By Christine Mendoza
Immigrants are deeply embedded in the fabric of the United States, and North Carolina is no exception. As of 2019, approximately 884,000 people in NC (or 8.4% of the total population) are foreign-born, of which most were born in Latin America (49.4%), especially Mexico (24.8% of the total), although many (27.7%) were born in Asia, especially either India (8.6% of total) or mainland China (3.6%) (MPI, “Demographics”). Given the significant proportion of patients who share the immigrant experience, it is important to understand how linguistic and cultural barriers may affect the healthcare provided to immigrants in North Carolina by shaping the relationships such patients have with their healthcare providers.
The most apparent barrier to healthcare that immigrant patients face is that of language differences. Language barriers can negatively impact healthcare by hindering the flow of information between providers and patients, leading to uninformed decisions, patient confusion, and medication errors (Al Shamsi et al). Ysaura Rodriguez, an immigrant from Mexico and resident of North Carolina, attests to the greater likelihood of errors in healthcare posed by language barriers as she states that without many people in healthcare who could interpret for her, communicating to the doctor “was kind of difficult because [she] didn’t know much English … what [she] didn’t know, [she] made it up” (0:15:42-0:15:48). Similarly, in a study by Ngo-Metzger et al., Chinese and Vietnamese immigrants note the negative impact of language barriers on their ability to make appointments and understand health education materials. Given that approximately 430,000 people in North Carolina (or over 4% of the total population) have limited English proficiency and that there is great diversity in the languages they understand (with over 30 different languages identified among immigrants in NC), the need for greater numbers and a greater diversity of interpreters is evident.
Yet regardless of their level of English proficiency, immigrant patients may also encounter a variety of cultural barriers that negatively affect their relationships with their providers. Cultural challenges, while just as important as language barriers, are less tangible and therefore can be less understood; therefore, the rest of this essay explores causes and solutions to cultural barriers.
One potent cultural barricade some immigrants face in the Western biomedicine of the US healthcare system is providers’ lack of understanding of immigrants’ alternative medicines. For instance, some Latinos use home remedies such as herbs, teas, and oils, as these items are both easily accessible from grocery stores or botánicas (places selling herbal remedies alongside oils and religious figurines to help in the treatment of illness) and viewed as more natural (Ransford et al.). However, these practices may be disregarded by physicians unfamiliar with them (Rodriguez). Likewise, in Ngo-Metzger et al.’s study, some Chinese and Vietnamese-American patients noted that their providers responded negatively to their use of alternative and Western treatments. For example, some providers dismissed the use of herbal medicine, while some mistook the bruises arising from traditional practice of cupping (wherein a heated cup is placed onto skin, usually to treat symptoms of minor illnesses) as signs of disease or abuse (Ngo-Metzger et al.) This lack of understanding of alternative medicine makes patients hesitant to inform their providers about their use of alternative medicine and discontent with providers’ rejection of it. Lack of trust and communication can then jeopardize the health of immigrants who utilize alternative medicine by not only risking potential side effects caused by interactions between home remedies and prescribed treatments, but also by potentially deterring immigrants from seeking healthcare and openly communicating with providers in the future.
On the other hand, cultural beliefs held by some immigrants regarding acceptable conversations and medical decision-making can also serve as a barrier to healthcare. This is relevant when these beliefs hinder the flow of information between patient and provider or potentially risk patients’ lives when their decisions violate expected practices in Western medicine. For example, in a study in the AMA Journal of Ethics on immigrants and refugees, nurse Ann O’Fallon notes that cultural factors such as prioritizing elders’ or other family members’ decisions over those of physicians and viewing sexual health as a taboo topic can keep immigrants from seeking care in the US. Additionally, in minutes 18:22 to 20:43 in her interview, Rodriguez notes that when her children came down with illness in their tonsils, she scheduled the surgery to remove them, but changed her mind after talking to her mother and went against the doctor’s advice by cancelling the surgery, as her and her mother believed that tonsils were necessary for protection against infection. Although her children recovered in this instance, her experience shows the power of elders and cultural beliefs in decision-making and highlights the question of what decisions at what times are ‘best’ (whether physically, emotionally, or socially) for the patient.
