Strategies to establish and maintain trust when working in immigrant communities

Abstract

The nursing profession has historically advocated a strong commitment to social justice. As immigration issues have become increasingly politicized, nurses are being called upon to integrate principles of social justice when caring for immigrant populations. Nurse researchers have a particular challenge in winning and maintaining trust in immigrant communities. Data from several studies suggest that erosion of trust in the health care system, due to fears of detention and deportation, is resulting in adverse health outcomes among immigrants. The purpose of this article is to discuss a variety of strategies to establish and maintain trust in immigrant communities. These strategies were developed to maintain an academic-community partnership focused around obesity prevention among Mexican immigrant families. Strategies included: 1) Conceptualize trust as a dynamic continuum; 2) Recognize the scope and impact of the stressors; 3) Separate fact vs fiction; 4) Identify deportation related stressors and community responses; 5) Manage trust and mistrust issues; 6) Build bridges and 7) Establish a positive presence. Nurses are well poised to intervene to repair the damaged trust between immigrant communities and the health care system, using community based participatory methods.

The nursing profession has historically advocated a strong commitment to social justice, dating back to trailblazers such as Florence Nightingale and Lillian Wald (Buettner-Schmidt & Lobo, 2012). As a core nursing value, our early leaders clearly understood the importance of administering to the needs of marginalized populations, while at the same time, working to change legal and social structures to advance the public’s health and well-being (Donley, 2010). Although some have lamented that interest in social justice issues has diminished over the past two decades (Boutain, 2005), social justice is reemerging as a significant tenet, especially for public health nurses (PHNs). The recent COVID pandemic is one illustration of how social determinants of health (SDOH) are profoundly impacting morbidity and mortality in low-income communities of color (Abrams & Szefler, 2020). In a similar manner, at a time when immigration issues have become politicized around the world, nurses are being called on to integrate principles of social justice in the care of immigrant populations (Fitzgerald, Myers & Clark, 2017). As described in the American Nurses’ Association (ANA) Issue Brief, Nursing Beyond Borders: Access to Health Care for Documented and Undocumented Immigrants Living in the U.S., it is nurses’ ethical obligation and fundamental responsibility to provide equitable health care to all individuals, including documented and undocumented immigrants (ANA, 2010). The ANA’s Code of Ethics emphasizes that healthcare is a basic human right, which validates nursing’s professional responsibility to address unjust systems and structures (ANA, 2015, p.36).

The Code of Ethics stresses that nurses establish relationships of trust and provide nursing care according to need, without bias or prejudice (ANA, 2015, p.1). The International Council for Nurses (ICN) adds that the nursing profession typifies a respect for human rights, cultural rights, the right to life and choice, and the right to be treated with respect and dignity (ICN, 2012). Nursing is entrusted to: 1) advocate for care across the spectrum of healthcare levels from individual to population health : 2) provide moral respect, worth, and dignity to all individuals irrespective of their personal characteristics and 3) promote equitable/fair distribution and access of health care services on national and global levels (ANA, 2010).

Community Based Participatory Research (CBPR) has been identified as a social justice-based approach to research that engages marginalized community residents as valued participants in decision-making and community solution-building processes (Jacobsen & Rugeley, 2007). A key ingredient in establishing community-academic partnerships (CAPs) is the ability to win and maintain trust. Nurse researchers engaged in CBPR have a particular challenge in winning and maintaining trust in immigrant communities, given the strong anti-immigrant sentiment that has become pervasive in various cities and towns across the globe. Data from a variety of studies suggest that erosion of trust in the health care system, due to discrimination and fears of detention and deportation, is resulting in adverse health outcomes among immigrants (D’Alonzo et al, 2020; Novak et al, 2017; Szaflarski & Bauldry, 2019; Torres et al, 2018). In addition, immigrants are more likely to report instances of healthcare discrimination (Hacker et al, 2015; Rivenbark & Ichou, 2020). Nurses are often on the front lines in these confrontations.

The purpose of this “lessons learned” article is to discuss a variety of strategies that can be used by nurse researchers to establish and maintain trust in immigrant communities. These strategies were developed in response to difficulties encountered in maintaining a CAP focused around obesity prevention among Mexican immigrant families-Project PESO (2015-2019). Several of these approaches were suggested by the community partners themselves.

Background

The history of the CAP has been described elsewhere (D’Alonzo et al., 2020; D’Alonzo, et al (in press). While the research team did not initially anticipate a problem planning and carrying out the study, it became apparent that to deal with the loss of trust in the Mexican immigrant community, it would be necessary to modify study procedures and expectations. The following is a list of trust-building strategies developed by the CAP.

