POLICY BRIEF
The Impact of COVID-19 on Immigrant Communities in St. Louis:
Perspectives and Lessons Learned on Language Accessibility in a Public Health Emergency
By Julia Uyttewaal[1], Sarah Lawrence[2], Julia D. López[3], Leah Kemper[4], Adriana Aramburu[5], Kim Thuy
Seelinger[6]
Language Access as a Public Health Imperative
The Coronavirus 2019 (COVID-19) pandemic and related public health measures disproportionately impacted underserved communities. For certain immigrants in the U.S., this can mean trying to navigate the pandemic while contending with poverty, insufficient access to healthcare, precarious employment, and legal vulnerabilities related to immigration status. Having information, services, and other pandemic-related support available can help. If those resources are not accessible in languages other than English, communities face a prolonged public health crisis and alreadymarginalized groups are further excluded from needed support. A comprehensive and culturally-informed translation, interpretation, and dissemination strategy is key to ensuring immigrant communities are not left behind.
This brief presents key evidence and recommendations related to language access for immigrant communities in St. Louis during the COVID-19 pandemic. Findings are drawn from a larger mixed methods study focused on how COVID-19 impacted immigrant communities and immigrant service providers in the St. Louis region, co-developed by the St. Louis Immigrant Service Providers Network (ISPN) and researchers at Washington University’s Institute for Public Health. 1
Key Recommendations to enhance language access in a public health emergency in St. Louis
1. Identify key immigrant communities in the St. Louis metropolitan area and translate key public health documents into relevant languages. This includes application forms, advisory notices, operational guidelines, and scientific news.
Prioritize documents that may impact health, safety, and access to services.
2. Survey diverse immigrant communities to identify their questions and additional information needs related to COVID19 (or other public health crisis). Develop this content with relevant experts and tailor it to the specific populations in question.
3. Seek input from diverse immigrant communities about the most effective formats for informational material about COVID-19, as well as their preferred methods of dissemination and access. Seek additional feedback from community leaders and key service providers.
4. Allocate resources to create and disseminate public health information in different languages, in diverse formats (e.g., video, audio, written, printed, visual), through relevant channels and methods as identified through community-based consultations.
5. Ensure availability of in-person or phone interpreters at public health and other service provision organizations (e.g., vaccination sites, hospitals, clinics, service providing organizations, courts). Train staff on how to reach an interpreter in a timely manner.
6. Call centers are often particularly important during public health crises. For hotlines and other information desks, make sure phone interpretation is available and easily accessible for callers with questions about social services (e.g., 511, food stamps, WIC, social security, unemployment, rental assistance).
7. Build teams with diverse linguistic and cultural backgrounds. Having personnel with both language fluency and understanding of specific immigrant community groups and customs can enhance outreach and encourage help-seeking behavior among immigrant communities.
8. Build pre-emergency language capacity at institutional and systems levels; enter durable contracts with interpretation and translation agencies that can be quickly activated in an emergency. Preparedness is critical.
9. Develop a comprehensive communication strategy for emergency response for the entire St. Louis metropolitan area. Engage representatives of immigrant communities and their trusted service providers to participate in strategy development.
10. Conduct research to explore the relationship between language accessibility and health among immigrant communities in the St. Louis area. Use findings to strengthen communication and service delivery in future public health crises.
Background
The St. Louis metropolitan region is home to a diversity of immigrant communities, who make up just over 5% of the population. This number is growing, with recent analyses indicating that St. Louis has the third-fastest-growing foreign-born population among major metropolitan areas in the U.S..2 Immigrants from many countries call St. Louis home, with large communities from China, India, Mexico, Vietnam, and Europe.3 Smaller but still significant numbers from countries in Africa, Asia, the Middle East, South America, and Europe have also settled in St. Louis. In addition to the general challenges associated with the immigrant experience, many people face added difficulty accessing necessary services and support – particularly among those with no, or limited, English language proficiency. These barriers were exacerbated and spotlighted during the COVID-19 pandemic. A comprehensive language access strategy is one way to work toward greater inclusion of immigrant communities in response to public health crises.
Findings and recommendations in this brief are drawn from three data sources: 1) an online survey distributed to immigrant community members in St. Louis (276 responses)4; 2) interviews conducted with immigrant community members (31 total); and 3) interviews conducted with immigrant service providers in St. Louis (23 total). Survey data was collected between March and July 2021. Interviews occurred from May to September 2021. Specific findings on language access, including communication and service provision with immigrant communities in St. Louis, are analyzed below.
Key Findings
Analysis of survey and interview data revealed key challenges and strategies pertinent to language access for immigrant communities in St. Louis.
Language access as a compounding barrier in a public health crisis
Language and information access
Results from the survey of immigrant community members reveal a link between language spoken and the ability to access information during and about COVID-19. Of survey respondents who struggled to obtain information during the pandemic, the top reason cited was speaking a language other than English (50%), and 25% reported feeling that the information did not apply to them.