Another culture-related challenge some immigrants may face when seeking quality healthcare is the deleterious effects of stereotypes. Stereotyping can degrade the quality of healthcare when providers’ assumptions about a patient blind them to considering other possibilities that may more effectively address the patient’s condition. This is exemplified in the experience of Lata Chaterjee, an immigrant from India who went to a research hospital for a diagnosis, as she notes: “African disease, Indian disease, every kind of disease they were testing me for, when nobody did a simple test to find out if I had mononucleosis” (Chaterjee 0:31:17 – 0:32:36). The doctors’ assumption that she must have a foreign disease because she was a foreigner negatively impacted her health, as they could not identify her illness and she ended up staying in a friend’s house for a few months to recover without medical treatment (Chaterjee). Stereotyping may also negatively impact the care received by a patient through its disregard for the patient’s individuality and the potential that some population groups may be viewed as less or more ‘worthy’ to care for than others, leading to inequities in healthcare. For example, in “The ‘Worthy’ Patient: Rethinking the ‘Hidden Curriculum’ in Medical Education,” Higashi et al. note on page 15 that students training to be providers “learn to use [their biomedically-focused] cultural beliefs and values to make assessments about patient worthiness, and these determinations guide decisions about the quality and quantity of care provided to each patient.” Notably, patients who did not adhere to treatment plans prescribed by their physicians could be seen as ‘difficult’ and therefore potentially less deserving of care. This could disadvantage people in cultures that do not align with Western medical ideals as providers struggle to understand their viewpoints and subconsciously use the system of assumptions they employ to characterize patient worthiness to make generalizations to people sharing a culture.
While many barriers may restrict the access of some immigrants to quality healthcare through their negative effects on the provider-patient relationship, there are also many ways in which these barriers have been and can be broken down. For example, greater access to interpreter services (whether in-person or over the computer or phone) can help ensure that language differences pose less of a barricade to communication between providers and patients.
Meanwhile, cultural barriers can be reduced by ensuring that providers are culturally competent to serve their patients (whether through sharing a cultural background with patients or extra training). For example, Mexican immigrant Ysaura Rodriguez details one positive way in which providers may respect patients’ desires to incorporate home remedies into their healthcare and earn their trust:
“… when I talk about home remedies, she doesn’t say, ‘You’re not supposed to do that,’ or, ‘You’re not supposed to do this,’ you know, or, ‘It’s not good,’ or, ‘You need to take the medicine first.’ She’s given me choices, which, it is very important for us to have choices. And if I said I want to try this home remedy, and she said, ‘Let me know if it works. But think about your medicine. Take your medicine. But let me know if it works.'” (0:25:14-0:27:00)
Rodriguez’s emphasis on the importance of allowing patients to have a voice reveals that even if providers are not intimately familiar with the home remedies their patients use, or even if they disagree with the choices a patient arrives at, they can still help forge positive relationships with their patients by treating them with respect for their decisions. Forging positive relationships can then in turn benefit future healthcare experiences as providers earn patients’ trust and willingness to seek future care.
Shared cultural backgrounds can also lessen the impact of cultural barriers on immigrants by allowing providers to better empathize with their patients and understand the nuances of different cultures. For example, Claudia Garrett, the daughter of migrant workers from Mexico, states that her experiences with immigration and migration affects how she delivers healthcare to migrant workers at the clinic she works at in that:
“…I understand how they feel, I understand where they come from as far as a language barrier … I know how hard they work because I was out there doing it myself, so I understand how exhausting they are when they come home and they don’t want to exercise or they come home and they don’t want to cook the special diet for diabetes they just eat what is available.”(0:44:59-0:45:40)
Her understanding of the hidden factors influencing the lives of her patients then helps her identify when her patients may need additional help from her to ensure that they maintain their health or why patients may make certain choices. Similarly, in response to a question on how important she thinks it is for providers and patients to share experiences, Garrett reveals that shared backgrounds between providers and patients can allow providers to be more alert to the differences between patients of a certain background. Garrett states:
I think it’s very important because they’re not just zoned in on one minority or another. That way, they understand the different lifestyles, they understand the culture, and they understand why it’s easier for maybe one race to do something than it is another. (0:46:18-0:46:39)
By emphasizing the role of cultural understanding in avoiding making generalizations of immigrant populations, Garrett suggests that the barrier of stereotyping can be addressed by increasing providers’ understanding of their patients’ culture.
