Many newly resettled Afghans in the United States came through a coordinated interagency effort to resettle over 90,000 Afghans displaced by the Taliban takeover of Kabul in August 2021. In the midst of the COVID-19 pandemic, resettlement agencies around the country had to work rapidly with federal partners, health systems, public health practitioners, social service and community-based organizations to support newly arrived Afghans. Newly arrived Afghans are simultaneously adapting to a new life, contributing their skills to their new communities, securing public benefits, seeking opportunities for the adults and children in their families and experiencing ongoing challenges related to the trauma of sudden displacement, and navigating health care as English-language learners in new systems.
The importance of public health roles that directly partner with refugee, immigrant, migrant, and newcomer communities to navigate complex health systems was highlighted by the COVID-19 pandemic and reinforced in the welcoming of people from Afghanistan. Linguistically and culturally concordant public health professionals advocate and coordinate across different parts of the health system and/or social services in partnership with communities. Innovative adaptations to COVID-19 programming and existing systems of support for Afghan communities are key to supporting the health and wellbeing of people newly arrived from Afghanistan.
Patient Navigator Role
A patient navigator specifically works within the healthcare system to support patients in accessing healthcare services. This may be different from community health workers and those with similar titles, who are predominantly based in community care contexts. Patient navigators have a clinical care focus and serve as a bridge between individual patients and the healthcare team. Responsibilities may include addressing barriers to healthcare access (e.g., transportation, insurance, fear, stigma, language), assisting with making appointments and teaching patients how to access appointments independently, attending healthcare appointments with patients as a cultural liaison, and supporting people through family meetings with clinicians. Depending on how integrated or comprehensive the local healthcare system is, patient navigators may connect patients with social service resources and community networks. The lived experiences of the patient navigators are as important as formal preparation for the role. Skills in public health education and healthcare systems navigation can be developed. Linguistic and cultural expertise cannot be underestimated or replicated.
This promising practice describes the potential structures for the implementation of United States-based patient navigator programs focused on the Afghan response.
CBO-Led Navigation in Minnesota
Afghan Cultural Society (ACS) is a nonprofit organization that was started in 2018 to preserve Afghan culture in Minnesota and challenge the narrative of how Afghans were portrayed. After the evacuation, an organizational priority has been to help Afghans understand and navigate the US health system. ACS recognized that the needs of Afghan newcomers of rural origin were unique and tailored programs to support this population. Most notably, formal education levels vary including limited opportunity for prior education, presenting challenges in the navigation of technology and culture, and language acquisition. The program adapted using oral, interactive and group-based information sharing and education. Health Navigators employ a public health triage approach and algorithm-based decision resources. The Health Navigator program connects community members to the right level of care at the right time, and ensures they have the resources to get there, including rides to appointments through an innovative collaboration with Lyft. Navigators verbally validate client understanding at every interaction. ACS recognizes that missed communication and assumptions alter how information is received and processed. The organization shifted their approach to health education and incorporated a policy to ‘Never Make Assumptions’. Navigators provide information, check for understanding, and offer clarification and repetition. Before they close an interaction between Health Navigators and clients, they ask the client to repeat back and validate their understanding of the key messages of the education.
“This whole journey that these folks have made has been very complicated for them to navigate. There’s so much for them to learn and I think we also need to be patient and help them break down all this information, help them learn it.”
State Public Health and CBO Co-Led Navigation in Colorado
Colorado Department of Public Health and Environment (CDPHE) and iNOW initiated a navigator partnership during the COVID-19 pandemic to serve newcomer communities with reduced access. This community-based navigator program was leveraged by the state and expanded during the OAW response. Partners leveraged different strengths, unique to state and community systems and applied the coordinated efforts to support surveillance, contact tracing, outbreak response, and communicable disease containment to the transitional housing initiative within the OAW response. CDPHE leveraged state public health system strengths to supplement navigator skillsets with curriculum supporting public health surveillance and response and disease focused training. The state led surveillance efforts and provided communicable disease consultation. iNOW leveraged their position as the first point of contact for community members and navigator skillsets supplemented with state technical training to establish an immediate and trusted newcomer support network. These community-level connections allowed iNOW to share with CDPHE valuable community concerns and insights related to COVID prevention and public health. Through their federal designation as Colorado Center of Excellence for Newcomer Health (COE), the CO-COE team went on to develop a Cultural Navigation toolkit that provides resources for other entities interested in starting a similar program. iNOW curated an informational video platform focused on Afghan and other newcomer communities called the New American Neighbors Program. The platform includes videos developed within the CDPHE/iNOW partnership and was further developed as a resource for CBOs, Health Systems, and Public Health departments. Videos are now available in thirteen languages and focus on topics like self-efficacy, vaccine deliberation, and health system navigation.
“Instead of pipeline, we need to have straws. Where any community member can contact a community-based organization…and say I’m struggling, I’m having problems with something, and how can you help. And that we figure out how that engagement is deemed eligible, fundable, but that we take some of that red tape off so that we create many more on ramps to services.”
Health System-Led Navigation in Colorado
The Denver Health Refugee, Immigrant, and Newcomer Navigation was implemented with the goal of providing robust linkages to care for communities historically underserved within the US healthcare system. Navigators specifically work with refugee, immigrant, and newcomer populations within Denver Health, connecting these communities with culturally and linguistically accessible direct patient care while providing support in navigating health system barriers. As part of the initiative, patient navigators disseminate pertinent public health information and recommendations to communities in their preferred language. Key activities include vaccine education, communicating masking and social distancing requirements, partnering with refugee health screening programs, supporting pediatric developmental screenings for families who prefer languages other than English and Spanish, and coordinating scheduling and medical home connections for refugees. The program prioritizes sustainable and culturally grounded care for refugee, immigrant, migrant, and newcomer communities. Navigators are from refugee and immigrant communities and have aspects of lived experience in common with the communities they serve. The initiative's success relies on strong partnerships with funding bodies, state-based programs, public health, and resettlement agencies. Denver Health intentionally addresses navigator team power dynamics by providing equitable opportunities to team members. Navigators support the evaluation and dissemination of program activities. The program intentionally offers and seeks professional career development opportunities for navigators, for example, presenting at a national conference or being the face of public health messaging.
“If I’m really going to define success, it’s looking back to my former start as a refugee when I came in and went to the [clinic] for screening, and it was like, ‘it shouldn’t be this way; it should be different.’ So when I stepped in, I always think about I need to make a difference…that when the new ones are coming in, they’re having that welcome and understanding on those things and making sure that there is someone here for them that supports them.” –Refugee, Immigrant, and Newcomer Navigator
"The lived experiences of the patient navigators are as important as formal preparation for the role."