Interview participants from numerous immigrant communities and service providers highlighted language access barriers or delays in receiving materials in their language. Barriers varied by language, with most interviewees agreeing that information in Spanish eventually became more readily available than in other languages. Despite this, interviewees observed a persistent lag in information sharing in other languages, including Spanish, whenever new pandemic-related developments occurred (e.g., at the beginning of the vaccination campaign for children). One interviewee explained that this lag created a greater sense of fear among the Bosnian community, which ended up relying on news and information sources coming from Bosnia. This then compounded the spread of misinformation, including about vaccines and mask-wearing.
Some immigrant communities face an additional barrier, where members may not read or write in their native language. One interviewee explained that this was the case for many Somali speakers, so video and audio communication strategies would be more effective than written translations.
Interviewees wanted a wide range of information available in different languages during the pandemic. In addition to advisory information (e.g., shelter-in-place orders), interviewees also wanted information about testing and vaccination sites, restaurant ordinances, business operational guidelines, and information about where to access crucial pandemic support and relief services. Interviewees generally expressed a belief in ensuring equitable and timely access to COVID-19 information for everyone, regardless of language spoken. One service provider noted that, communication was consistently the biggest challenge during the COVID-19 response. Frontline workers found themselves sorting through differing guidelines coming from the Centers for Disease Control and Prevention (CDC), the City of St. Louis, and the Office of the Mayor, trying to discern which information to share with the community. This was already challenging in English. Translation created a new level of complexity. Overall, agencies and service providers emphasized that cost and time were the key barriers to providing more translated materials and interpretation services during the pandemic.
Language and access to services
Study results suggest that, in addition to information access, immigrants’ ability to access services was often influenced by which language they spoke. For instance, several service providers commented that their Spanish speaking clients struggled to access hospital care because there were few interpreters on site. This made it difficult for their clients to speak with doctors about their loved ones severely ill with COVID-19. Providers acknowledged that hospitals were overwhelmed and understood the difficulty of fully attending to patients and families.
In the early stages of vaccination campaigns, providers recognized that language barriers played a role in immigrants’ ability to secure vaccination. Here again, providers commented that vaccine forms were initially only available in English. Many clients arriving at vaccination sites could not read the forms and ended up leaving. The COVID-19 pandemic exacerbated existing challenges. Providers noted that access to services can be complicated when forms and processes do not account for those with limited English proficiency. One service provider commented that applications for orders of protection for domestic violence were only available in English, forcing providers to accompany non-English speaking clients to court to file an application. Other providers also highlighted language as a barrier for clients trying to apply for unemployment assistance, rental assistance, and to the Paycheck Protection Program. They noted that applications are already quite complicated in English. Those who do not speak English often give up on applying despite needing the support. On a positive note, one service provider mentioned that food stamp applications are available in Spanish. However, when nonEnglish speakers call in with questions, the person answering from the help desk often only speaks English. These observations highlight the need for a comprehensive translation and interpretation strategy, spanning from initial forms to customer service.
Language and technology
Particularly during the COVID-19 pandemic, limited access to technology and digital literacy intersected with language barriers to create additional or compounded challenges for certain immigrants. Some simply did not have Internet access. Access to virtual services could also be difficult: some interviewees noted that, when attempting to help clients to set up virtual communications platforms like Zoom or Microsoft Teams, it was almost impossible to find tutorials in Swahili or Arabic.
During the COVID-19 pandemic, many parents across the St. Louis area struggled to help their children attend school virtually from home. Interviewees reported that many immigrant parents experienced specific struggles helping their children with technology issues or questions about their homework. Our immigrant community survey revealed that 80% of respondents with children reported Spanish as their preferred language and 60% of those with children reported an annual income less than $25,000 (compared to 51% of the general survey population). Of those, only a third (38%) agreed or strongly agreed that they had adequate internet access for virtual schooling. Even where cities and schools attempted to offset these challenges by providing free computers and Wi-Fi to families, language barriers could frustrate these accessibility efforts.
Cultural competence and diversity
Interviewees noted how supporting immigrants during the pandemic required interpretation support and translated materials, which can vary greatly in terms of quality. For example, one interviewee received a call from a friend who speaks Swahili complaining about poor quality translations they had received. Poor interpretation or translation can not only cause confusion, but it can negatively affect decision-making, behavior, or help-seeking.
Interviewees also emphasized the importance of providing culturally-informed training to service providers and interpreters on how to approach clients and provide resources in a respectful manner. Making information and services available in different languages is imperative; ensuring that information and services are delivered using culturally appropriate and sensitive communication strategies is also essential. Ideally, staff itself should possess as much linguistic and cultural diversity as possible, to increase a team’s ability to support immigrants directly and effectively.
Cultural competence and diversity of service providers can enable deeper understanding of the reasons for vaccine hesitancy within a community. This can also inform strategies for information design and dissemination for specific groups.