While having providers who share experiences with immigrant patients can help lessen the impact of cultural barriers, the biggest factors in reducing the impact of cultural barriers are simply respect and cultural understanding, which can be gained through training. The viability of both personal experience and professional training in addressing cultural barriers is evidenced in how Ysaura Rodriguez’s provider earned her trust simply by listening openly and respecting Rodriguez’s choices and in how Garrett emphasizes the importance of cultural understanding in minimizing the effects of stereotypes on the healthcare of immigrants. Additionally, Tammy Blackman, a Caucasian healthcare worker native to the US who gained an understanding of the culture of the Latinos she served as she worked, notes that while gain cultural understanding was difficult, she now has a positive experience with the patients she serves:
“… the Latino population, I love them … To learn the culture, it probably takes you a little while, and we have a lot of culture sensitivity kind of programs here and such, but you learn you don’t look at a baby and not touch him. That’s very offensive. And it’s not for everybody. It all depends on where they came from …” (0:06:24 – 0:07:31).
Blackman’s good relationships with patients of different backgrounds than hers and consideration of the individual experience of each patient emphasizes that overall respect for the individuality of each patient can be of much greater importance than a shared background in ensuring that immigrants receive quality healthcare.
As seen above, multiple cultural barriers associated with immigration can impair the communication and understanding essential to the provider-patient relationship, even when language barriers are addressed. However, linguistic and cultural barriers have been and can be largely addressed by increasing access to interpreter services, increasing understanding of the cultures of populations of immigrants (whether through professional training or through providers’ personal experiences) and ensuring that providers in the US healthcare system value both non-Western ideals and those who espouse them.
Al Shamsi, Hilal et al. “Implications of Language Barriers for Healthcare: A Systematic Review.” Oman Medical Journal, vol. 35, no. 2, 2020, doi:10.5001/omj.2020.40.
Blackman, Tammy. Interview with Maddy Kameny. Stories to Save Lives: Health, Illness, and Medical Care in the South, 25 Jun 2018.
Chatterjee, Lata. Interview with Nicholas Allen. Stories to Save Lives: Health, Illness, and Medical Care in the South, 1 Dec 2018.
Garrett, Claudia. Interview with Joanna Ramirez. Stories to Save Lives: Health, Illness, and Medical Care in the South, 25 Jun 2018.
Higashi, Robin, et al. “The ‘Worthy’ patient: Rethinking the ‘Hidden Curriculum’ in Medical Education.” Anthropology & Medicine, vol. 20, no. 1, 2013, pp. 13-23. doi: 10.1080/13648470.2012.747595
MPI. “North Carolina: Demographics and Social.” Migration Policy Institute, MPI, www.migrationpolicy.org/data/state-profiles/state/demographics/NC. Accessed 29 Mar 2021.
MPI. “North Carolina: Language and Education.” Migration Policy Institute, MPI, www.migrationpolicy.org/data/state-profiles/state/language/NC. Accessed 9 Apr 2021.
Ngo-Metzger, Quyen et al. “Linguistic and cultural barriers to care.” Journal of General Internal Medicine, vol. 18, no. 1, 2003, pp. 44-52. doi:10.1046/j.1525-1497.2003.20205.x
O’Fallon, Ann. “Culture Within a Culture: US Immigrants Confront a Health System that Many Citizens Can’t Manage.” Virtual Mentor vol. 7, no. 7, 2005, pp. 509-513. doi:10.1001/virtualmentor.2005.7.7.msoc1-0507.
Ransford, H. Edward, et al. “Health Care-Seeking among Latino Immigrants: Blocked Access, Use of Traditional Medicine, and the Role of Religion.” Journal of Health Care for the Poor and Underserved, vol. 21 no. 3, 2010, p. 862-878. Project MUSE, doi:10.1353/hpu.0.0348.
Rodriguez, Ysaura. Interview by Joanna Ramirez. Stories to Save Lives: Health, Illness, and Medical Care in the South, 29 Jun 2018.