Handmade artwork decorates the walls of SKY Pediatric Dentistry, and echoing out from multiple treatment rooms are some of the many languages spoken by Bowling Green residents as employees communicate with patients and their families.

“We have patients from all over the world,” Sabina Avdic, a SKY Pediatric dental assistant originally from Bosnia and Herzegovina, said. “The Japanese, the Burmese, Bosnian, Spanish, like anything, you name it, we have it.”

SKY Pediatric Dentistry has over 12 languages spoken by its employees. Somali, Burmese, Spanish and Arabic are just a few of the languages provided to patients and family members who need translation services.

Dr. Amanda Ashley, a dentist originally from a small town in upstate New York, owns the practice – and put into place its position as a cultural hub for staff members and patients in Bowling Green.

After opening in August 2013, Ashley recognized how strongly language barriers impacted how some Bowling Green residents received dental care.

SKY Pediatric now provides translation services by employees for these residents, covering a diverse set of languages necessary for a refugee city.

“The main part was starting with Spanish and just realizing that there were so many people in the community that needed to access care,” Ashley said. “But just the simple fact of having difficulties picking up the phone and calling or feeling like if they came into the office, they would kind of be lost. I’d like to have a guide or point person in their language taking the family through, start to finish during the appointment, and now that we have so many languages.”

These languages are provided by employees from other countries, those that moved to Bowling Green as immigrants or refugees. According to the Migration Policy Institute, approximately 18% of healthcare workers are immigrants.

“It [the staff] is very reflective of the community that we’re serving,” Ashley said. “If you look at our Christmas card or our holiday cards, you can see, basically this is the breakdown of what Bowling Green looks like nowadays, and I’m very proud of that.”

A core issue in providing care to patients who do not speak English is the difficulty in accurately translating complicated health topics or medical guidelines. Rules such as no eating before a procedure or specific appointment times can lose their meaning when translated directly.

In most healthcare settings that provide translation services, a “language line,” or interpretation services over the phone for patients, are what is used. This direct translation service can limit how healthcare is communicated “with empathy,” Ashley said.

For this reason, Ashley said having employees who can directly speak the language of patients is much more effective, since they are able to communicate in a way that makes more conversational sense to the patient.

“You can pull up the little cell phone language line, but it doesn’t do anything in the way that like having one of our staff members there and having her talk through everything,” Ashley said. “I feel like we’re providing such a better level of service for families when we have a point person there that speaks their language.”

Ashley hopes that other healthcare offices understand the necessity of employing those from the refugee and immigrant community. She believes the key to increasing this employment is by making healthcare training programs more accessible financially.

“If there was some type of partnership, like funding available, I think that there would be a lot more offices that would employ people from the refugee community,” Ashley said. “If they knew that they could have a great employee that would access that language [and] open up a new patient population.”

The stories of the refugee and immigrant employees at SKY Pediatric are vastly different.

Avdic immigrated to Bowling Green with her family at 16. When war broke out in Avdic’s home country of Bosnia and Herzegovina when she was 11, her father was given the chance to move his family anywhere.

In 1996, the refugee center in Bowling Green was accepting refugees from Bosnia and Herzegovina. Avdic and her family didn’t know what to expect when chosen to come here.

“We didn’t pick it,” Avdic said. “I have no clue what kind of city [it was] or anything. In 1996 is when we came to the United States.”

Avdic used the ESL resources at the refugee center to pick up English during the summer before attending Bowling Green High School. She explained the difficulty in adjusting to her new life.

“I did not speak a word of English,” Avdic said. “Everything was super new to me, like a new lifestyle. It was super hard. I cried for months. After I couldn’t get used to that, I said to my dad, let’s just go back. Can we just do that? It was a really hard experience at first, but then I got started.”

Avdic attended Bowling Green High School after arriving and then pursued a degree at WKU. After working at Lost River Elementary School for years, she became certified as a dental assistant and was employed at SKY Pediatric in 2018.

Healthcare across the globe differs vastly. Whether in specific practices or an overall healthcare system, immigrants and refugees face an immediate challenge in trying to receive care in the United States.

Avdic said healthcare is just one factor in adapting to living in the United States.

“It’s a different lifestyle in general,” Avdic said. “Not just health care. It was just like learning to talk, learning to walk, learning to live like all over again. It’s still super different. But then, over the years, it just becomes your new normal.”

As a dental assistant, Avdic has connected with patients from her home country and from others. Avdic said the most important thing she and other employees can do is simply extending kindness, as the patients have been through so much.

