This article is part of State of Health, a series examining health disparities, how they affect Michigan's children and seniors, and the innovative solutions being developed to address them. It is made possible with funding from the Michigan Health Endowment Fund.

When Julia Brodeur's* refugee foster daughter first arrived in Michigan from her home country, she spoke just enough English to tell her new foster parents what food she liked and what sport she was interested in playing. But when it came to the knee pains she sometimes suffered, the girl had no way to describe the sensations or talk about what might be triggering them.

"We realized pretty quickly that language barriers were going to be an issue when it came to her medical health," Brodeur says. "She didn't have the vocabulary needed to tell us what she was feeling, or even to explain her symptoms to a doctor when she was sick."

Brodeur's daughter struggles with any kind of physical discomfort, which isn't unusual for refugee foster youth with histories of trauma. But the result was a minefield of misunderstandings. The doctor once diagnosed Brodeur's daughter with asthma after she complained of being unable to breathe when she runs, not understanding that she was just having the normal experience of getting winded.

"A lot of the time she doesn't understand what medical staff are really asking her," Brodeur says. "I often have to act as the go-between, explaining to her what they're saying and doing while it's happening, and trying to fill them in on her history so they have a clearer picture of where she's coming from."

Having a health care translator like Brodeur is vitally important for many Michiganders who may struggle with health literacy – the ability to effectively understand and communicate with health care providers. Although almost everyone has likely experienced not understanding their doctor, health literacy issues may be especially pronounced for refugees, youth, and disadvantaged communities. But a number of organizations and programs in the state are working to bridge the communication gap.

Foster care agencies provide extra support

Anna Yamaguchi-Gradilla, an unaccompanied refugee minor supervisor at Samaritas foster agency in Lansing, says all foster parents of refugee children will face health literacy issues at some point.

"We've had young girls arrive here in Michigan from other countries, and struggle to explain something to a doctor or a foster parent because there's so much stigma attached to women's health in their cultures," Yamaguchi-Gradilla says. "As a result, they're afraid to talk about their medical concerns. Overcoming cultural barriers is very important if you want to ensure that people get the care they need."

Those barriers may differ depending on what community you live in. Yamaguchi-Gradilla says doctors in Lansing, where she works, are generally well-equipped to deal with the city's large refugee population, but Brodeur says doctors in her community are not as culturally aware.

Another barrier to health literacy has to do with a refugee patient's country of origin. All doctor's offices are required by law to provide translators to people who can't speak English, but Yamaguchi-Gradilla says that's "easier said than done."

"Finding a Spanish-speaking translator is relatively easy here in Lansing," she says. "Finding one that speaks Tagalog isn't!"

That's why Samaritas works so hard to make sure each foster family has the necessary resources to address their foster child's health care needs, whether it's sending a caseworker to doctor's visits or finding a translator for the child.

"That way these kids can get the medical care they so desperately need," Yamaguchi-Gradilla says.

Mini medical school teaches children preventative awareness

Language and culture barriers are huge, but so is general lack of education about the importance of preventative care. However, the Michigan Health Council (MHC) has found that one way to overcome Michigan youngsters' lack of health literacy is to begin their medical education at a young age. Mini Medical School, a program developed by the MHC, teaches children how to take care of their growing bodies while also focusing on the importance of disease prevention.Brandess Wallace.

"We cover a lot of ground with these kids," says Brandess Wallace, MHC's community engagement and education coordinator. "We talk about bone health, dental care, nutrition, the importance of exercise, and basic first aid. We also introduce them to medical instruments, letting them touch and play, which helps them understand the purpose of each instrument."

But this particular playtime addresses another major barrier to health literacy in children, and even in many adults: fear of going to the doctor.

"One of Mini-Medical School's goals is to address some of the fear and anxiety that children feel when they're in the health care setting," Wallace says. "We give kids a chance to interact with different medical instruments that a medical professional may use during a visit. That helps to alleviate their fears, and hopefully leads to more positive encounters with health care professionals in the future."

Michigan Health Council's Mini Medical School.

The whole point of Mini Medical School, according to Wallace, is that kids learn the importance of preventative medicine.

"It's more than just eating your fruits and vegetables and staying active," she says. "But to understand that, they have to be taught to take ownership of their own health and wellbeing."

Teaching children about preventive health, anatomy, and basic body functions empowers them to have agency over their own bodies, now and in the future.

"We want to promote health literacy and plant the seed that encourages Michigan's kids to advocate for their health as they grow into adulthood," Wallace says.

The state is making strides towards reaching vulnerable populations

Brenda Jegede, the manager of the Michigan Department of Health and Human Services' Health Disparities Reduction and Minority Health Section (HDRMHS), agrees that what we learn as children plays a major role in how we approach health care as adults. She says minority populations' fear and mistrust of the health care system are among the largest barriers to health literacy in Michigan.Brenda Jegede.

"We have to look at the relationships certain racial groups have with institutionalized care," Jegede says. "Native Americans, for example, have a long history of being oppressed by institutions. So they're only slowly rebuilding their relationships with the institutions that provide that care."

HDRMHS public health consultant Shronda Grigsby says HDRMHS has worked with providers statewide to address and overcome those barriers. But how exactly does one overcome the ingrained fear of institutions that comes after generations of oppression?

"It can take a long time to repair that damage," Grigsby says, but even small steps can make a big difference.

"Having someone that looks like you behind the counter when you walk in, or seeing a poster on the wall that represents your culture, are small things that can go a long way towards helping people feel welcomed when they step into a medical health facility," she says. "We also provide training for medical staff to help them understand the existing barriers and how to overcome them."Shronda Grigsby.

HDRMHS is also addressing health literacy issues in Michigan by awarding capacity-building grants to health care organizations that can reach out into communities and directly impact disadvantaged populations. Jegede says several Detroit-area primary care clinics are currently using HDRMHS grant funds.

"It allows them to increase access to health care for people, with a focus on building relationships between patients and providers," Jegede says. "That helps significantly with overcoming some of the barriers to health literacy."

The grants allow clinics to provide training for onsite health care providers. Some also hire health care workers to do outpatient work in their communities, providing better education about available services and teaching people to advocate for themselves in a health care setting.

"Health literacy affects every aspect of people's care. People can't be connected to the care they need when they don't know it's there, or they don't understand what they need, or they don't understand what's being offered," Jegede says. "By investigating issues like cultural competency, historical relationships with institutions, and ethnic disparities in health care, we can work towards making sure all people in Michigan are more health literate."

* Name changed to protect the identity of the foster youth.

Sarah Hillman is the news editor at Capital Gains and has been writing stories about issues that impact people's lives for years. She is also the writer and illustrator of a children's book about leadership qualities.

Mini Medical School photos courtesy of Michigan Health Council.