigators

Community survey quotes Q : What factors lead to choosing particular health information sources? “If these information remain at MDH, no community will go to MDH and pick up the information by themselves and would probably not know what types of information is important that resonate to them since MDH is housed with tons of health information.” “When you don't know any thing about your new home, the only people you can trust is your community, your family & friends.”

“Latino communities are not likely to turn to printed forms of information to get information on resources. Latinos are likely to get information orally and via radio. Also should printed information be available, it should be culturally and contextually appropriate for each respective large group. Venezuelan folks related differently to government and "its services" than do Mexican folks and Puerto Rican folks. A cookie-cutter approach to outreach will not be effective nor efficient when working with Latino populations.”

“These new refugees need people who cannot only interpret information for them, but help explain the nuances and the systems, that can help them navigate these various systems, their paperwork, expectations, know what questions to ask, help them to know their rights and their responsibilities. Community leaders, community organizations and family tend to be the most trusted and give the most time to actually walk people through these processes and systems.”

Next steps World Café style conversations with MDH staff and community advisors (Spring 2013) Present project and key recommendations/findings thus far to leadership and staff Skeleton of website/intranet (Summer 2013) Compile and upload LEP Data and Profile Information Framework onto intranet webpage for Metro area and largest ‘rural’ counties (Summer/Fall 2013) – using user guide and in-kind graduate student support

Next steps continued Launch ongoing trainings for MDH staff (Fall 2013) – Translation (policies, finding a translator, tips for using a translator, etc.) – Working with community partners Key Lesson – Funding is needed for LEP communications position to continue/sustain this work (ongoing) Integrate LEP projects into program workplans and budgets across the department – Finalize templates and protocols Continue to highlight and build directory of MDH Champions

Contact info: Minnesota Department of Health Phone: Website: