Master's Project Title:

Improving Access to Immunizations for Refugees in Iowa City (Executive Summary)

MCH Student:

Megan Schmidt

Date of Defense:

October 20, 2017


Iowa has experienced significant growth in its immigrant and refugee population over the
past few years. According to the Iowa Refugee Health Program (2017), there were 1105 primary
refugee arrivals in Iowa in 2016. This was a 32.8% increase from 2015. State agencies have
accurate data on the number of refugees who are primarily resettled, but the same is not true of
those who choose to migrate. Professionals close to the situation unanimously agree that most
refugees in Johnson County are secondary migrants who have migrated from the cities and
states where they were initially resettled. According to the United Nations High Commissioner
for Refugees (UNHCR), this secondary migrant resettlement often occurs because refugees
seek new economic opportunities (Marks, 2014). This secondary resettlement can lead to
confusion and difficulty for refugees, particularly in regard to immunizations.

Refugees are required to complete immunizations in order to adjust their immigration
status and become Legal Permanent Residents. According to the Executive Director at IC
Compassion, a number of area refugees have not completed their immunizations because of
high out of pocket costs, the belief that they must travel to Des Moines, and overall confusion
surrounding the issue. These barriers are not unique to Iowa. According to Mishori, Aleinikoff,
& Davis (2017), barriers to health care for refugees include lack of transportation, lack of
familiarity with the health care system, limited time, limited English, fragmented resources, and
low health literacy. Area public health offices and community organizations have recognized the
need for a program to link refugees with their previous health records, assist them in
establishing primary care to receive the rest of their immunizations, and connect them to a civil
surgeon to finalize approval of health records.

This particular field experience took place at IC Compassion, a faith-based non-profit
located in Iowa City, Iowa that engages culturally diverse communities and strives to equip
people at their point of need so that they are able to move out of poverty. Two main objectives
guided this field experience: (1) exploring and applying methods of working effectively with
Congolese refugees, and (2) participating in establishing MCH programs. Area refugees
identified a specific need in regards to immunizations. After consulting with a representative
from Linn County Public Health in January of 2017, a program was designed to address those

The program’s overall objective was to improve access to immunizations for refugees
living in Iowa City. The team proposed to implement the program as follows. First, consent
forms were created and translated so that immunization records could be obtained. Once
consent forms were obtained, IC Compassion interns and volunteers acquired previous
immunization records from health departments and hospitals where refugees were initially
resettled. IC Compassion interns and volunteers then assisted refugee clients in making an
appointment with a primary care physician and a dentist at University of Iowa Hospitals and
Clinics (UIHC). These appointments were set up to complete necessary immunizations and to
facilitate the establishment of primary care among refugee clients. Once all immunizations were
complete, IC Compassion interns and volunteers set up at appointment at Linn County Public
Health so that the records could be reviewed and signed off on by a civil surgeon.
Implementation of this program began in March of 2017.

IC Compassion serves approximately 250 families per week through services including food
assistance, transportation assistance, low-cost legal immigration, ESL classes, one-on- one
tutoring, and nutrition workshops. This particular field experience fit with the mission in several
ways. First, the program focused on a specific need that was identified by a group of clients.
Secondly, this particular program made it easier for refugees to obtain reasonably priced
immunizations, which will enable them to obtain legal permanent residency and move out of

Lessons Learned
Building Trust with Refugees. During implementation, volunteers and staff were
reminded of the importance of building trust within a community. Several clients were resistant
to making an appointment to see a dentist, regardless of the fact that they had assistance in
making the appointment, a language line and/or interpreter would be available during the
appointment, and the dentist would accept Medicaid. My co-workers, several of whom entered
the United States as refugees, explained that a refugee child recently had an adverse reaction
to a medication used by a dentist. Therefore, most individuals in the community felt a level of
distrust and felt it better to avoid making an appointment with a dentist. Had I known this in
advance, I could have spoken to my co-workers to obtain insight on how to address these fears
with clients.

Bringing in Outside Experts. Initially, Johnson County Public Health indicated that it
would be at least a year before they would be able to have a civil surgeon sign off on
immunizations for refugees. Shortly after implementing the program at IC Compassion, a
volunteer and an attorney by trade, took the time to examine the requirements for county health
departments who would like to sign off as a civil surgeon. Based on his interpretation of CDC
requirements, it appeared that Johnson County Health could, indeed, provide immunizations
and sign off on immigration paperwork for refugees. His review led to the conclusion that
Johnson County could move forward much faster than they initially envisioned, and our program
was no longer necessary once they were able to provide immunizations and gather records in
June of 2017. This illustrated the importance of having multiple experts look at rules and

Vaccines Should be Administered Immediately. It is important that “refugees with no
records or incomplete immunizations should receive vaccines at the first health assessment visit
unless there are contraindications at that time” (Barnett, 2004). Because refugees face barriers
such as limited transport, limited health literacy, and limited English, it is important to provide as
many services as possible during the first health assessment.

Collaboration. Because secondary migration often occurs before immunizations have
been completed, health departments and non-profits in cities with a significant number of
refugees must collaborate to ensure refugees know where they can receive finish their
immunizations, obtain primary care, and if necessary, complete medical screening.
Creation of Comprehensive Programs. Kennedy, Seymour, and Hummel (1999), discuss
a comprehensive screening program that has been utilized by University of Colorado and
Colorado Refugee Services. The program requires interpreters, health care workers trained in
the provision of culturally responsive care, and a multidisciplinary team to assist with health
screening and care. Due to the frequency of secondary resettlement, it is no longer enough to
provide such services in capital cities and/or through formal resettlement agencies.

This field experience was created to improve access to immunizations for refugees in
Iowa City. Key lessons learned include the importance of building trust within communities and
the importance of bringing in outside experts. Refugees who have entered the United States
still face barriers accessing health services such as immunizations and primary care. Local
health departments and non-profits must partner to reduce barriers and improve access to care.



Barnett, E. D. (2004). Infectious disease screening for refugees resettled in the United States.
Clinical Infectious Diseases, 39(6), 833-841.

Iowa Refugee Health Program. (2017). Data snapshot, 2016. Des Moines, IA: Iowa
Department of Public Health.

Kennedy, J., Seymour, D. J., & Hummel, B. J. (1999). A comprehensive refugee health
screening program. Public Health Reports, 114(5), 469.

Marks, J. (2014, March). Rural Refugee Resettlement: Secondary Migration and Community
Integration in Fort Morgan, Colorado. Jessica A. Marks. Retrieved February 11, 2017,
from refugee-
resettlement-secondary- migration-community- integration-fort.html

Mishori, R., Aleinikoff, S., & Davis, D. (2017). Primary Care for Refugees: Challenges and
Opportunities. American family physician, 96(2), 112-120.

Stecker, T. (2017, February 8). Refugees and Immunizations [Personal interview].