Strategies

Conceptualize trust as a dynamic continuum

There is little research to date on defining and conceptualizing trust in CAPs. What research exists has its limitations. For example, for a variety of reasons, trust is often described exclusively from the perspective of the researcher. In such cases, trust can be conflated with power; the researcher receives funding to carry out a research study and must feel some trust that the community will work with them to carry out the study (D’Alonzo, 2010). In contrast, the community’s perception of trust often focuses on personal attributes of the researcher (e.g. personal charisma, good listener, commitment to community, taking a facilitator rather than a director role). Unfortunately, neither perspective really addresses the dynamics of the trust building process.

Lucero et al (2018) have developed a trust typology model (Table 1) that differs from the traditional, dichotomous “trust vs mistrust” idea. In this model, trust is conceptualized as more of a dynamic continuum, that is built over time. The arrow down the left side of the model reflects an increase in the strength of the trust relationship. The partnership may start at any stage in the model and depending on the initiative, the CAP may move back and forth between trust types. While some of these forms of trust are considered weak and/or temporary, they can serve as a “foot in the door.” For example, functional trust often occurs when the academic partner has a research grant; however functional trust can be a stepping stone to another stronger form of trust over time.

Table 1.

Trust typology with characteristics

Trust types	Characteristics
Trust deficit (suspicion)	Partenership members do not trust each other
Role-based trust	Trust is based on a member’s title or role with limited or no direct interaction
Neutral trust	Partners are getting to know each other; there is neither trust mistrust
Functional trust	Partners are working together for a specfic purpose and time-frame but mistrust may still be present
Proxy trust	Partners are trusted because someone who is trusted invited them
Critical-reflective trust	Trust is at the place where mistakes and other issues resulting from differences can be talked about and rsolves

Note. This table defines various types of trust that exist in community based participatory research (CBPR) partnerships, in order of increasing strength. Reprinted from Lucero et al (2017). Trust development in CBPR partnerships. In N. Wallerstein, B. Duran, J. Oetzel & M. Minkler (eds). Community Based Participatory Research for Health (3^rd ed) (pp.61-71). Jossey-Bass. Copyright by John Wiley & Sons, Publishers.

Recognize the scope and impact of the stressors

Many immigrant families are of mixed legal status, meaning that at least one member of a family unit may be undocumented. The mixed legal status creates a unique set of stressors for those family members who remain in the U.S. and may partially explain the fear of deportation raids among individuals who have legal status. As many as half of those immigrants currently classified as undocumented actually entered the country legally (Warren, 2017). In the majority of these cases, the individuals let their visas expire due to fear of going to immigration officials, exposing their newly undocumented status and risking deportation. Deportation for many undocumented immigrants would have major repercussions; at least two-thirds of the undocumented have been in the U.S. for at least 10 years (Passel & Cohn, 2019), while it is common to encounter undocumented individuals who have lived in the U.S. for 2-3 decades. In such cases, it is not uncommon to see undocumented individuals who own homes and cars, who have educated children and who would be totally lost if returned to their birth country.

Separate fact from fiction

Rumors about deportation often abound in uncertain times and can be a tremendous source of stress both to community residents and to nursing faculty and students. In Project PESO, the research team found many immigrants were suspicious of faculty members because they were employees of the state University, which they interpreted as an extension of the federal government. Even immigrants who had worked with the research team in the past were uneasy, which illustrates the tenuous nature of the trust process. Nursing faculty should explain to their immigrant patients that they have no legal obligation to inquire into or to report to federal immigration officials any information concerning a patient’s immigration status. In addition, nurse researchers working in immigrant communities can request a Certificate of Confidentiality (CoC) from NIH if they are conducting biomedical, behavioral, clinical, or other research in which identifiable, sensitive information, such as immigration status, is collected. https://grants.nih.gov/policy/humansubjects/coc/what-is.htm.

Most nurses are unfamiliar with the details of an ICE raid; there are few factual published accounts of immigration raids and the impact on a community’s health and these vary widely, depending on the individual community. Most often, immigration officials will come to an address with an arrest warrant for a specific individual(s) known to have a criminal history. The subject of the arrest warrant may have moved and other individuals may now live at that residence. This encounter with immigration officials may unfortunately lead to the arrest of other individuals at the residence, of varying legal status. The American Civil Liberties Union (ACLU, 2020) has posted guidelines for community residents to take if they are approached by immigration officials: https://www.aclu.org/know-your-rights/immigrants-rights/. Nurses working in immigrant communities should also be aware of these guidelines.