“You can tell they’ve been through a lot,” Avdic said. “So what can you do? Just talk to them nicely. If you can’t help them, don’t add to that [difficulty], just be nice to them to fill their needs. That’s it. That’s what I try to do.”

Outside of direct healthcare, immigrants and refugees are finding places in healthcare administration and business – and are hoping to see structural change.

Nadia Houchens, a WKU healthcare administration professor and program coordinator of the undergraduate health administration program, immigrated to Bowling Green from Bangladesh in 2015.

Houchens did not grow up in Bangladesh. Although she was born there, she spent her childhood in Saudi Arabia and her middle and high school years in the United States. She then returned to Bangladesh for college and got into an arranged marriage, but never felt a true sense of belonging.

“It just wasn’t for me,” Houchens said. “That lifestyle, that culture. It wasn’t 100% me. Now that culture is a huge part of me, but it’s not entirely where I belong […] then education was always on my mind, because my family has this thing like, it doesn’t matter what you do in your life, you have to be educated.”

Houchens immigrated to Bowling Green with her infant son specifically for the WKU health administration masters program.

“For some reason, Kentucky called out to me and I really don’t know why,” Houchens said. “I’m not a very spiritual person, nor am I religious, but something inside me said you need to go to Kentucky.”

She worked at a hospital for less than a year after graduation, but five years ago, applied for a faculty position in healthcare administration at WKU, and said that it has been the “best five years of my life.”

Houchens calls herself a “third culture kid,” a term used to describe those born in one culture and raised in another that often move to the United States.

“For people like us, if you ask me where I’m from, yeah, I was born in Bangladesh, but am I Bangladeshi?” Houchens said. “Not 100%, not even 50%. Am I Arab because I grew up in the Middle East? Not even 50%. Am I American? Not even 50%. But am I a mixture of all of that? Probably.”

As a third culture kid, defining who she is has been difficult.

“It’s hard for us to define who we are,” Houchens said. “It’s hard for us to figure out what our values and cultures and traditions are that we agree with 100%. And America is a place that kind of allows you to just be whoever however you want to be with all opportunities. So I’ve always wanted to come back here because I wanted to feel like myself.”

Throughout her first few years in the United States, Houchens described the “really, really hard work” to settle here, as well as the detrimental effects on her mental health, not only as an immigrant but as a single mother.

She also explained the help she tries to give international students as a faculty member who understands their stories.

“I think what I try to do even now is when I have international students in the department in my program, or even around the university, I try to tell them my story because WKU was a place where you can make yourself at home, all the resources are there,” Houchens said. “But the problem is that when we come in from outside of the country, we don’t even know what resources to look for […] that’s one way I tried to support students here as a healthcare professional.”

Houchens said a key part of providing reliable healthcare to immigrants and refugees is tackling the language barrier and differences in health literacy in these communities.

“The language barrier actually stops a lot of refugees from receiving any kind of health care to begin with,” Houchens said.

Even though services like the language line and telehealth appointments with translators are available, Houchens said those that need these services most don’t know about them. She also said cultural barriers and traditions could interfere with how medicine is received.

“These people are not even aware of those services,” Houchens said. “So that’s part of what I want to do. I want to spread that message. I want to create that awareness that ‘hey, it doesn’t matter what language you speak, we will figure out for you that service [that] is available for you.’”

Moving to the United States gave Houchens the opportunity to become self-sufficient and “do something for myself I could have never done sitting in Bangladesh.”

“I’m a Bengali woman coming from a very, very strict patriarchal society, having lived through a very patriarchal lifestyle,” Houchens said. “I was able to break all of that and come to this country and establish myself as an independent person, not just a woman.”

Houchens said being an example to the women in her home country has been one of the most rewarding things she has done here.

“I have been able to inspire other women back home, friends, cousins, sisters, whatever, to do the same, to break out of that society, and come here and build a life for themselves,” Houchens said.

She also explained the rewarding part of working at WKU as a healthcare educator – sharing her experience and point of view with students across the university.

“As a healthcare educator, I’m able to serve the Commonwealth, and thus serve the United States,” Houchens said. “I feel like I am giving back what little I can in return for the space that you guys have allowed me to live in this country. That’s the rewarding part for me, that I’m able to contribute something to the country by educating the people of this country.”

Healthcare is changing to meet the needs of increasing numbers of immigrants and refugees, with healthcare professionals working to solve language barriers, cultural differences and administrative issues.