Existing language access strategies in St. Louis
Strategies for information dissemination
Agencies in St. Louis collaborated during the pandemic to provide COVID-19-related information — especially about vaccines — in different languages, particularly Spanish. Social media communication tools such as WhatsApp and WeChat were popular for sharing information. Additional communication methods included paid advertisement on social media, billboards, and Spanish language magazines and webinars. In an effort to share key information about the pandemic, agencies also utilized text message blasts, as well as direct and automated calls to clients in different languages. This could be as simple as taking screenshots of PDFs with basic information about COVID-19 in different languages and texting it to clients. Service providers adapted their outreach methods to clients based on factors such as age. For instance, texting and social media were effective with younger immigrants. With some older generations, particularly in the Vietnamese community, phone calls from a known number were more effective, highlighting the importance of a trusted messenger who can speak to clients in their preferred language.
Service providers and immigrants continually emphasized the importance of identifying and engaging trusted messengers, such as religious or other community leaders, to share accurate and timely information. This was particularly true for reaching older immigrant clients. Bilingual caseworkers who had already established open communication channels and relationships with a specific immigrant group were also effective trusted messengers.
Strategies for service provision
Service providers adapted their service provision models during the pandemic to support immigrant clients in different languages. For example, school districts contracted with Spanish-speaking service providers, who would contact families weekly to make sure students were able to connect with teachers. Some healthcare providers wrote letters for their patients in both English and Spanish, attesting to the patient’s COVID-19 diagnosis or need to quarantine. This ensured that patients understood their provider’s attestation while also enabling them to pass the letter to their employer.
Providers often worked with interpreters, acted as interpreters, or referred clients to other agencies with relevant language capacity and cultural competency. Working with phone-based interpreters allowed providers to continue counseling and services even when no interpreters could be physically present. Some providers partnered with mobile vaccination programs, traveling to people’s homes and acting as interpreters and facilitators during the vaccination process. Additionally, some agencies hosted testing and vaccine clinics on site and made sure bilingual staff were available.
Conclusion
Communication with and service to immigrant communities in St. Louis during the COVID-19 pandemic was hindered by a lack of language accessibility. In particular, the lack of systematic dissemination of public health information in languages other than English impeded access to support services for many immigrant communities. This, in turn, may have negatively impacted the ability of the public health system to control the spread of COVID-19 in these populations. Service providers in the St. Louis area reported limited access to COVID-19 information in languages other than English and limited interpretation services for those seeking health care and other support.
Despite this, many organizations worked to adapt their service provision models to meet community needs during the public health crisis. These adaptations included home-based programming, use of phone-based interpreters, and engaging bilingual healthcare workers in the field (e.g. community health workers, case managers). Service providers highlighted the importance of continued outreach using diverse communication methods throughout the pandemic, despite the trying times. This contributed to deepening trust and opportunity for further engagement through community events (e.g., vaccine clinics) during the COVID-19 pandemic.
Immigrant communities are a significant and important part of any population – urban or rural. Language accessibility is essential when responding to a public health crisis. In the case of St. Louis, recent experience during the COVID-19 pandemic highlighted the necessity of expanding high quality translation and interpretation services across sectors (e.g., housing, legal, health, city and county government, media). Furthermore, effective translation and interpretation services – and the dissemination of this rendered material - requires cultural competence and sensitivity to various immigrant groups. Additional resources should be allocated to develop a more community-informed and inclusive response to future public health challenges and to improve the quality of health care and other services for all residents of the St. Louis area. Moreover, additional research should measure the impact of expanded language access services on the health of immigrant communities and its potential to reduce exclusion of and further harm to these communities during public health crises.
References
1 For information about the overall project, visit: St. Louis Immigrant Service Providers Network, “COVID-19 Impacts Project,” https://www.ispnstl.org/covid-impacts.
2 Andrea Smith, “St. Louis Region Has Third-Fastest-Growing Foreign-Born Population Among Major Metros,” St. Louis Public Radio (October 10, 2019): https://news.stlpublicradio.org/government-politics-issues/2019-1010/st-louis-region-has-third-fastest-growing-foreign-born-population-amongmajor-metros.
3 Subhayu Bandyopadhyay and Praew Grittayaphong, “How Does St. Louis-Area Immigration Differ from National Trends?” Federal Reserve Bank of St. Louis
(January 10, 2022), https://www.stlouisfed.org/on-theeconomy/2022/january/how-does-st-louis-immigration-differ-nationaltrends.
4 The majority of survey respondents (65%) were originally from Mexico, Honduras, and Guatemala. Seventy percent of respondents identified as female, and 88% were between 18 and 49 years old. The St. Louis area was defined to include zip code areas where the first two digits were 62, 63, or 64. For a detailed report of survey results, see Washington University and St. Louis Immigrant Service Providers Network, “Determining COVID-19-related impacts, experiences, and needs among immigrants and service providers in St. Louis,” Institute for Public Health, 2022 (forthcoming).
[1] Center for Human Rights, Gender and Migration; WashU School of Public Health
[2] Center for Human Rights, Gender and Migration
[3] Center for Human Rights, Gender and Migration; WashU School of Medicine; WashU School of Public Health
[4] WashU School of Public Health
[5] Center for Human Rights, Gender and Migration
[6] Center for Human Rights, Gender and Migration; WashU School of Public Health; WashU School of Law