Identify deportation related stressors and community responses

Seclusion is a common response to the threat of deportation. Individuals at risk may avoid going to work, for fear they will be arrested and detained. This fear forces the undocumented community to assume an isolated lifestyle in order to remain under the radar of government and authoritative figures (Raymond-Flesch, Siemons & Brindis, 2016). Undocumented parents may take extreme steps to protect themselves and to avoid being separated from their children, particularly if the children are US-born. Although children in immigrant families frequently assume adult responsibilities at an early age, current events have intensified this shift in the parent-child relationship (Van Hook & Glick, 2020). For example, fears of detainment and deportation lead parents to send children to do grocery shopping. Teenagers are often expected to prepare meals for themselves and younger siblings; parents admit they are too busy working multiple jobs to teach their children how to cook.

Deportation related stressors also impact immigrants’ health and health-related behaviors. Immigrants may refrain from addressing health problems, e.g. follow up medical visits or refilling prescriptions, in order to prioritize funds to pay for an attorney if a threat of deportation occurs. Many immigrants are also fearful of being arrested/detained during a visit to a federally qualified health center (FQHC). Nurses can assure their immigrant patients that the U.S. Immigration and Customs Enforcement (ICE) considers hospitals and other health care facilities to be “sensitive locations” where immigration enforcement actions are generally avoided (https://www.ice.gov/doclib/ero-outreach/pdf/10029.2-policy.pdf.).

Manage trust and mistrust issues

In 2015, the research team began a community dialog about what could be done to improve health care resources for undocumented immigrants. The School of Nursing (SON) established a clinical partnership with the Mexican Consulate of New York City (NYC) in the form of the Buen Vecino (Good Neighbor) Program, where volunteer faculty and nursing students participate in blood pressure and diabetes screenings and health education sessions. These visits took place with the NYC Mexican Consulate on Wheels; this arrangement provided added assurance to immigrant patients, as police and security forces are not permitted to enter Consular space unless they have the permission of the ambassador (https://legal.un.org/ola/Default.aspx). During these sessions, faculty and students learned the importance of giving the community time to absorb the impact of the new political climate, listening to their feedback/concerns, and being open to criticism. A history of working together for ten years helped the research team to engage in and develop a trust building relationship with the community. The researchers waited at least 6 weeks after the election before meeting with community partners to discuss how political policies might impact the study. A comment commonly heard from community members was, “I never realized how many people in this country hate us.” One of the promotoras remarked that although she walked past the SON building every day, none of the students acknowledged her or even made eye contact with her. After listening to these painful comments, the researchers recognized the need to revisit and repair the CAP. The lead author (KD’A) met with students participating in Buen Vecino, provided some background information on the history of Mexican immigration to the area and stressed the importance of trust building gestures such as eye contact, a handshake on introduction, and attentive body posture. Over time, Buen Vecino Became a popular site for health education and screening among Mexican immigrants, as well as a sought-after clinical rotation for nursing students.

Build bridges

The research team relied on community health workers/promotoras to gauge the readiness of community members to work with new faculty members and become involved in new initiatives. The promotoras were key to reestablishing ties with the community and repairing the trust deficit intensified by the anti-immigrant environment. The promotoras helped identify trusted locations where community members and their families could meet with members of the research team to discuss their concerns and to plan grant-related activities in their native Spanish language. Many of these meetings took place in local churches or in private homes, where food and refreshments were served. The promotoras also accompanied the faculty members and students on the Buen Vecino visits.

Establish a positive presence

To counteract these negative perceptions, the research team began spending time talking informally with members of the community and their children, attending cultural events, and supporting local Mexican businesses. In addition to establishing the Buen Vecino program, the SON partnered with Lazos America Unida, a local Mexican American organization, on Camp Lazos, a popular summer day camp experience for high school students (D’Alonzo et al, in press).

Discussion:

There is growing evidence in the U.S. that erosion of trust in the health care system, due to anti-immigrant sentiment as well as fears of detention and deportation, is resulting in adverse health outcomes among immigrants, independent of legal status. The consequences of this mistrust are in direct opposition to the ANA’s social justice mission, which assures the protection and promotion of human rights in health and health care (ANA, 2016).

Nurses are well poised to intervene to repair the damaged trust between immigrant communities and the health care system, using community based participatory methods. The restoration process can begin using the strategies discussed in this paper. By attending to the erosion of trust within the immigrant community, nurses can honor the “inherent dignity, worth and unique attributes of every person … regardless of the factors contributing to the person’s health status” (ANA, 2015, p. 1).

Nursing has a duty and an obligation to address social justice issues, to assure that all individuals living in the U.S., including documented and undocumented immigrants, have adequate access to health care. Nurses are duty bound to advocate for patients’ rights, particularly for groups such as immigrants, who are susceptible to violations of their fundamental human rights. Now more than ever, nurses need to work to foster social justice issues among vulnerable, disenfranchised communities.