Manzar Rzayeva, a U.S. citizen and former immigrant from Baku, Azerbaijan, graduated from WKU in spring 2022 with a degree in biology, with plans to attend medical school. She is currently pursuing a masters degree in public health from WKU and works as a medical laboratory assistant at Med Center Health during her gap year.

Rzayeva immigrated to the United States with her family in July 2015.

“[We] literally had everything you could imagine back home, and we chose to start from zero in a different country just because my dad wanted to provide us a better future,” Rzayeva said.

She began as a sophomore at Bloomington High School, but then transferred to Greenwood High School, where she was placed in regular classes.

“All I knew was just basic English grammar,” Rzayeva said. “I started my sophomore year and I served as an ESL student. Then, I passed my ESL classes and I was supposed to continue on with ESL until the end of the year, but they put me in regular classes when I moved to Greenwood, so you can just imagine the transition.”

After graduating high school, Rzayeva was accepted to the Mahurin Honors College at WKU. She chose WKU because she “did not want to go anywhere else” after already starting her life here from “zero.”

“It was really tough, especially as a first generation [student],” Rzayeva said. “Because you don’t have anybody to ask things, you don’t have anybody that you can look up to and you don’t really have a person to guide you. My experience was probably the craziest one that could ever happen to anybody.”

Coming into college as a STEM major, Rzayeva was told by one of her high school teachers to take a chemistry class by Lester Pesterfield, a chemistry professor and pre-med advisor. Rzayeva said he helped her find the right path to take after meeting him during M.A.S.T.E.R. Plan.

“It was just a lot of trial and error of me figuring it out, of me taking an exam and failing it and then saying okay, we have to change your studying, going to my professor’s office asking questions, being afraid to ask questions,” Rzayeva said. “Even in my Honors 251 class, which was discussion based. I was still learning English […] Overall, it was just filled with a lot of emotional roller coasters of trying to figure things out. I managed 19 credit hours at 17. I think I turned out fine.”

Rzayeva did not always want to go into medicine. After experiences with her own health in the Azerbaijan healthcare system, she said “it didn’t feel the best.” Rzayeva received a new perspective on medicine after going to doctors appointments in Bowling Green with her mother and learning medical terminology to be able to translate.

At one appointment, she had to translate her mother’s possibility of having breast cancer.

“It’s just that process of translating to your mom and knowing before your mom that she could possibly have breast cancer,” Rzayeva said. “It was just horrifying. It was terrifying, to say the least, but we made our way through.”

Seeing and understanding these healthcare inequities inspire Rzayeva to be a physician, and also inspired her to pursue a public health degree. She explained that “being a doctor is more than the clinical aspect of it.”

“I saw medicine in the United States and I also saw the gaps where I would love to be able to fill in in the future as a physician,” Rzayeva said. “That was also one of the reasons why I’ve been enjoying public health […] We’re also learning about health inequalities, health inequities of persons with limited English proficiency not having that healthcare and not receiving the care from your doctors in the best way possible compared to those who do speak English proficiently.”

At WKU, Rzayeva found a community not only in academics but through her extracurricular activities. Through the Honors College, she served as an HonorsTopper as well as president of the Honors Social Planning Board.

“One of the things that the Honors College did to me was bring people into my life, which is important in my opinion throughout your college experience,” Rzayeva said.

Rzayeva also worked as a chemistry lab teaching assistant, including working as the only undergraduate lead TA of a chemistry lab. She hoped to help her students in the way that her TAs helped her.

“I tried to be that person for my students,” Rzayeva said. “Be the TA [teaching assistant] that you wish you had, be the TA you wish would have helped you out. And when I had an opportunity to be a lead TA, that was life changing.”

Rzayeva described these moments as vital to her motivation as a first generation student, immigrant and hijabi woman.

“It’s just these little pieces of experiences and moments where as much as it felt like I was the only one, I was the only immigrant from Azerbaijan and I was a hijabi woman in a group of 100, 500, 20 [people] even, it was just that it was also an element of motivation for me to keep on being a person that I wish that I would have had,” Rzayeva said.

In her undergraduate experience, Rzayeva was also able to complete
a capstone experience and thesis through the Honors College on research that she conducted.

“It was challenging, but it was a great experience that it provided me that I wanted to be a doctor essentially,” Rzayeva said.

Rzayeva also reflected on the final dedication of her thesis.

“I dedicated my thesis to the 17 year old me who persisted and did not give up through college, and also to my parents who chose to come to the United States to provide [us a] better education,” Rzayeva said.

Content editor Alexandria Anderson can be reached at [email protected].